What are the appropriate dosing, administration technique, contraindications, side effects, and alternative therapies for Nasonex (mometasone furoate) nasal spray in adults and children with allergic rhinitis or nasal polyps?

Nasonex (Mometasone Furoate) Nasal Spray: Clinical Guide

Indications and FDA Approval

Nasonex is FDA-approved for seasonal and perennial allergic rhinitis in patients ≥2 years and for nasal polyps in adults ≥18 years. 1

• Allergic rhinitis: Treatment of seasonal and perennial allergic rhinitis 1
• Nasal polyps: Treatment in adults ≥18 years 1
• Prophylaxis: Can be initiated before allergen exposure in seasonal allergic rhinitis 2

Dosing by Age and Indication

Allergic Rhinitis

• Children 2-11 years: 1 spray (50 µg) per nostril once daily (total 100 µg/day) 1, 3
• Adolescents and adults ≥12 years: 2 sprays (100 µg) per nostril once daily (total 200 µg/day) 1, 3
• Onset of action: Symptom relief begins within 7-12 hours, with maximal efficacy requiring days to weeks of continuous use 4, 5

Nasal Polyps

• Adults ≥18 years: 2 sprays per nostril twice daily (total 400 µg/day) 1
• The twice-daily regimen for polyps addresses the more severe inflammatory burden 3

Optimum Dose Evidence

The 200 µg once-daily dose is the optimum dose for allergic rhinitis based on dose-ranging studies. 6 The 50 µg and 100 µg doses showed less consistent activity at early timepoints, while the 800 µg dose provided no additional benefit over 200 µg 6

Proper Administration Technique

Correct spray technique reduces epistaxis risk by four times compared to improper technique. 3

Step-by-Step Administration

• Prime the bottle before first use by actuating several times until a fine mist appears 3
• Shake the bottle prior to each use 3
• Have the patient blow their nose before administration 3
• Keep the head upright during administration 3
• Use the opposite hand for each nostril (right hand for left nostril, left hand for right nostril) to direct spray away from the nasal septum 3
• Do not close the opposite nostril during spraying 3
• Breathe in gently during spray actuation 3
• If using nasal saline irrigations, perform them before administering Nasonex to avoid rinsing out the medication 3

Contraindications

Nasonex is contraindicated only in patients with hypersensitivity to mometasone furoate or any component of the formulation. 1, 3

Common Side Effects

The most frequently reported adverse events are generally mild to moderate: 1, 4

• Headache (most common systemic side effect) 1
• Viral infection 1
• Pharyngitis (throat irritation) 1
• Epistaxis (nasal bleeding, typically blood-tinged secretions) 1
• Cough 1
• Nasal irritation/burning 4

Managing Epistaxis

Epistaxis occurs as a class effect of all intranasal corticosteroids but can be minimized: 3

• Use contralateral hand technique (opposite hand for each nostril) 3
• Direct spray away from nasal septum 3
• Blood-tinged mucus or occasional streaks are common and generally tolerable 3

Systemic Safety Profile

Mometasone furoate has negligible systemic bioavailability (<1%), resulting in virtually no systemic corticosteroid exposure. 3

No Systemic Effects at Recommended Doses

• No HPA axis suppression in children or adults 3, 4, 2
• No effect on growth in children at approved doses 3, 4
• No ocular complications (cataracts, glaucoma, elevated intraocular pressure) 3
• No bone density effects 3

Duration of Treatment

Initial Trial Period

A minimum treatment duration of 8-12 weeks is recommended to allow adequate time for symptomatic relief and proper assessment of therapeutic benefit. 3

• Patients must be counseled to continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this period 3

Long-Term Use

Intranasal corticosteroids are safe for indefinite use when clinically indicated and do not cause rhinitis medicamentosa (rebound congestion). 3

• Long-term studies up to 52 weeks demonstrate no safety concerns 1, 3
• No evidence of nasal mucosal atrophy after 1-5 years of continuous use 3
• For perennial allergic rhinitis, continuous year-round therapy is more effective than intermittent use 3

Monitoring During Long-Term Use

• Periodically examine the nasal septum every 6-12 months to detect mucosal erosions that may precede septal perforation (a rare complication) 3

Alternative Therapies

When Nasonex Fails or Is Not Tolerated

If intranasal corticosteroid monotherapy provides inadequate control, add an intranasal antihistamine (azelastine) rather than an oral antihistamine. 3

• The combination of fluticasone propionate + azelastine provides >40% relative improvement compared to either agent alone 3
• Oral antihistamines added to intranasal corticosteroids provide no additional benefit for nasal symptoms 3

Other Options

• Intranasal antihistamines (azelastine): Rapid onset, effective for seasonal allergic rhinitis, but generally less effective than intranasal corticosteroids 1, 3
• Oral second-generation antihistamines: Less effective for nasal congestion but useful for sneezing and itching 3
• Intranasal cromolyn sodium: Strong safety profile but less effective than intranasal corticosteroids 3
• Intranasal ipratropium bromide: Specifically effective for rhinorrhea but has no effect on other nasal symptoms 3

Not Recommended as Primary Therapy

Leukotriene receptor antagonists (montelukast) are markedly less effective than intranasal corticosteroids and should not be used as first-line treatment. 1, 3

Comparative Efficacy

Mometasone furoate 200 µg once daily is as effective as twice-daily beclomethasone dipropionate and once-daily fluticasone propionate for perennial allergic rhinitis. 4, 7

• In head-to-head trials, mometasone furoate and fluticasone propionate showed equivalent efficacy at 200 µg once daily 7
• Mometasone furoate was slightly more effective than once-daily oral loratadine for seasonal allergic rhinitis 4

Clinical Pearls and Common Pitfalls

Key Points for Success

• Start immediately upon diagnosis—do not delay for allergy testing results 3
• Emphasize daily use—Nasonex is maintenance therapy, not rescue therapy 3
• Teach proper technique—improper administration increases side effects and reduces efficacy 3
• Set realistic expectations—onset is 7-12 hours, maximal benefit takes days to weeks 4, 5

Pitfalls to Avoid

• Do not prescribe oral antihistamine + intranasal corticosteroid as initial therapy; intranasal corticosteroid monotherapy is equally effective and more cost-efficient 3
• Do not use topical decongestants beyond 3 days due to rebound congestion risk 3
• Do not assume all intranasal steroids are equivalent for children; beclomethasone dipropionate should be avoided in pediatric patients due to growth suppression risk 3
• Do not use parenteral or intraturbinate corticosteroid injections for rhinitis—they can cause prolonged adrenal suppression, muscle atrophy, and fat necrosis 3