Indications
Seasonal or perennial allergic rhinitis. Nonallergic rhinitis
(fluticasone). Treatment of nasal polyps.
Action
Potent, locally acting anti-inflammatory and immune
modifier. Therapeutic Effects:pin symptoms of
allergic or nonallergic rhinitis.pin symptoms of nasal
polyps.
Pharmacokinetics
Absorption: Beclomethasone—27–44% absorbed;
budesonide—34% absorbed; flunisolide—
50% absorbed; ciclesonide, fluticasone, mometasone—
negligible absorption. Action of all agents is
primarily local following nasal use.
Distribution: All agents cross the placenta and enter
breast milk in small amounts.
Metabolism and Excretion: Following absorption
from nasal mucosa, corticosteroids are rapidly and
extensively metabolized by the liver.
Half-life: Beclomethasone—2.7 hr; budesonide—
2–3 hr; ciclesonide—unknown; flunisolide—1–2
hr; fluticasone—7.8 hr; mometasone—5.8 hr; triamcinolone—
3–5.4 hr.
TIME/ACTION PROFILE (improvement in
symptoms)
ROUTE ONSET PEAK DURATION
Beclomethasone
1–3 days up to 2 wk unknown
Budesonide 1–2 days 2 wk unknown
Ciclesonide 1–2 days 2–5 wk unknown
Flunisolide few days up to 3 wk unknown
Fluticasone few days unknown unknown
Mometasone within 2 days 1–2 wk unknown
Triamcinolone
few days 3–4 days unknown
Contraindications/Precautions
Contraindicated in: Some products contain alcohol,
propylene, or polyethylene glycol and should be
avoided in patients with known hypersensitivity or intolerance.
Use Cautiously in: Active untreated infections; Diabetes
or glaucoma; Underlying immunosuppression
(due to disease or concurrent therapy); Systemic corticosteroid
therapy (should not be abruptly discontinued
when intranasal therapy is started); History ofqintraocular
pressure, glaucoma, or cataracts; Recent nasal
trauma, septal ulcers, or surgery (wound healing may
be impaired by nasal corticosteroids); OB, Lactation,
Pedi: Pregnancy, lactation, or children 12 yr (beclomethasone
[QNASL]), 6 yr (beclomethasone [Beconase
AQ], budesonide, ciclesonide, flunisolide) 4 yr
(fluticasone [Flonase Allergy Relief]) or 2 yr (fluticasone
[Flonase Sensimist], mometasone, triamcinolone)
(safety not established; prolonged or high-dose therapy
may lead to complications).
Adverse Reactions/Side Effects
CNS: dizziness, headache. EENT: epistaxis, nasal
burning, nasal congestion, nasal irritation, nasal perforation,
nasal ulceration, pharyngitis, rhinorrhea, sneezing,
tearing eyes. GI: dry mouth, esophageal candidiasis,
nausea, vomiting. Derm: rash (fluticasone),
urticaria (fluticasone). Endo: adrenal suppression
(high-dose, long-term therapy only), growth suppression
(children). Resp: bronchospasm, cough. Misc:
ANAPHYLAXIS, ANGIOEDEMA.
Interactions
Drug-Drug: Ketoconazoleqeffects of budesonide,
ciclesonide, and fluticasone. Ritonavirqeffects of fluticasone
(avoid concurrent use).
Route/Dosage
Beclomethasone
Intranasal (Adults and Children 12 yr): Beconase
AQ—1–2 sprays in each nostril twice daily (not to
exceed 2 metered sprays in each nostril twice daily);
QNASL—2 sprays in each nostril once daily.
Intranasal (Children 6–12 yr): 1–2 sprays in each
nostril twice daily; once adequate control achieved,p
dose to 1 spray in each nostril twice daily.
Budesonide
Intranasal (Adults and Children 12 yr): 1 spray
in each nostril once daily (not to exceed 4 sprays in
each nostril once daily). For OTC use, administer 2
sprays in each nostril once daily; once symptoms improve,
pto 1 spray in each nostril once daily.
Intranasal (Children 6–11 yr): 1 spray in each nostril
once daily (not to exceed 2 sprays in each nostril
once daily).
Ciclesonide
Intranasal (Adults and Children 12 yr): Omnaris
(for perennial allergic rhinitis only)—2
sprays in each nostril once daily (not to exceed 2
sprays in each nostril/day); Zetonna—1 spray in each
nostril once daily (not to exceed 1 spray in each nostril/
day).
Intranasal (Adults and Children 6 yr): Omnaris
(for seasonal allergic rhinitis only)—2 sprays in
each nostril once daily (not to exceed 2 sprays in each
nostril/day).
Flunisolide
Intranasal (Adults and Children 14 yr): 2 sprays
in each nostril twice daily, may beqto 2 sprays in each
nostril 3 times daily if greater effect needed after 4–7
days (not to exceed 8 sprays in each nostril/day).
Intranasal (Children 6–14 yr): 1 spray in each nostril
3 times daily or 2 sprays in each nostril twice daily
(not to exceed 4 sprays in each nostril/day).
Fluticasone
Intranasal (Adults): Fluticasone Rx—2 sprays in
each nostril once daily or 1 spray in each nostril twice
daily (not to exceed 2 sprays in each nostril/day); after
several days, attempt topdose to 1 spray in each nostril
once daily.
Intranasal (Adults and Children 12 yr): Flonase
Sensimist (OTC) and Flonase Allergy Relief (OTC)—
2 sprays in each nostril once daily; after 1 wk, may adjust
to 1–2 sprays in each nostril once daily; discuss
with health care professional if need to continue longer
than 6 mo.
Intranasal (Children 4–11 yr): Flonase Allergy Relief
(OTC)—1 spray in each nostril once daily; discuss
with health care professional if need to continue longer
than 2 mo.
Intranasal (Children 4 yr): Fluticasone Rx—1
spray in each nostril once daily; mayqto 2 sprays in
each nostril once daily if no response; once symptoms
controlled, attempt topdose to 1 spray in each nostril
once daily.
Intranasal (Children 2–11 yrs): Flonase Sensimist
(OTC)—1 spray in each nostril once daily; discuss
with health care professional if need to continue longer
than 2 mo.
Mometasone
Intranasal (Adults and Children 12 yr): Treatment
of seasonal and perennial allergic rhinitis—2
sprays in each nostril once daily (not to exceed 2
sprays in each nostril once daily).
Intranasal (Adults): Nasal polyps—2 sprays in each
nostril twice daily (not to exceed 2 sprays in each nostril
twice daily).
Intranasal (Children 2–11 yr): Treatment of seasonal
and perennial allergic rhinitis—1 spray in
each nostril once daily.
Triamcinolone
Intranasal (Adults and Children 12 yr): 2 sprays
in each nostril once daily.
Intranasal (Children 6–11 yr): 1 spray in each nostril
once daily (not to exceed 2 sprays in each nostril/
day).
Intranasal (Children 2–5 yr): 1 spray in each nostril
once daily.
Availability
Beclomethasone
Nasal spray (Beconase AQ): 42 mcg/metered spray
in 25-g bottles (delivers 180 metered sprays). Cost:
$173.37/bottle. Nasal spray (QNASL): 80 mcg/metered
spray in 8.7-g bottles (delivers 120 metered
sprays). Cost: $139.94/bottle. Nasal spray (Rivanase
AQ): 50 mcg/metered spray in 25-g bottles (delivers
200 metered sprays).
Budesonide (generic available)
Nasal spray: 32 mcg/metered spray in 8.6-g canister
(delivers 120 metered sprays), 5–mL bottle (delivers
60 metered sprays)OTC, and 8.43–mL bottle (delivers
120 metered sprays)OTC. Cost: $153.97/bottle.
Ciclesonide
Nasal spray (Omnaris): 50 mcg/metered spray in
12.5-g bottle (delivers 120 metered sprays). Cost:
$152.07/bottle. Nasal spray (Zetonna): 37 mcg/actuation
in 6.1-g bottle (delivers 60 metered sprays).
Cost: $159.43/bottle.
Flunisolide (generic available)
Nasal solution: 25 mcg/metered spray in 25-mL bottle
(delivers 200 metered sprays). Cost: Generic—
$44.56/bottle.
Fluticasone (generic available)
Nasal spray : 50 mcg/metered spray in 16-g bottle
(delivers 120 metered sprays). Cost: Generic—
$19.52/bottle. Nasal spray (Flonase Allergy Relief):
50 mcg/metered spray in 9.9–mL bottle (delivers
60 metered sprays)OTC. Nasal spray (Flonase
Sensimist): 27.5 mcg/spray in 9.9 mL bottle (delivers
60 metered sprays). In combination with: azelastine
(Dymista); see Appendix B.
Mometasone (generic available)
Nasal spray (scent-free): 50 mcg/metered spray in
17-g bottle (delivers 120 metered sprays). Cost:
$162.27/bottle.
Triamcinolone (generic available)
Nasal spray: 55 mcg/metered spray in 16.5-g bottle
(120 metered sprays)OTC. Cost: Generic—$86.05/
bottle.
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