Corticosteroids nasal

Antihistamines are drags used to counteract the effects of histamine on body organs and structures. Examples of antihistamines include diphenhydramine (Benadryl), loratadine (Claritin), fexofenadine (Allegra), and cetirizine (Zyrtec). A new antihistamine, deslorata-dine (Clarinex), is die active metabolite of loratadine and is intended to eventually replace loratadine (Claritin). Topical corticosteroid nasal sprays such as fluticasone propionate (Flonase) or triamcinolone ace-tonide (Nasacort AQ) are also used for nasal allergy symptoms. See Chapter 56 for more information on die topical corticosteroids. 

Ophthalmic corticosteroids (high risk) Systemic corticosteroids Nasal/inhaled corticosteroids Fenoldopam... 

Mistlin A, Gibson T. Osteonecrosis of the femoral head resulting from excessive corticosteroid nasal spray use. J Clin Rheumatol 2004 10 45-6. 

Systemic corticosteroids Nasal/inhaled corticosteroids Fenoldopam... 

Sharpe SA, Sandweiss V, Tuazon J, Giordano M, Witchey-Lakshmanan L, Hart J, Sequeira J (2(X)3) Comparison of the flow properties of aqueous suspension corticosteroid nasal sprays under differing sampling ecmditions. Drag Dev Ind Pham 29 1005-1012... 

Most corticosteroids nasal sprays (licensed preparations) are suspensions in which croscarmellose sodium is used as viscosity enhancer. The inhalation liquids for nebulisation with the same type of active substances however only contain polysorbate and sorbitan laureate to stabilise the suspension. For atomisation in jet nebulisers, the liquid should not be too viscous, in order to prevent clogging of the nebuliser. 

Rhinitis is characterized by nasal stuffiness with partial or full obstmction, and itching of the nose, eyes, palate, or pharynx, sneezing, and rhinorrhoea. If left untreated it can lead to more serious respiratory diseases such as sinusitis or asthma. Although several types of dmgs are available for treatment, nasal spray topical corticosteroids are widely regarded as the reference standard in rhinitis therapy (250). 

There are few definitive data to substantiate the efficacy of LTRA therapy in refractory asthma, except for patients with aspirin-sensitive asthma. This is a fairly uncommon form of asthma that occurs generally in adults who often have no prior (i.e., childhood) history of asthma or atopy, may have nasal polyposis, and who often are dependent upon oral corticosteroids for control of their asthma. This syndrome is not specific to aspirin but is provoked by any inhibitors of the cycloxygenase-1 (COX-1) pathway. These patients have been shown to have a genetic defect that causes... 

AIA runs a characteristic clinical course [9]. It is more frequent in women than men, and is unusual in children, beginning in adulthood, on average at the age of 30 years. Rhinorrhea and nasal congestion are usually the first symptoms, subsequently complicated by polyposis. Asthma and aspirin hypersensitivity develop 2-15 years later. Once developed, aspirin intolerance remains through life, although sporadic disappearance of intolerance has been reported. Asthma, characterized by blood and nasal eosinophilia, rims a protracted course despite avoidance of analgesics. In about half the patients, the course of asthma is severe, necessitating use of systemic corticosteroids. 

In general, treatment of the asthma underlying NSAlDs sensitivity should follow standard asthma guidelines. This type of asthma is often severe and frequently high doses of inhaled corticosteroids and daily doses of oral corticosteroids are necessary. A special treatment option is a chronic desensitization to aspirin [8]. Desensitization and aspirin maintenance is routinely used in some centers for treatment of chronic rhinusinusitis with nasal polyposis. It is the only available procedure which allows AIA patients with ischemic heart disease to use aspirin. During the state of desensitization to aspirin, not only aspirin but almost all strong NSAIDs are tolerated, so desensitization and NSAID maintenance could be used for treatment of rheumatic disease or chronic pain syndromes. 

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... 

Systemic corticosteroids, administered orally or by depot injection, are considered last-resort options when all other treatments for SAR are inadequate. Systemic steroids may be used to control rhinitis symptoms in patients with severe PAR or nasal polyposis. Data comparing oral and parenteral steroid therapy are lacking however, oral therapy is preferred due to its low cost... 

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. 

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) ... 

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. 

Rhinocort Aqua and Nasonex are preparations containing topical nasal corticosteroids (budesonide and mometasone furoate respectively). Otrivine contains a nasal decongestant (xylometazoline) and Sudafed is a systemic preparation containing a nasal decongestant (phenylephrine). Molcer is a preparation for ear-wax removal and which contains docusate sodium. Emadine contains an antihistamine (emedastine) and is presented as eye drops. 

Triamcinolone is a corticosteroid that is more potent than hydrocortisone and has a longer duration of action. Triamcinolone has only slight mineralocorticoid activity, whereas hydrocortisone has high mineralocorticoid activity and therefore triamcinolone is unsuitable for disease suppression on a long-term basis. Triamcinolone is available as injection, dental paste, nasal spray and as cream or ointment preparations. Hydrocortisone is available as cream, tablets and injections. 

Rhinocort Aqua is the proprietary preparation of a topical nasal spray containing the corticosteroid budesonide and is marketed by AstraZeneca. 

Sofradex contains dexamethasone, framycetin and gramicidin and is indicated in otitis externa. Canesten contains clotrimazole and is indicated for fungal infections and may be used in otitis externa where a fungal infection is suspected. Nasonex contains mometasone, a corticosteroid, and is used in nasal allergy. 

Fluticasone is a potent corticosteroid that is available as a nasal spray indicated in allergic rhinitis (hay fever) and as an inhaler used in asthma. 

Wound healing Because of the inhibitory effect of corticosteroids on wound healing in patients who have experienced recent nasal septal ulcers, recurrent epistaxis, nasal surgery, or trauma, use nasal steroids with caution until healing has occurred. Vasoconstrictors In the presence of excessive nasal mucosa secretion or edema of the nasal mucosa, the drug may fail to reach the site of intended action. In such cases, use a nasal vasoconstrictor during the first 2 to 3 days of therapy. 

Nasal corticosteroids are effective in vasomotor rhinitis, but because of the duration of the disorder, certain caution is advised to avoid systemic effects and local adverse reactions after long-term use. Ipratropium bromide spray works well if the dominating problem is runny nose. 

Systemic corticosteroid effects from inhaled and nasal steroids inadequate to prevent adrenal insufficiency in patients withdrawn from corticosteroids abruptly... 

Contraindications Hypersensitivity to any corticosteroid or its components, persistently positive sputum cultures ior Candida albicans, primary treatment of status asth-maticus, systemic fungal infections, untreated localized infection involving nasal mu-... 

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