What intranasal corticosteroids (INCS) are prescribed for allergic rhinitis or nasal polyps?

Intranasal Corticosteroids Prescribed for Allergic Rhinitis and Nasal Polyps

The intranasal corticosteroids commonly prescribed include fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide, beclomethasone dipropionate, and flunisolide, with fluticasone and mometasone being the most widely recommended first-line agents due to their superior efficacy, once-daily dosing convenience, and excellent safety profiles. 1, 2, 3

Available Intranasal Corticosteroid Formulations

The following intranasal corticosteroids are FDA-approved and clinically available:

First-Line Agents (Preferred)

• Fluticasone propionate - Available as aqueous nasal spray, highly effective with once-daily dosing, approved for adults and children ≥4 years at 50 mcg per spray 2, 4, 5

• Mometasone furoate - Available as nasal spray delivering 50 mcg per spray, approved for adults and children ≥2 years, demonstrates no growth effects at recommended doses 2, 6, 3

• Triamcinolone acetonide - Available over-the-counter as Nasacort Allergy 24HR, approved for children ≥2 years, making it the youngest age-approved option 2

Alternative Agents

• Budesonide - Available as Rhinocort AQ, approved for children ≥6 years, shows no growth suppression at recommended doses 7, 2, 3

• Beclomethasone dipropionate - Older formulation requiring higher doses (typically 168-200 mcg twice daily), associated with growth suppression when exceeding recommended doses in children 7, 3, 8

• Flunisolide - Less commonly prescribed, requires twice-daily dosing 3

Comparative Efficacy and Selection Criteria

Superior Efficacy Profile

• Intranasal corticosteroids are more effective than oral antihistamines for all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itching, with high-quality evidence supporting their use as first-line monotherapy 7, 1

• Fluticasone propionate demonstrates superior efficacy compared to beclomethasone dipropionate at equivalent or lower doses, with faster onset of action (within 12-24 hours) and better relief of nasal obstruction 7, 5

• Fluticasone propionate is significantly more effective than the antihistamine terfenadine, with 49% reduction in total nasal symptom scores versus 27% for terfenadine after 2 weeks 9

• Intranasal corticosteroids are significantly more effective than leukotriene receptor antagonists (montelukast), with clinically meaningful differences in symptom scores 1

Age-Specific Prescribing

• Children 2-5 years: Triamcinolone acetonide (1 spray per nostril daily) or mometasone furoate (1 spray per nostril daily) 2

• Children 4-11 years: Fluticasone propionate (1 spray per nostril daily, 50 mcg per spray) 2

• Children ≥6 years: Budesonide becomes an additional option 2

• Adolescents and adults ≥12 years: Any intranasal corticosteroid, typically starting with 2 sprays per nostril once daily (200 mcg total) for fluticasone or mometasone 2

Dosing Regimens by Indication

Allergic Rhinitis

• Standard dosing: 200 mcg once daily (2 sprays per nostril) for most agents in adults and adolescents 1, 2

• Pediatric dosing: 100 mcg once daily (1 spray per nostril) for children under 12 years 2

• Severe symptoms: May initiate with 200 mcg twice daily, then reduce to maintenance dosing once controlled 2

Nasal Polyposis

• Higher dosing required: 400 mcg daily (2 sprays per nostril twice daily) due to more severe inflammatory burden 2, 8

• Fluticasone propionate 200 mcg twice daily demonstrates significant efficacy in reducing polyp size and improving nasal airflow after 14 weeks of treatment 8

• Consider short course of oral prednisone followed by daily intranasal corticosteroids for severe polyposis 1

Critical Safety Considerations

Systemic Safety Profile

• No clinically significant effects on hypothalamic-pituitary-adrenal axis function at recommended doses in adults or children 7, 10

• No increased risk of ocular pressure elevation, cataract formation, or bone density reduction with long-term use 7, 10

• Fluticasone propionate, mometasone furoate, and budesonide show no growth suppression in children at recommended doses (even up to twice recommended doses) 7, 2, 10

• Growth suppression reported only with beclomethasone dipropionate exceeding recommended doses or when administered to toddlers 7, 10

Local Adverse Effects

• Epistaxis is the most common adverse event (5-10% of patients), minimized by directing spray away from nasal septum using contralateral hand technique 2, 10, 3

• Nasal irritation, burning, and stinging occur in some patients, particularly with propylene glycol-containing formulations 7, 10

• Nasal septal perforation is extremely rare but requires periodic examination of nasal septum during long-term use 7, 10

Administration Technique to Optimize Efficacy

• Direct spray away from nasal septum (use opposite hand for each nostril) to reduce epistaxis risk by four-fold 2

• Keep head tilted downward during administration to prevent medication from draining into throat 2

• If using nasal saline irrigations, perform them prior to administering intranasal corticosteroid 2

• Prime pump before first use and reprime if not used for 3 or more days 11

Common Prescribing Pitfalls to Avoid

• Do not prescribe beclomethasone dipropionate as first-line in children due to documented growth suppression at higher doses; prefer fluticasone, mometasone, or budesonide 7, 2, 10

• Do not discontinue therapy when symptoms improve - continuous daily use is required for maintenance of symptom control throughout allergen exposure 1, 2

• Do not expect immediate relief - counsel patients that onset occurs within 12-24 hours but maximal efficacy requires days to weeks of regular use 7, 2

• Do not combine with topical decongestants beyond 3 days due to risk of rhinitis medicamentosa, though intranasal corticosteroids can be used long-term safely 1

• Do not use as-needed dosing - regular daily use is significantly more effective than intermittent use 7, 1