What are the names of intranasal corticosteroids (INCS) used to treat allergic rhinitis?

Intranasal Corticosteroids for Allergic Rhinitis

The available intranasal corticosteroids include fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide, flunisolide, ciclesonide, beclomethasone dipropionate, and fluticasone furoate. 1

FDA-Approved Intranasal Corticosteroids

First-Generation Agents

• Beclomethasone dipropionate - Available for allergic rhinitis, though associated with growth suppression when used long-term at doses exceeding recommendations 1, 2
• Flunisolide (Nasalide, Nasarel) - 25 µg per spray, approved for ages ≥6 years for seasonal and perennial allergic rhinitis 1
• Triamcinolone acetonide (Nasacort Allergy 24HR) - 55 µg per spray, approved for ages ≥2 years, available over-the-counter 1

Newer-Generation Agents (Preferred)

• Fluticasone propionate (Flonase) - 50 µg per spray, approved for ages ≥4 years for allergic rhinitis and nonallergic rhinitis, available over-the-counter 1, 3
• Mometasone furoate (Nasonex) - 50 µg per spray, approved for ages ≥2 years for seasonal and perennial allergic rhinitis and nasal polyps 1
• Budesonide (Rhinocort AQ) - 32 µg per spray, approved for ages ≥6 years for allergic rhinitis and nonallergic rhinitis 1
• Ciclesonide (Omnaris) - 50 µg per spray, approved for ages ≥6 years for seasonal and perennial allergic rhinitis 1
• Fluticasone furoate (Veramyst) - 27.5 µg per spray, approved for ages ≥2 years for seasonal and perennial allergic rhinitis 1

Clinical Efficacy Considerations

All intranasal corticosteroids are the most effective medication class for controlling allergic rhinitis symptoms, superior to oral antihistamines and leukotriene receptor antagonists. 1, 2

• The overall clinical response does not vary significantly between available intranasal corticosteroids, regardless of differences in topical potency, lipid solubility, or binding affinity 1, 2
• All agents effectively control the four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1, 4
• Onset of action typically occurs within 3-12 hours, with maximal efficacy reached over days to weeks 5, 2

Safety Profile Differences

Fluticasone propionate and mometasone furoate demonstrate superior safety profiles in children, with no demonstrated effects on growth at recommended doses. 1, 2

• Studies show fluticasone propionate, mometasone furoate, and budesonide have no effect on growth compared to placebo at recommended doses 1, 2
• Growth suppression has only been reported with beclomethasone dipropionate when used long-term at doses exceeding recommendations 2, 6
• Common adverse effects across all agents include epistaxis (5-10%), nasal irritation, pharyngitis, and headache 1, 4

Practical Selection Algorithm

For pediatric patients ages 2-5 years: Use triamcinolone acetonide or mometasone furoate, as these are the only agents approved for this age group 1, 6

For pediatric patients ages 4-11 years: Prefer fluticasone propionate (1 spray per nostril daily) or mometasone furoate (1 spray per nostril daily) due to proven growth safety 1, 2, 6

For patients ≥12 years: Any intranasal corticosteroid is appropriate, with fluticasone propionate and mometasone furoate offering once-daily dosing convenience 1, 2

For cost-conscious patients: Triamcinolone acetonide and fluticasone propionate are available over-the-counter, potentially reducing costs 1, 3

Common Pitfalls

• Avoid beclomethasone dipropionate in children due to documented growth suppression risk at higher doses 1, 2
• Ensure proper administration technique with spray directed away from nasal septum to reduce epistaxis risk by four-fold 2, 6
• Counsel patients that continuous daily use is more effective than as-needed use, though as-needed dosing (>50% of days) can provide significant relief 1, 5
• All intranasal corticosteroids are safe for long-term use without systemic effects on hypothalamic-pituitary-adrenal axis, bone density, or ocular pressure when used at recommended doses 2, 6