II. Efficacy

  1. Significantly reduces allergic symptoms
    1. Reduces nasal obstruction
    2. Reduces Rhinorrhea, sneezing, and nasal itching
    3. More effective than Antihistamines
    4. Small effect on impaired smell
  2. References
    1. Bronsky (1996) J Allergy Clin Immunol 97:915-21 [PubMed]
    2. Yanez (2002) Ann Allergy Asthma Immunol 89(5): 479-84 [PubMed]

III. Safety

  1. Pregnancy Category: C (except Budesonide which is pregnancy category B)
  2. Appears safe in children as young as age 2 years
    1. No hypothalamic-pituitary-adrenal axis suppression
    2. Galant (2003) Pediatrics 112:96-100 [PubMed]

IV. Pharmacokinetics

  1. Onset of action within hours, but maximal effect requires 2-4 weeks of continuous use

V. Adverse Effects

  1. Epistaxis
    1. Reduced by spraying away from septum
    2. Use left hand when spraying right nostril
    3. Use right hand when spraying left nostril
    4. (2004) Prescribers Letter 11(1):2 [PubMed]

VI. General

  1. Aqueous Preparations: Better for dry nose, winter
    1. Moisturizing: Nasarel (Flunisolide)
    2. Moisture neutral: Nasocort AQ and Rhinocort AQ
    3. Drying agents (Alcohol): most AQ agents
  2. Non-Aqueous: Better for "wet", watery nose

VII. Preparations: By Age Restriction

  1. All agents are pregnancy category C (except Budesonide which is pregnancy category B)
  2. Age 2 years and older
    1. Fluticasone furoate (Veramyst)
    2. Mometasone (Nosonex)
  3. Age 6 years and older
    1. Beclomethasone (Beconase)
    2. Budesonide (Rhinocort, Pregnancy category B)
    3. Ciclesonide (Omnaris)
    4. Flunisolide
  4. Age 12 years and older
    1. Fluticasone propionate (Flonase)
    2. Triamcinolone (Nasocort)

VIII. Preparations: Low potency agents (especially in children)

  1. Triamcinolone Acetonide (Nasacort)
    1. As of 2014, available as OTC ($20 per 120 spray bottle)
    2. Relative potency: 1
    3. Dose (age 6 and older)
      1. Child: 1 sprays per nostril daily
      2. Adult: 2 sprays per nostril daily (then taper to 1 spray per nostril daily as able)
  2. Mometasone (Nasonex)
    1. Dose (2 years and older): 1 spray each nostril daily (adults should use 2 sprays each nostril)
    2. Relative potency: 1

IX. Preparations: Medium potency agents

  1. Flunisolide (Nasalide)
    1. Dose: 2 sprays per nostril twice daily
    2. Relative potency: 3
    3. Age 6 years and older
  2. Beclomethasone (Beclovent)
    1. Dose (age 6 and older): 1-2 sprays per nostril twice daily
    2. Relative potency: 5
    3. Pregnancy Category C

X. Preparations: Higher potency agents

  1. Budesonide (Rhinocort)
    1. As of 2016, over-ther-counter without a prescription
    2. Dose (age 6 to older): 1-2 sprays each nostril daily
    3. Adults may bolus start with 4 sprays/nostril daily for 1 week then use standard dose (1-2 sprays)
    4. Relative potency: 10
    5. Pregnancy Category B
  2. Fluticasone propionate (Flonase)
    1. As of 2015, over-ther-counter without a prescription
    2. Dose (age 12 years and older): 1-2 sprays per nostril daily
    3. Relative potency: 10
  3. Qvar 80 mg (use oral Inhaler with baby bottle nipple as nasal adapter)
    1. Dose: 1-2 sprays each nostril daily
  4. Ciclesonide (Omnaris, Zetonna)
    1. May be less irritating then other Intranasal Corticosteroids
    2. Omnaris (aqueous nasal spray)
    3. Zetonna (dry aerosol version)

XI. Preparations: Combination Agents

  1. Fluticasone with Azelastine (Dymista)

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Cost: Medications

beconase (on 1/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
BECONASE AQ 0.042% SPRAY $10.80 per gram
flonase (on 9/21/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
FLONASE ALLERGY RLF 50 MCG SPR Generic OTC $0.96 per ml
omnaris (on 1/18/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
OMNARIS 50 MCG NASAL SPRAY $18.11 per gram
zetonna (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
ZETONNA 37 MCG NASAL SPRAY $36.36 per gram
dymista (on 5/16/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
DYMISTA NASAL SPRAY $7.47 per gram

Ontology: Flonase (C0286677)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C065382
English Flonase, flonase

Ontology: Beconase (C0591154)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D001507
English Becotide, Beconase Hayfever, Becodisk, becotide, beconase, Beconase, Becloforte, Becodisks, Propaderm, Allen & Hanburys Brand of Beclomethasone Dipropionate, Glaxo Wellcome Brand of Beclomethasone Dipropionate, GlaxoSmithKline Brand 1 of Beclomethasone Dipropionate, Sanasthmyl, Shire Brand of Beclomethasone Dipropionate, A & H Brand of Beclomethasone Dipropionate

Ontology: Nasacort (C0594040)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
English Nasacort, nasacort

Ontology: Rhinocort (C0678163)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D019819
English rhinocort, Rhinocort

Ontology: Vancenase (C0699072)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D001507
English vancenase, Vancenase, Schering Brand 1 of Beclomethasone Dipropionate

Ontology: Nasarel (C0721979)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH C007734
English nasarel, Elan Brand 2 of Flunisolide, Nasarel

Ontology: Nasal form ciclesonide (C1827940)

Concepts Steroid (T110) , Biologically Active Substance (T123) , Pharmacologic Substance (T121)
SnomedCT 424048001
English Nasal form ciclesonide, Nasal form ciclesonide (product)
Spanish ciclesonida, forma nasal, ciclesonida, forma nasal (producto)

Ontology: Corticosteroid nasal preparations for topical use (C3539185)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
English Corticosteroids, Corticosteroid nasal preparations for topical use