Corticosteroids intranasal

Perennial rhinitis is common in both adults and children and is usually treated with intranasal corticosteroids, intranasal ipratropium bromide, antihistamines, intranasal cromones, and decongestants. Treatment-related adverse effects are common and monotherapy is often inadequate. There are few published studies of the comparative efficacy of rhinitis treatments. 

Up to 80% of asthmatics have symptoms of rhinitis, and inflammation of the upper airways may increase AHR.1,3 Treatment of rhinitis with intranasal corticosteroids may improve asthma symptoms and is recommended for asthma patients with rhinitis. 

Antihistamines and intranasal corticosteroids are considered first-line therapy for allergic rhinitis, whereas decongestants, mast cell stabilizers, leukotriene modifiers, and systemic corticosteroids are secondary treatment options. 

The anti-inflammatory actions of intranasal corticosteroids make them highly effective agents for allergic rhinitis treatment, especially as first-line treatment for patients presenting with persistent or moderate to severe allergic rhinitis. 

Pharmacotherapy has an important role in managing AR symptoms (Table 59-2). Intranasal corticosteroids, systemic and topical antihistamines and decongestants, mast cell stabilizers, and immunotherapy all are beneficial in treating symptoms of AR.9 Antihistamines and intranasal corticosteroids are considered first-line therapy for AR, whereas decongestants, mast cell stabilizers, leukotriene modifiers, and systemic corticosteroids are secondary treatment options10-12 (Fig. 59-2). Whenever exposure to allergens can be predicted (e.g., SAR or visiting homes with a pet), medications should be used pro-phylactically to maximize effectiveness.11... 

Currently, six intranasal corticosteroids—beclomethasone, budesonide, flunisolide, fluticasone, mometasone, and triamcinolone—are available commercially. Although all... 

Intranasal steroids are considered to have a slow onset of action (12-24 hours). Some patients may experience relief within a few days. Maximum treatment response may take up to several weeks to be observed.9,10,12 To achieve optimal effects, use at regular intervals is recommended.15 With the exception of beclomethasone and flunisolide, which are administered twice daily, the recommended doses for the intranasal corticosteroids are one to two sprays in each nostril once daily.15... 

Topical intranasal decongestants (e.g., oxymetolazine, xylome-tolazine, phenylephrine, and naphazoline) are OTC options that provide prompt relief of nasal congestion. Nasal decongestants are dosed multiple times daily.15 Tachyphylaxis, rebound congestion, and rhinitis medicamentosa may occur with chronic use therefore, use should be limited to 3 to 5 days.8,12 These may be used 5 to 10 minutes before administration of intranasal corticosteroids in patients with blocked nasal passages.15... 

Intranasal anticholinergic agents (e.g., ipratropium) reduce the severity and duration of rhinorrhea but have no effect on other nasal symptoms.11,12,21 Ipratropium reduces cholinergic hyperreactivity and cholinergically mediated histamine- and antigen-induced secretion. Intranasal ipratropium acts locally, with only minimal systemic absorption. Clinical trials demonstrated that ipratropium bromide 0.3% reduced rhinorrhea in adults and children with PAR.11,12 Intranasal ipratropium is an option for patients in whom rhinorrhea is refractory to topical intranasal corticosteroids and/or antihistamines.8,12 Intranasal ipratropium is available only by prescription, and the dose is two sprays nasally two to three times daily.15 Adverse effects are minimal, but dry nasal membranes have been reported.11,12... 

Intranasal corticosteroids are the most effective anti-inflammatory agents used in pediatric patients with allergic rhinitis. Although fewer studies have been conducted in children, results demonstrate that intranasal corticosteroids are effective and well tolerated, with an adverse-effect profile similar to placebo. Mometasone is indicated for children as young as 2 years of age, fluticasone is indicated for children 4 years of age and older, and beclomethasone, budesonide, flunisolide, and triamcinolone are indicated for children 6 years and older.15 Because concerns regarding effect of intranasal steroids on growth exist, the growth of pediatric patients prescribed intranasal steroids should be monitored routinely via stadiometry. 

Azelastine nasal spray is indicated for children 5 years of age and older and is considered an alternative to intranasal corticosteroids in patients with persistent severe symptoms. Intranasal cromolyn, another commonly used agent in children, is indicated in patients 2 years of age and older and has an acceptable safety profile. However, limited efficacy and multiple daily administrations limit its use to mild and early rhinitis or for prophylaxis of a known imminent exposure. 

Moderate or frequent symptoms require treatment with an intranasal corticosteroid. 

Patients with severe symptoms or those that persist despite intranasal corticosteroid treatment are treated with a combination of intranasal corticosteroid and antihistamine. 

Is the patient taking antihistamines and/or intranasal steroids Is the patient experiencing adverse effects (e.g., sedation from antihistamines or nasal itching, burning, or bleeding from intranasal corticosteroids) ... 

Develop a plan to assess the effectiveness of the antihistamine and/or intranasal corticosteroid therapy after 3 months. 

Transgrund AJ, Whitaker AL, Small RE. Intranasal corticosteroids for allergic rhinitis. Pharmacotherapy 2002 22 1458-1467. van Cauwenberge P, Bachert C, Passalacqua G, et al. Consensus statement on the treatment of allergic rhinitis. Allergy 2000 55 116-134. 

Intranasal corticosteroids are the most effective treatment for allergic rhinitis during pregnancy. Beclomethasone and budesonide have been used most. Nasal cromolyn and first-generation antihistamines (chlorpheniramine, tripelennamine, and hydroxyzine) are also considered first-line therapy. Loratadine and cetirizine have not been as extensively studied. 

Intranasal corticosteroids effectively relieve sneezing, rhinorrhea, pruritus, and nasal congestion with minimal side effects (Table 79-4). They reduce inflammation by blocking mediator release, suppressing neutrophil che-motaxis, causing mild vasoconstriction, and inhibiting mast cell-mediated, late-phase reactions. 

Although leukotriene antagonists represent a new therapeutic alternative, published studies to date have shown them to be no more effective than peripherally selective antihistamines and less effective than intranasal corticosteroids. However, combined use with antihistamines is more effective than antihistamine treatment alone. 

Intranasal corticosteroids are preferred therapy unless allergy symptoms are mild and infrequent... 

Salib RJ, Howarth PH. Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis. Drug Saf 2003 26 863-93. 

Wilson AM, Lipworth BJ. 24 hour and fractionated profiles of adrenocortical activity in asthmatic patients receiving inhaled and intranasal corticosteroids. Thorax 1999 54(l) 20-6. 

Bennett ML, Fountain JM, McCarty MA, Sherertz EF. Contact allergy to corticosteroids in patients using inhaled or intranasal corticosteroids for allergic rhinitis or asthma. Am J Contact Dermat 2001 12(4) 193-6. 

Antihistamines and intranasal corticosteroids are the first-line treatments for allergic rhinitis. Sodium cromoglicate, ipratropium bromide and decongestants, are alternative or add-on treatments. Drug treatment should be selected according to the severity, frequency and duration of symptoms ... 

Mild persistent or moderate-severe intermittent use an oral or intranasal antihistamine, or an intranasal corticosteroid (e.g. beclometasone or fluticasone). Intranasal decongestants and sodium cromoglicate are useful add-on drugs. 

Moderate-severe persistent intranasal corticosteroids are the drug of choice. Antihistamines, intranasal decongestants, and sodium cromoglicate are alternatives if steroids are contraindicated, or can be used as add-on drugs. Ipratropium bromide is useful for people with persistent watery effusion. 

Intranasal corticosteroids are effective in reducing ocular symptoms as well as nasal symptoms. The mechanism of action is unclear it may partly be due to a systemic effect resulting from local absorption, although system-ically related adverse effects are uncommon. These are used once or twice daily depending on choice and should be used regularly during the hay fever season. 

Intranasal corticosteroids are safe if used correctly. Adverse effects are usually localised and include dryness, irritation and nose bleed (which may require stopping treatment for a period). Rarely, ulceration and nasal septal perforation (usually after nose surgery) can occur. Headaches, smell and taste disturbances, and hypersensitivity reactions have been reported. 

Systemic effects caused by intranasal corticosteroids are rare. The MHRA... 

Intranasal corticosteroids are not routinely recommended for acute sinusitis. Any beneficial effect is likely to take at least a week to develop. However, they may have a role in chronic sinusitis. 

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