What is the recommended treatment for a patient with allergic rhinitis, asthma, or chronic sinusitis using intranasal corticosteroids (INCS)?

Intranasal Corticosteroids for Allergic Rhinitis, Asthma, and Chronic Sinusitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be initiated immediately upon diagnosis in adults and children, with strong evidence supporting their superiority over all other medication classes including oral antihistamines, intranasal antihistamines, and leukotriene receptor antagonists. 1

Primary Indication: Allergic Rhinitis

When to Start Treatment

• Begin intranasal corticosteroids immediately when patients present with any combination of nasal congestion, runny nose, itchy nose, or sneezing that affects quality of life—no allergy testing is required before starting treatment. 2

• For patients with predictable seasonal patterns, initiate treatment before symptom onset and continue throughout the allergen exposure period for maximum effectiveness. 2

• Symptom relief begins within 12 hours, with some patients experiencing benefit as early as 3-4 hours, though maximal efficacy requires days to weeks of regular use. 2

Comparative Efficacy

Intranasal corticosteroids demonstrate superior efficacy compared to all alternative treatments:

• Versus oral antihistamines: Intranasal corticosteroids are more effective for all four major symptoms (sneezing, itching, rhinorrhea, nasal congestion) in both seasonal and persistent allergic rhinitis. 1

• Versus intranasal antihistamines: Strong recommendation for intranasal corticosteroids over intranasal antihistamines based on high-quality evidence. 1

• Versus leukotriene receptor antagonists: Strong recommendation for intranasal corticosteroids over montelukast, with significantly greater symptom reduction. 1

• Versus combination antihistamine plus leukotriene antagonist: Intranasal corticosteroids alone are more effective than the combination in most studies. 1

Age-Specific Dosing Recommendations

Adults and children ≥12 years:

• Fluticasone propionate: 2 sprays per nostril once daily (200 mcg total) 2
• Mometasone furoate: 2 sprays per nostril once daily (200 mcg total) 2
• May use twice-daily dosing for severe congestion initially, then reduce to maintenance dosing 2

Children 6-11 years:

• Fluticasone propionate: 1 spray per nostril once daily (100 mcg total) 2
• Mometasone furoate: 1 spray per nostril once daily (100 mcg total) 2

Children 2-5 years:

• Triamcinolone acetonide: 1 spray per nostril daily 2
• Mometasone furoate: 1 spray per nostril daily 2
• Note: Budesonide is only approved for children ≥6 years 2

Proper Administration Technique (Critical for Efficacy and Safety)

Use the contralateral hand technique to reduce epistaxis risk by four times: 2

• Hold the spray in the opposite hand relative to the nostril being treated
• Direct the spray away from the nasal septum toward the outer nasal wall
• Keep head upright during administration
• Do not close the opposite nostril during spraying 2

Additional technique points:

• Prime the bottle before first use and shake before each use 2
• Have patient blow nose prior to administration 2
• Instruct patient to breathe in gently during spraying 2
• If using nasal saline irrigations, perform them before administering the steroid spray 2

Duration of Treatment

Long-term continuous use is both safe and indicated for persistent symptoms:

• Minimum treatment duration of 8-12 weeks is required to properly assess therapeutic benefit. 2

• Intranasal corticosteroids do not cause rhinitis medicamentosa and are safe for indefinite daily use, unlike topical decongestants which must be limited to 3 days maximum. 2

• Long-term studies up to 52 weeks demonstrate no hypothalamic-pituitary-adrenal axis suppression, no growth effects in children at recommended doses, and no ocular complications. 2

• For perennial allergic rhinitis, continuous year-round therapy is more effective than intermittent use due to unavoidable ongoing allergen exposure. 2

Safety Profile and Monitoring

Systemic safety is excellent at recommended doses:

• No HPA axis suppression in children or adults 2
• No growth suppression with fluticasone propionate, mometasone furoate, or budesonide at recommended doses 2
• No increased risk of cataracts, glaucoma, or bone density effects 2

Local side effects:

• Epistaxis (blood-tinged secretions) is the most common adverse event, occurring in 4-8% short-term and up to 20% with year-long use—typically mild and manageable with proper technique 2
• Nasal irritation and burning occur in 5-10% of patients 3
• Headache and pharyngitis are reported but generally mild 2

Monitoring requirements during long-term use:

• Examine the nasal septum periodically (every 6-12 months) to detect mucosal erosions that may precede septal perforation, a rare complication 2

When Monotherapy Fails

For inadequate response to intranasal corticosteroids alone:

• Add intranasal antihistamine (azelastine): The combination of fluticasone propionate plus azelastine shows >40% relative improvement compared to either agent alone. 2

• For severe or intractable symptoms: Consider a short 5-7 day course of oral corticosteroids, but never use intramuscular or repeated parenteral corticosteroids due to serious systemic side effects. 1

• If no improvement after 3 months of intranasal corticosteroid therapy, proceed to CT imaging and consider surgical evaluation. 2

Use in Patients with Concurrent Asthma

Critical distinction: Intranasal corticosteroids treat rhinitis symptoms but should NOT be used as primary asthma therapy:

• In patients with both allergic rhinitis and asthma, intranasal corticosteroids effectively treat rhinitis symptoms but provide only minimal benefit for asthma control. 1

• For asthma control, use inhaled corticosteroids (not intranasal), which are strongly recommended over leukotriene receptor antagonists as the single controlling medication. 1

• Patients with both conditions should receive intranasal corticosteroids for rhinitis AND inhaled corticosteroids for asthma—these are separate treatments targeting different anatomic sites. 1

Use in Chronic Rhinosinusitis

• Long-term treatment with intranasal corticosteroids is both effective and safe in chronic rhinosinusitis, with studies demonstrating safety for up to 52 weeks of continuous use. 2

• For nasal polyps specifically, higher dosing (400 mcg/day of mometasone furoate twice daily) is indicated due to the more severe inflammatory burden. 2

Common Pitfalls to Avoid

Do not delay treatment waiting for allergy testing results—testing is reserved for patients who fail empiric treatment or when specific allergen identification is needed for immunotherapy. 2

Do not start with oral antihistamines or leukotriene antagonists as first-line therapy—they are significantly less effective than intranasal corticosteroids for all major nasal symptoms. 1, 2

Do not discontinue when symptoms improve—intranasal corticosteroids are maintenance therapy, not rescue therapy, and require continuous use for sustained benefit. 2

Do not use intramuscular corticosteroids—possible side effects may be far more serious than allergic rhinitis itself, including prolonged adrenal suppression and muscle atrophy. 1

Teach proper administration technique using visual aids or demonstrations—studies show significantly higher competency when patients are taught using animated cartoons or direct demonstration, and improper technique increases local side effects while reducing efficacy. 2