Allergic Rhinitis - Guidelines for Prescribing Intranasal Corticosteroids

Description of Allergic Rhinitis (AR)
  • An inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens.

  • Mediated by immunoglobulin E (IgE). Exposure to allergens results in the release of histamine and other inflammatory agents from mast cells.

  • Rhinitis is found in up to 40 % of population. Lifetime prevalence of allergic rhinitis in adult population is 20 to 30 %. Some studies suggest the incidence is increasing.

  • Often associated with asthma and atopic dermatitis.

  • Initial presentation of AR or exacerbation of pre-existing  AR symptoms occurs commonly in pregnancy.

  • Children of school age and adolescents most commonly affected by intermittent (seasonal) AR.

  • Adults more likely to have persistent (perennial) AR.

  • Common allergens:  Seasonal - pollens, molds;  Perennial: house dust mite, pets.

  • Can significantly impair quality of life.  Symptoms can interfere with work and school performance, cause absenteeism and even traffic accidents.

  • Classification based on the following:
    • Sleep
    • Impairment of daily activities, sport, leisure
    • Impairment of work and school
    • Troublesome symptoms

     1.  Frequency/Duration of symptoms  

    • Intermittent:  Symptoms up tor 4 days per week and  for less than 4 – 6 consecutive weeks
    • Persistent:  symptoms on more than 4 days per week for 4 – 6 consecutive weeks

    2.  Severity / Effect  

    • Mild: symptoms are present but do not interfere with normal daily activities (work, school, leisure) or sleep
    • Moderate to Severe: symptoms are very bothersome, interfere significantly in performance of normal daily activities and disturb sleep
     
  • For more information, see:

    • e-therapeutics+. Allergic Rhinitis. Available at SHIRP (free access, registration required)
    • Emedicine - Allergy and Immunology - Rhinitis, Allergic
Signs and Symptoms
  • Early phase:
    • Rhinorrhea - discharge usually clear and watery
    • Sneezing
    • Itchiness - eyes and throat
    • Minor congestion

  • Late phase:
    • Major congestion
    • Early phase symptoms
Differential Assessment

AR is diagnosed based on the presence of typical symptoms (listed above). Rule out the following conditions that may present with similar signs/symptoms:

Hypersensitivity Reaction:

  • Rapid onset (within hours)
  • Anaphylaxis - symptoms associated with difficulty breathing, difficulty swallowing, swelling of face, mouth or throat.

  • Ensure patient receives medical attention immediately.

Infective rhinitis: colds, influenza, sinusitis

  • Rapid onset, short duration
  • Sudden onset, duration 1 week or less, associated with upper respiratory tract infection symptoms such as fever, purulent nasal discharge, swollen glands which are not typical of AR. Other distinguishing features of AR are itchiness (throat, eyes) and persistent symptoms.

  • Recommend appropriate nonpharmacological, and/or over-the-counter treatment.

Irritant (non-allergic, vasomotor) rhinitis:

  • Symptoms follow a known physical or chemical irritant  - change in temperature, humidity; exercise; exposure to chemicals, odours. Patient history is important in differentiating irritant and allergic rhinitis because symptoms are similar.

  • Identify irritant and avoid when possible.

Drug-induced rhinitis:

  • AR symptoms following start of treatment with drugs such as angiotensin-converting enzyme inhibitors, methyldopa, alpha-blockers, beta-blockers, chlorpromazine, nonsteroidal anti-inflammatory drugs (including ASA).

  • Rebound symptoms after discontinuing use of nasal decongestants (for longer than 3 - 5 days).

  • Can medication be changed /discontinued?

Hormonal rhinitis:

  • AR symptoms coinciding with pregnancy, starting oral contraceptives or thyroid dysfunction (hypo- or hyper-).

Structural or mechanical factors:

  • Deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy.

  • Foreign bodies and nasal tumours (rare) suggested by unilateral symptoms (only one nostril involved).

Systemic conditions:

  • Primary defects in mucus (e.g. cystic fibrosis), primary ciliary dyskinesia (Kartagener's syndrome), and granulomatous disease (e.g. Wegener's granulomatosis, sarcoidosis).

When to Refer

Patients with typical symptoms of AR often do not require further investigation, however an assessment by a proper health care practitioner should be recommended in the following situations:

  • Children with moderate to severe symptoms – immunotherapy may alter progression of allergies, and may prevent subsequent asthma.

  • Persistent moderate to severe symptoms.

  • Patient is interested in allergy testing and/or immunotherapy.

  • Pregnancy (since the symptoms could be due to hormonal rhinitis, rather than allergic rhinitis)

  • Co-morbidities  - asthma, recurrent or chronic sinusitis, otitis media.

  • Shortness of breath, wheezing  (uncontrolled asthma).

  • Symptoms primarily unilateral nasal symptoms (polyps, foreign body, structural problem, etc.).

  • Suspected adverse effect of a prescription medication.

  • Pain in eyes (infection, iritis, etc.).

  • Persistent headache, facial pain (sinusitis, etc.).

Treatment

Non-pharmacological treatment

  • Patient education regarding allergen and irritant avoidance:

    • Central air conditioning
    • Removing dusty furniture
    • Hypo-allergenic mattress cover
    • Dehumidifier

  • Saline rinses
    • Small benefit in AR
    • Adherence difficult

  • Nasal gels
    • Small benefit in AR
    • Reduces irritation

Over-The-Counter Drug Options

Oral antihistamines

  • First line therapy for mild, intermittent AR.

  • Effective in reducing symptoms of itching, sneezing, and rhinorrhea.

  • First generation and older second generation antihistamines have little effect on nasal congestion. Fexofenadine and desloratadine have some decongestant activity.

  • May also reduce symptoms of allergic conjunctivitis associated with AR..

  • Little or no benefit in other forms of rhinitis (eg, vasomotor, infectious).

  • Effective on an as needed basis, but work best to control AR symptoms when taken regularly.

  • When exposure to an allergen is anticipated, antihistamines can be administered as prophylaxis 2 - 5 hours prior to exposure.

Decongestants

  • Oral and nasal decongestants are effective in reducing AR-induced nasal congestion.

  • Can be used in combination with antihistamine and intranasal corticosteroids.

  • Long term use may be required in AR so intranasal decongestants are generally not recommended. If used, limit duration to 3 - 7  days to prevent rebound congestion.

  • Avoid use in children under 6

Mast-Cell Stabilizer

  • Sodium cromoglycate - less effective than nasal corticosteroids;  4 - 7 days to onset of activity; full benefit several weeks.

Intranasal corticosteroid

  • Triamcinolone acetate (Nasacort®) is available.  Two sprays in each nostril once daily for adults; 4-11 years old use 1 spray in each nostril once daily.
  • Fluticasone Proprionate 50mcg / dose is now available is an OTC preparation.  Two sprays, each nostril, once daily.  Can use one spray in each nostril once daily once symptoms controlled.


Prescription Drug Options

Intranasal corticosteroids (INCS) (Table 1)

  • Note:  Fluticasone is now available OTC, and is not eligible for billing the assessment fee.
  • Drugs of choice for moderate to severe intermittent symptoms or mild persistent rhinitis.[Grade A recommendation (consistent high-quality evidence)].

  • Control the four major symptoms of AR -  sneezing, itching, rhinorrhea and nasal blockage -   may also improve ocular symptoms.

  • Superior to oral and intranasal antihistamines, antileukotrienes and cromolyn  in relieving AR symptoms.

  • A combination of antihistamine and INCS is needed in 50 % of patients to adequately control symptoms.

  • Available prescription products: beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone furoate, fluticasone propionate, mometasone. (See Table 1 below).

  • No evidence that any one agent is more effective than the other.

  • Considerations in choice of product: 

    • aqueous solution provides better intranasal deposition than dry powder

    • products with polyethylene glycol (flunisolide) have a moisturizing effect
    • patient preference for scented (formulations containing phenylethyl alcohol) versus non-scented products

    • newer products (ciclesonide, mometasone) have a smaller spray volume

    • convenience of once daily dosing versus multiple daily doses

    • cost

    • pediatric dosing limits vary, see table 1
  • An unobstructed airway is necessary for optimal effect. Use of a intranasal decongestant spray prior to the intranasal corticosteroid for first 2 – 3 days of therapy may be recommended to improve deposition of the corticosteroid.

  • Prescribe maximum dose to start, then taper dose at intervals of one week to the lowest effect dose. Some patients can be adequately controlled with one dose every other day or as needed dosing.

  • Can be dosed as-needed  in seasonal AR but regular use is likely to provide better symptom relief.

  • Well tolerated: some nasal irritation or nose bleeds possible if spraying on septum.  Minor headache in some.
  • For adults, once daily dosing in the evening is suggested since inflammation is usually more severe at night.

  • Pregnancy: Refer pregnant patients to MD. Note that INCS are not effective for hormonal rhinitis in pregnancy (nasal congestion without any signs of upper respiratory infection or known allergic cause).  If the patient has previously diagnosed allergic rhinitis, treatment with antihistamines and/or intranasal corticosteroids is considered safe.

  • Lactation: Use of nasal corticosteroids while breastfeeding is considered acceptable. 

  • Children: Mometasone or fluticasone recommended because systemic absorption is minimal and there is no evidence of growth suppression with long-term use. Once daily dosing in the morning is preferred as this appears to reduce risk of growth suppression.

Other prescription drug options for AR (physician prescription required)

  • Intranasal ipratropium - decreases rhinorrhea but little effect on congestion - may be useful for vasomotor rhinitis.

  • Leukotriene receptor antagonists  - montelukast  has modest effect, approved for AR when other agents are ineffective or not tolerated.

  • Intranasal and ocular antihistamines.

  • Short course of prednisone for severe symptoms.

  • Immunotherapy.

 

TABLE 1: Intranasal corticosteroids

DrugAdult DosePediatric Dose

Beclomethasone
50 ug/spray *

2 sprays in each nostril BID
Max: 12 sprays/day

> 6 yrs: 2 sprays in each nostril BID
Max: 8 sprays/day

Budesonide
Susp:64 ug/dose
Pwdr: 100 ug/dose

Susp: 2 sprays in each nostril daily or 1 spray in each nostril BID
Pwdr: 2 applications in each nostril AM or 1 application in each nostril BID
Max: 400 ug/day

> 6 yrs: As per adults

Ciclesonide
50 ug/spray

2 sprays in each nostril daily
Max: 200 ug/day

> 12 yrs: As per adults

Flunisolide
25 ug/spray

2 sprays in each nostril BID
Max 400 ug/day

> 6 yrs: 1 spray in each nostril TID
Max: 150 ug/day

Fluticasone propionate◊
50 ug/spray *

2 sprays in each nostril daily
Max 400 ug/day

> 12 yrs: As per adults
4 - 11 yrs: 1-2 sprays in each nostril daily. Max 200 ug/day

Fluticasone furoate
27.5 ug/spray

2 sprays each nostril daily
Max: 110 ug/day

> 12 yrs: As per adults
2 – 11 yrs: a spray in each nostril daily. Max: 110 ug/day

Mometasone
50 ug/spray

2 sprays in each nostril daily
Max: 800 ug/day

> 12 yrs: As per adults
3 – 11 yrs: 1 spray in each nostril daily.
Max 100 ug/day

* Formulation contains phenylethyl alcohol which has a floral scent; ** Available with or without phenylethyl alcohol

◊ Now available as an OTC product.  Private insurance may not cover, and you cannot bill the assessment fee if choosing fluticasone.

    Advice / Monitoring

    Provide verbal and printed instructions on use of INCS:

    • Use of saline spray to clean nose  prior to corticosteroid if the nose is crusted or contains mucus.

    • Spray should be directed away from the nasal septum.

    • Small sniff after spray to pull it into the higher parts of the nose. Avoid a strong sniff as this will draw medication down into the throat.  

    • Holding the other nostril closed with a finger may improve ability to draw the spray into the upper nose.

    • Spit out medicine that drains into the throat.

    Assess benefit after 1 - 2 weeks

    • Symptomatic relief within 1 - 2 days; may take up to 2 weeks for maximum benefit. (For INCS)

    • If not effective, assess compliance and administration technique.

    • If being used appropriately but not effective, refer to appropriate healthcare practitioner for further evaluation of condition.

    • If partially effective, consider adding antihistamine; reassess  in 1 -2 weeks.

    • If symptoms are controlled, consider tapering to maintenance dose.  If the patient requires year-round therapy, refer to their doctor.

    Assess for adverse effects 

    • Drowsiness (if using an antihistamine): Instruct patient to take at bedtime, or switch to less sedating agent, or switch to an INCS.

    • Frequent nose bleeds: ensure patient is directing spray away from septum.
    • Persistent nasal irritation: Switch to a different INCS, or add a moisturizing nasal gel or spray.

    • Change in vision - refer to appropriate healthcare practitioner (glaucoma, cataracts).

    Allergic Rhinitis Products

    Generic Name

    Beclomethasone

    50ug/dose AQUEOUS NASAL SPRAY

     

    Budesonide

    64ug/dose NASAL SPRAY

    100ug/dose NASAL SPRAY

    100ug/dose POWDER FOR INHALATION

     

    Ciclesonide

    50ug/dose METERED DOSE NASAL PRAY

     

    Flunisolide

    25ug/dose NASAL SOLUTION

    Fluticasone Furoate

    27.5ug/dose NASAL SPRAY

     

    Mometasone Furoate Monohydrate

    50ug/dose AQUEOUS NASAL SPRAY
     
    Prescribing and Billing Details
    • pseudoDIN: 00951090
      • May bill 4 claims per 365 days per patient

    • May prescribe sufficient quantity for patient's allergy season (but only one assessment fee applicable).
      • Ensure patient is having adequate response before giving refills 
      • If the patient requires year-round therapy, must refer to their doctor.

    • Only products with an official indication from Health Canada for allergic rhinitis are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing.
      • Fluticasone has been removed from the list, since it is now available OTC.  If you choose this product for a patient, you cannot bill an assessment fee.
    Treatment Flowchart
    Pharmacist Assessment Documents
    References / Suggested Reading
    1.  Keith P. Allergic Rhinitis.  In RxTx - CTC online. Available at www.e-therapeutics.ca (by subscription).
    2.  Kendrick J. Allergic Rhinitis. In RxTx - CTMA. Available at www.e-therapeutics.ca  (by subscription).
    3.  Sheikh J. Allergic Rhinitis. In Emedicine. Available at  http://emedicine.medscape.com/article/134825-overview (free access).
    4.  C-Health. Allergic Rhinitis Fact Sheet. Available at www.chealth.canoe.com  (free access).
    5.  Intranasal corticosteroids chart. RxFiles Charts. Available at www.rxfiles.ca .
    6.  Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1-43. Available at http://www.ncbi.nlm.nih.gov/pubmed/25644617.
    7.  The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clinic Immunol  2008;122:S1-84  (American guidelines). Available at www.aaaai.org  (free access).
    8.  deShazo R, Kemp S. Pharmacotherapy of allergic rhinitis. In UpToDate online. Available at  www.uptodate.com (by subscription).
    9.  Allergic rhinitis. In Dynamed online. Available at www.dynamed.com  (by subscription).

    Prepared by medSask.
    Reviewed by Dr. L. Sandomirsky, Family Physician and Dr. J. Taylor, Professor, College of Pharmacy and Nutrition,
    Funded by the Saskatchewan College of Pharmacists
    Posted May 2010, Updated Feb 2017