What are the indications for intramuscular (IM) and oral (po) corticosteroids for seasonal allergic rhinitis?

From the FDA Drug Label

Intramuscular Where oral therapy is not feasible, injectable corticosteroid therapy, including KENALOG-40 Injection and KENALOG-80 Injection (triamcinolone acetonide injectable suspension, USP) is indicated for intramuscular use as follows: Allergic states: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, transfusion reactions. SINGULAIR is indicated for the relief of symptoms of allergic rhinitis (seasonal allergic rhinitis in adults and pediatric patients 2 years of age and older, and perennial allergic rhinitis in adults and pediatric patients 6 months of age and older).

IM and PO steroids for seasonal allergies can be used as follows:

• Intramuscular (IM) steroids, such as triamcinolone, are indicated for the control of severe or incapacitating allergic conditions, including seasonal allergic rhinitis, when oral therapy is not feasible 1.
• PO steroids, such as montelukast, are indicated for the relief of symptoms of seasonal allergic rhinitis in adults and pediatric patients 2 years of age and older 2. Key points:
• IM steroids are used for severe or incapacitating allergic conditions.
• PO steroids, such as montelukast, are used for the relief of symptoms of seasonal allergic rhinitis.

From the Research

Intramuscular (IM) and oral (PO) corticosteroids should be reserved for severe, debilitating seasonal allergy symptoms that do not respond to first-line treatments like antihistamines, nasal corticosteroids, and leukotriene modifiers, due to their potential side effects and the availability of more effective and safer alternatives, such as intranasal corticosteroids, as shown in a recent systematic review with meta-analysis 3. When considering treatment options for seasonal allergies, it is essential to prioritize treatments with the best safety and efficacy profiles.

• The most recent and highest quality study, a systematic review with meta-analysis published in 2024, found that intranasal corticosteroids were more effective than oral antihistamines and leukotriene receptor antagonists in improving symptoms and quality of life in patients with seasonal allergic rhinitis 3.
• This study suggests that intranasal treatments, such as intranasal corticosteroids, should be considered as first-line treatments for seasonal allergies, rather than IM or PO corticosteroids.
• IM and PO corticosteroids, such as methylprednisolone (Depo-Medrol) and prednisone, can be effective for managing severe seasonal allergies, but their use should be cautious due to potential side effects, including mood changes, increased blood sugar, fluid retention, and increased infection risk, as well as more serious complications like osteoporosis, adrenal suppression, and cataracts with long-term or frequent use.
• Other treatment options, such as sublingual immunotherapy tablets, have also shown promise in reducing symptoms and improving quality of life in patients with seasonal allergic rhinitis, with some studies suggesting that they may be as effective as intranasal corticosteroids, or even more effective than some pharmacotherapies, such as montelukast and desloratadine 4, 5.
• The treatment of seasonal allergies should be individualized, taking into account the severity of symptoms, patient preferences, and the potential risks and benefits of each treatment option, as outlined in recent guidelines for the treatment of seasonal allergic rhinitis 6.