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Intranasal Corticosteroids & Allergic Rhinitis 2004

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Intranasal Corticosteroids & Allergic Rhinitis 2004 INTRANASAL CORTICOSTEROIDS a Supplement to the OTC Products Chart January, 2004 The RxFiles Academic Detailing Program c/o Saskatoon City Hospital, 701 Queen Street Saskatoon, SK, CANADA S7K 0M7 www.RxFiles.ca Intranasal corticosteroids (INCS) are potent and effective Table 2: Treatment of Allergic Rhinitis 1 (ARIA) ,2,3,8,9,10 drugs. Uses may include chronic sinusitis, nasal polyps Moderate- and rhinitis. In allergic rhinitis, a stepwise treatment Mild Severe approach is usually recommended which may include Persistent Persistent 1,2,3,4 Moderate- ↑ antihistamines for mild or intermittent symptoms. Severe Step-up options: dosage or add-on therapy as required; following improvement, Administration of INCS should be reserved for more severe Mild Intermittent Intermittent consider step-down treatment after 3 months or persistent conditions particularly when nasal obstruction nasal corticosteroid – regular dosing most effective is a factor. Appropriate drug therapy will depend on - best to begin ~1 week before allergy season diagnosis and individual considerations (See Tables 1 & 2). - double dose if severe/nasal obstruction. (leukotriene receptor antagonists orally less effective option11,12) Six INCS agents are currently available (See Table 3). cromoglycate – (QID) seasonal & prophylactic use Agents share similar efficacy and side effect potential. oral antihistamine - especially for itching, sneezing, rhinorrhea Differences that may factor into the product selection decongestant: oral; or short-term nasal (≤3-7 days) – for congestion process include: scented versus non-scented 23,34, spray environmental controls: allergen & irritant avoidance (pollen mask; shower after dusting/vacuuming/mowing; air conditioning, etc.) versus powder, “with additives” versus “without additives”, systemic bioavailability, and cost. Specific Considerations Rhinorrhoea - skier-jogger’s nose, non-allergic perennial rhinitis: Table 1: Rhinitis: Symptoms & Associated Factors 1,3 ( ipratropium ATROVENT nasal spray: rapid onset & most effective ALLERGIC NON-ALLERGIC Severe Acute Symptoms – desire rapid effect / nasal blockage ( oral prednisone: Adult 30-50mg/day x3-7 days + concomitant INCS; Symptoms: Symptoms: may also consider other therapies such as antihistamines or LTRA. • watery rhinorrhoea • nasal obstruction without Conjunctival Symptoms ( antihistamines po or topical; ophthalmics • (e.g. H1 blockers: LIVOSTIN , EMADINE ; H1 & Mast Cell: ZADITOR , sneezing, paroxysmal other symptoms • PATANOL ; Mast Cell only: ALOCRIL ) • post-nasal drip -with thick nasal obstruction Poor Response / Intolerance to Drugs (consider immunotherapy (e.g. common cold, sinusitis) • nasal pruritis mucous eg. venom allergies; pollen/cat allergies unresponsive to other therapy • +/- conjunctivitis: itchy, &/or no anterior rhinorrhea Children (antihistamines (or LTRAs): oral route easier to administer • watery, red (NOT pain (ear or sinus) (cromoglycate: very safe, but slow onset & less effective photophobia, burning, dry) • recurrent epistaxis (INCS most effective; mometasone & fluticasone least • bilateral symptoms • anosmia: ↓ sense of smell systemic effect; however some prefer unscented (see Table 3) Associated Factors: Associated Factors: Pregnancy - congestion common; minimal data regarding drug use; • • historical data supports safety for beclomethasone nasal, cromoglycate & chlorpheniramine animals e.g. cats,dogs, horses respiratory irritants Intermittent (versus persistent) = occurring ≤4 days per week or for ≤4 weeks • trees, weeds, grass, hay -e.g. perfumes, smoke, paint, Mild= causing minimal interference with daily living (normal sleep; no impairment of • hair, spray, dust (irritants also daily activities, leisure and/or sport, school or work; & no troublesome symptoms) mites (in warm & humid areas) LTRA= leukotriene receptor antagonist (e.g. montelukast SINGULAIR: age ≥2yrs) an issue for allergic rhinitis) 13 • seasonal (spring & fall) See Table 3 & RxFiles OTC Products Chart for additional considerations • • drug causes family history overuse How can we reduce nasal bleeding with INCS? • e.g. nasal decongestant , asthma (~40% of rhinitis patients cocaine abuse, eyedrops, Aiming the spray toward the outer part of the nose rather 5 have asthma) , dermatitis α-adrenergic antagonists than the septum may lessen nasal bleeding, irritation & • drug causes: ASA/NSAIDs (rare) 14 septum perforation . Lubrication of the anterior nasal Do INCS affect growth in children? septum with vaseline may help. See Table 3 - Administration. Systemic bioavailability ranges from <1% to <50% with What is the treatment for drug-induced rhinitis? various agents although the total dose delivered is low. A Initiate INCS and stop the offending drug (if caused by small effect on growth over 1 year has been reported for nasal decongestant may stop after 3 days of INCS or taper beclomethasone 6; however, intranasal mometasone 45 over 1 week to minimize discomfort). 15 Oral decongestants 7 NASONEX and fluticasone FLONASE did not affect growth. may be used if necessary. In resistant cases, an oral The only 3 approved in preschoolers are: mometasone for corticosteroid may be required, tapering the dose over 7-10 ≥3yrs, and both fluticasone & triamcinolone NASACORT for days. INCS may be continued for up to 1 month or longer. 28 ≥4yrs. Although less effective , cromoglycate CROMOLYN For list of contributors and reviewers see reference page3. DISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the Board or Administration of Saskatoon Health Region (SHR). Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not is a safe non-steroidal option in children ≥2 yrs of age. responsible for any errors or omissions or for the result obtained from the use of such information. Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, its employees, servants or agents. Readers are encouraged to confirm the information contained herein with other sources. Copyright 2004 – RxFiles, Saskatoon Health Region (SHR) www.RxFiles.ca Table 3: INTRANASAL CORTICOSTEROIDS (INCS) 3,4,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31 Prepared by: B. Jensen, L. Regier – www.RxFiles.ca Jan 04 Generic/ Pregnancy Side Effects Contraindications Systemic Dose: For Perennial & $ per bottle Comments TRADE Category 32 (Common & Rare) CI Bioavailability 16 seasonal allergic rhinitis (~30-50cents/day) Precautions USUAL & MAX Scented vs Non Beclomethasone Common: Contraindications High: 44% 1-2 spray in EACH $22 / 200 doses i dipropionate Transient nasal Hypersensitivity 400ug/day did not nostril BID Max 3 spray EN BID C (metered pump & nasal irritation reaction to any affect HPA; however (Kids <6yr not rec.) <10% applicator in amber glass bottle) generic only ( burning/stinging ), component of the <10% 800ug/day did ↓ 50ug aqueous spray i epistaxis , medication; in pts. Scented pharyngitis<5%, With untreated fungal, urinary cortisol Also indicated for: i ii iii iv v vi vii <3% Storage: protect from light, discard (previously available as sneezing in bacterial, tuberculosis Growth retardation: ↓ nasal polyps if >5yr after 3 months use; shake well BECONASE AQ) hyperactive nose, & viral infections small but sig. effect in <3% 33 effectiveness / safety established rhinitis , Precautions: 6-9yr olds over 1yr headache<3% , & with >20yrs of experience Excess Nasal Budesonide taste/smell/voice 1-2 spray in EACH $18 / 10ml / ~120 doses64ug ii (Rhinocort Aqua), iii (Turbuhaler) ↓ Moderate: 31% Secretions: may Max 1 spray EN BID 100ug RHINOCORT AQUA , changes. 29 nostril OD $23 / 10ml / ~165 doses Turbuhaler has no additives, & less effectiveness (blowing → c generic (Turbuhaler 22% ) (Kids <6yr not rec.) {1 spray EN OD lowest price @ ~30 /day} bioavailability vs spray 41; may be ii C first +/- decongestants 34,35,36;? some effect 37 (metered dose, nasal adapter in 64ug , 100ug aqueous Rare: HPA:none important) favored if post nasal drip is bothersome suspension nasal spray Ulceration of Growth retardation: Also indicated for: amber glass bottle) effectiveness / safety established Steroid Withdrawal: RHINOCORT Turbuhaler mucous 38 some in asthma 39,40 yr ; if >5yr iii none at 2 ↓ nasal polyps with >20yrs of experience (100ug dry powder ) membranes, can occur if pt. stops $33 Turbuhaler / 200 doses systemic steroid Flunisolide pharyngeal High: 40-50% 1-2 spray in EACH $24 / 25ml / ~225 doses iv (Rhinalar) C therapy too quickly, RHINALAR , generic candidiasis, nostril BID Max 3 spray EN BID Contains polyethylene glycol iv after starting INCS Growth retardation: (metered pump & nasal ~25ug (0.025%) nasal spray ↓ wound healing 1spray EN TID (pain, depression & none at 1yr 42 in asthma Kids 6-14yr applicator in a plastic bottle) which may keep nose moist esp. in nasal area, (Kids <6yr not rec.) & skin rash. adrenal suppression Fluticasone propionate can occur; also can Very Low: ~0.5% 1-2 spray in EACH $33 / ~120 doses v (Flonase) 16, some effect 43 FLONASE Very rare: unmask existing HPA: none nostril OD Max 2 spray EN BID (metered pump & nasal Storage: shake gently before use v 50ug aqueous nasal spray Nasal septal asthma or eczema) Growth retardation: (Kids <4yr not rec.) applicator in amber glass bottle) 7, 44 C perforation,
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