323FM.2 INTRANASAL STEROID SPRAYS AND DROPS (NASULES)

Mild allergic rhinitis • Oral antihistamines (e.g. cetirizine, loratadine) are the usual first line treatment for mild allergic rhinitis, and are usually started in primary care where it is expected that they will be purchased by the patient (OTC).

Moderate and severe allergic rhinitis and nasal polyps • Intranasal steroids are first line prophylaxis and treatment of moderate and severe allergic rhinitis, either alone or in combination with oral antihistamines. They are also an essential arm of therapy in long term management of nasal polyps. • A range of drugs is necessary as some patients find tolerability better with one rather than another. Common reasons to change preparation include effects on taste, stinging, etc. • Initial treatment should use the maximum dose. • Each treatment choice should be tried for a minimum of 2 months. • Maintenance therapy can be down-titrated depending on symptoms. Many patients find that they can step the dose down to one puff in each nostril twice daily for beclometasone or daily for mometasone or fluticasone. • True seasonal allergic rhinitis may only need therapy with an intranasal steroids during seasonal months and can therefore be stopped at the end of the season. They should be started four weeks before the hay fever season starts for maximal efficacy. However, some patients with perennial rhinitis may require long term maintenance therapy. • Children require lower doses (see BNFc). Different products are licensed for different ages of children: - Mometasone (e.g. Nasonex®) is licensed from 3 years of age - Fluticasone propionate (e.g. Flixonase®) spray is licensed from 4 years of age. It should only be used in patients aged 4 and 5 years of age in Bucks. - Beclometasone (e.g. Beconase®) and fluticasone furoate (e.g. Avamys®) are licensed from 6 years of age. • It is important to consider steroid side effects in children especially in those concurrently on steroid inhalers. The MHRA CSM recommends monitoring the height of children receiving prolonged treatment with any intranasal steroid. • Intranasal steroids are not available to purchase OTC for children under 18 years of age and need to be prescribed.

Formulary choices of intranasal steroid sprays  1st choice: Beclomethasone dipropionate has a long record of safe use. It is cheap, has twice daily dosing and can be purchased over the counter (OTC) (adults only). Please note that other intranasal steroid sprays are approximately 3 x more expensive than beclometasone nasal spray.  2nd choice: Mometasone furoate is given once a day. This advantage needs to be balanced against the greater cost of mometasone compared to beclometasone. Mometasone spray is not available to purchase OTC.  3rd and 4th choices: Fluticasone furoate (e.g. Avamys®) is preferred locally to fluticasone propionate (e.g. Flixonase®) for reasons of cost and mode of delivery. Fluticasone furoate gives a mist rather than a spray which in theory can be useful in patients who have not tolerated 1st and 2nd choices. Fluticasone furoate and fluticasone propionate nasal sprays may be purchased OTC (adults only).

Guideline 323FM.2 1 of 3 Uncontrolled if printed Fluticasone propionate nasal drops (Flixonase® nasules – RED listed) Fluticasone propionate (Flixonase®) nasules are a potent topical corticosteroid preparation used on a once daily basis. They deliver a higher dose of the steroid to the nose. This preparation is not a first line agent and should only be used following a trial of all four standard topical nasal corticosteroid sprays at their maximum doses. Note: Because it is a high dose and potency corticosteroid, long term use of fluticasone propionate (Flixonase®) nasules poses a higher risk of steroid related side effects. They are also significantly more expensive than corticosteroid nasal sprays.

Pre-operative use of fluticasone propionate (Flixonase®) nasules for severe nasal polyposis • Fluticasone propionate (Flixonase®) nasules are a useful addition pre-operatively if the patient presents with nasal polyps which have not responded to a trial of four nasal corticosteroid sprays at their maximum doses. The nasules may prevent the need for surgery. • Fluticasone propionate nasules licensed dose in adults and children 16 to 17 years: 200 micrograms administered into each nostril once or twice a day. (200 micrograms is equivalent to approximately 6 drops or half a nasule.) • If the patient responds to the nasules after a one month trial, then the patient can be transferred back to a corticosteroid nasal spray to see if the improvement will be maintained. If polyps return, then the nasules can be re-administered for another month and used intermittently (one month courses) to control symptoms.

Post-operative use of fluticasone propionate (Flixonase®) nasules after nasal polyp removal • If the patient has had a successful response, he/she can use the nasules intermittently (one month courses) according to symptom improvement. • In many patients following surgical removal of polyps, symptoms are adequately controlled with a topical nasal corticosteroid spray. • Fluticasone propionate nasules are generally prescribed for one month and then stepped down to fluticasone propionate spray. Every attempt should be made to step the patient down after the initial four week acute treatment period. • If the polyps return, or for patients who have had multiple surgical procedures, benefit may be gained from re-treatment with a course of fluticasone propionate nasules for one month. • A small number of patients will require long term maintenance therapy. This should only be commenced by an ENT consultant. If a GP is requested to continue long term treatment, a non-formulary request should be made by the consultant to the Medicines Resource Centre and approved prior to discharge of the patient, in order to ensure that treatment is continued by the GP. Email: [email protected] for a non-formulary application form.

Guideline 323FM.2 2 of 3 Uncontrolled if printed Title of Guideline Intranasal Steroid Sprays and Drops Guideline Number 323FM Version 2 Effective Date May 2021 Review Date December 2021 Updated: March 2019 Approvals: Medicines Management March 2019 Subcommittee Formulary Management Group March 2019 Medicines Check (Pharmacy) 8th May 2021 Clinical Guidelines Group 18th May 2021 Author/s v. 1 Mr Ian Bottrill, ENT Consultant Mr Hamish Thompson, ENT Consultant Sarah Crotty, Interface Pharmacist, NHS Buckinghamshire v.2 Breda Cronnolly, Pharmacist, NHS Buckinghamshire, James Snelling, ENT consultant SDU(s)/Department(s) responsible for ENT updating the guideline Pharmacy Uploaded to Intranet 29th July 2021 Buckinghamshire Healthcare NHS Trust/NHS Buckinghamshire Clinical Commissioning Group

Guideline 323FM.2 3 of 3 Uncontrolled if printed