What are the recommended intranasal corticosteroid doses for treating chronic rhinitis in adults and children?

Intranasal Corticosteroid Dosing for Chronic Rhinitis

For chronic rhinitis in adults, use intranasal corticosteroids at standard once-daily dosing: mometasone furoate 2 sprays per nostril once daily (200 mcg total), fluticasone propionate 2 sprays per nostril once daily (200 mcg total), or equivalent alternatives, with treatment duration of at least 8-12 weeks to assess efficacy. 1, 2, 3

Adult Dosing Recommendations

Standard maintenance dosing:

• Mometasone furoate: 2 sprays per nostril once daily (200 mcg total daily dose) 2
• Fluticasone propionate: 2 sprays per nostril once daily (200 mcg total daily dose) 2
• Budesonide, triamcinolone acetonide, beclomethasone dipropionate: Equivalent once-daily dosing, as all approved agents demonstrate equivalent clinical efficacy 2

For severe nasal congestion unresponsive to standard dosing:

• Temporarily increase to 2 sprays per nostril twice daily (400 mcg total) until symptoms are controlled, then reduce back to maintenance dose 2
• This higher dosing is particularly beneficial for patients with severe congestion that has not responded to standard dosing 2

Pediatric Dosing Recommendations

Children ≥12 years:

• Use adult dosing: 2 sprays per nostril once daily 2

Children 6-11 years:

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

Children 2-5 years:

• Triamcinolone acetonide: 1 spray per nostril once daily 2
• Mometasone furoate: 1 spray per nostril once daily (approved for ages ≥2 years) 2
• Avoid budesonide in children under 6 years (not approved for this age group) 2
• Avoid beclomethasone dipropionate in all pediatric patients due to documented growth suppression risk at standard doses 2, 4

Treatment Duration and Monitoring

Minimum initial trial:

• Continue therapy for at least 8-12 weeks to allow adequate time for symptomatic relief and proper assessment of therapeutic benefit 1, 3
• Patients must be counseled that full benefit may not be evident for the first 2 weeks after initiation 2

Long-term use:

• Intranasal corticosteroids are safe for indefinite use when clinically indicated 2, 5
• No systemic effects on HPA axis, growth (in children at recommended doses), bone density, or ocular complications with long-term use 2, 6
• Periodic nasal septum examination every 6-12 months during long-term therapy to detect mucosal erosions that may precede septal perforation 2, 3

Delivery Methods and Formulations

The European Position Paper on Rhinosinusitis evaluated multiple delivery methods 1:

• Nasal spray (most common, used in 26 trials)
• Nasal drops (7 trials, may be used when spray fails to demonstrate efficacy) 5
• Nasal irrigation (4 trials)
• Nebulizer (2 trials)
• All delivery methods are effective; choice depends on patient preference and ability to use device correctly 1

Safety Profile and Common Pitfalls

Most common side effects:

• Epistaxis (nasal bleeding) occurs in 5-10% of patients, typically presenting as blood-tinged secretions 2, 6
• Nasal irritation, burning, stinging 6
• Headache 2
• Pharyngitis 2

Critical technique to minimize epistaxis:

• Direct spray away from nasal septum using contralateral hand technique (right hand for left nostril, left hand for right nostril) - this reduces epistaxis risk by four times 1, 2

Common pitfalls to avoid:

• Do not discontinue treatment when symptoms improve - intranasal corticosteroids are maintenance therapy, not rescue therapy 2
• Do not wait for allergy testing results before initiating treatment 2
• Do not use oral/systemic corticosteroids for chronic rhinitis except for rare severe intractable cases (short 5-7 day courses only) 2, 7
• Do not use parenteral (injectable) corticosteroids - they are contraindicated due to prolonged adrenal suppression risk 2
• Ensure proper administration technique is taught, as improper use increases local side effects and reduces efficacy 1, 2

Special Populations

Diabetic patients:

• Intranasal corticosteroids are safe and preferred over systemic steroids, which can adversely affect glucose control 3
• Recommended options: mometasone furoate, fluticasone propionate, fluticasone furoate, ciclesonide 3

Pregnant women and elderly:

• Use with appropriate caution, though intranasal corticosteroids have minimal systemic absorption (<0.5-1% bioavailability for newer agents) 2, 5

Patients with comorbid asthma:

• Monitor overall steroid intake when using both intranasal and inhaled corticosteroids 5

When to Escalate Therapy

If no improvement after 3 months of intranasal corticosteroid therapy:

• Consider adding a short course of oral corticosteroids (5-7 days maximum) 2
• Proceed to CT imaging and surgical evaluation 2
• For moderate-to-severe disease with inadequate response, add intranasal antihistamine (azelastine) rather than oral antihistamine 2