corticosteroids (nasal)

beclomethasone: be-kloe-METH-a-sone

budesonide: byoo-DESS-oh-nide

ciclesonide: sye-KLES-oh-nide

fluticasone: floo-TI-ka-sone

mometasone: moe-MET-a-sone

triamcinolone: trye-am-SIN-oh-lone

Therapeutic Classification: corticosteroids

Pharmacologic Classification: corticosteroids (nasal)

REMS

Seasonal or perennial allergic rhinitis.
Nonallergic rhinitis (fluticasone).
Chronic rhinosinusitis with nasal polyps.

Potent, locally acting anti-inflammatory and immune modifier.

Therapeutic effects:

↓in symptoms of allergic or nonallergic rhinitis.
↓in symptoms of nasal polyps.

Absorption: Beclomethasone: 27–44% absorbed; budesonide: 34% absorbed; ciclesonide, fluticasone, mometasone: Negligible absorption. Action of all agents is primarily local following nasal use.

Distribution: Unknown.

Metabolism/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; fluticasone: 7.8 hr; mometasone: 5.8 hr; triamcinolone: 3–5.4 hr.

( 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

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 of ↑ intraocular pressure, glaucoma, or cataracts;
Recent nasal trauma, septal ulcers, or surgery (wound healing may be impaired by nasal corticosteroids);
OB: Safety not established in pregnancy;
Lactation: Safety not established in breastfeeding;
Pedi: Safety and effectiveness not established in children <12 yr (beclomethasone]), <6 yr (budesonide, ciclesonide), <4 yr (fluticasone [Flonase Allergy Relief]), or <2 yr (fluticasone [Flonase Sensimist], mometasone, triamcinolone).

Derm: rash (fluticasone), urticaria(fluticasone)

EENT: ↑intraocular pressure, blurred vision, cataracts, epistaxis, glaucoma, nasal burning, nasal congestion, nasal irritation, nasal perforation, nasal ulceration, pharyngitis, rhinorrhea, sneezing, tearing eyes

Endo: adrenal suppression (high-dose, long-term therapy only), growth suppression (children)

GI: dry mouth, esophageal candidiasis, nausea, vomiting

Neuro: dizziness, headache

Resp: bronchospasm, cough

Misc: hypersensitivity reactions (including anaphylaxis and angioedema)

Drug-drug:

Strong CYP3A4 inhibitors, including atazanavir, clarithromycin, cobicistat, itraconazole, ketoconazole, nefazodone, nelfinavir, and ritonavir, may ↑ levels and risk of toxicity of budesonide, ciclesonide, fluticasone, and mometasone.

Beclomethasone

Intranasal (Adults and Children ≥12 yr): 2 sprays in each nostril once daily.
Intranasal (Children 4–11 yr): 1 spray in each nostril once 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, ↓ to 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): 2 sprays in each nostril once daily (not to exceed 2 sprays in each nostril/day);
Intranasal (Adults and Children ≥6 yr): 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 ↑ to 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 to ↓ dose to 1 spray in each nostril once daily. Xhance: 1 spray in each nostril twice daily; may adjust to 2 sprays in each nostril twice daily.
Intranasal (Adults and Children ≥12 yr): Flonase Sensimist Allergy Relief (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 provider if need to continue >6 mo.
Intranasal (Children 4–11 yr): Flonase Allergy Relief (OTC): 1 spray in each nostril once daily; discuss with health care provider if need to continue >2 mo.
Intranasal (Children ≥4 yr): Fluticasone Rx: 1 spray in each nostril once daily; may ↑ to 2 sprays in each nostril once daily if no response; once symptoms controlled, attempt to ↓ dose to 1 spray in each nostril once daily.
Intranasal (Children 2–11 yr): Flonase Sensimist Allergy Relief (OTC): 1 spray in each nostril once daily; discuss with health care provider if need to continue >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; not to be used in children for >2 mo.
Intranasal (Children 6–11 yr): 1 spray in each nostril once daily (not to exceed 2 sprays in each nostril/day); not to be used for >2 mo.
Intranasal (Children 2–5 yr): 1 spray in each nostril once daily not to be used for >2 mo.

Beclomethasone

Nasal spray: 40 mcg/metered spray in 4.9-g bottles (delivers 60 metered sprays); 80 mcg/metered spray in 8.7-g bottles (delivers 120 metered sprays)

Budesonide

(Generic available)

Nasal spray (Rhinocort Allergy): 32 mcg/metered spray in 5-mL bottle (delivers 60 metered sprays)^OTC, and 8.43-mL bottle (delivers 120 metered sprays)^OTC
Nasal spray (Rhinocort Aqua): 64 mcg/metered spray (delivers 120 metered sprays)

Ciclesonide

Nasal suspension: 50 mcg/metered spray in 12.5-g bottle (delivers 120 metered sprays)

Flunisolide

(Generic available)

Nasal solution: 25 mcg/actuation in 25-mL bottle (delivers 200 metered sprays)

Fluticasone

(Generic available)

Nasal spray: 50 mcg/metered spray in 16-g bottle (delivers 120 metered sprays)
Nasal spray (Flonase Allergy Relief): 50 mcg/metered spray in 9.9-mL bottle (delivers 60 metered sprays)^OTC
Nasal spray (Flonase Sensimist Allergy Relief): 27.5 mcg/spray in 9.9-mL bottle (delivers 60 metered sprays)^OTC
Nasal spray (Avamys): 27.5 mcg/spray in 4.5-g bottle (delivers 30 metered sprays) and 10-g bottle (delivers 120 metered sprays)
Nasal spray (Xhance): 93 mcg/spray in 16-mL bottle (delivers 120 metered sprays)
In combination with:
azelastine (generic only).

Mometasone

(Generic available)

Nasal spray (scent-free): 50 mcg/metered spray in 17-g bottle (delivers 120 metered sprays)
In combination with:
olopatadine (Ryaltris). See Combination Drugs.

Triamcinolone

(Generic available)

Nasal spray: 55 mcg/metered spray in 6.7-mL bottle (delivers 30 metered sprays)^OTC, 10.8-mL bottle (delivers 60 metered sprays)^OTC, and 16.9-mL bottle (delivers 120 metered sprays)^OTC

Assess degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing.
- Assess for hypersensitivity reactions (anaphylaxis); if occur, implement supportive measures (epinephrine) as indicated.
- Assess for signs of adverse effects on nasal mucosa (nasal discomfort, epistaxis, nasal ulceration, Candida albicans infection, nasal septal perforation, impaired wound healing) periodically during therapy. Avoid use in patients with recent nasal ulcers, nasal surgery, or nasal trauma.
- Patients on long-term therapy should have periodic otolaryngologic examinations to monitor nasal mucosa and passages for infection or ulceration.
- Monitor growth rate in children receiving chronic therapy; use lowest possible dose.

Lab Test Considerations:

Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in chronic therapy. Children and patients using higher than recommended doses are at highest risk for HPA suppression.

Do not confuse Flonase with Flovent.
After desired clinical effect is obtained, ↓ dose to lowest effective amount. Gradually ↓ dose every 2–4 wk as long as desired effect is maintained. If symptoms return, dose may briefly return to starting dose.
Intranasal: Patients also using a nasal decongestant should be given decongestant 5–15 min before corticosteroid nasal spray. If patient is unable to breathe freely through nasal passages, instruct patient to blow nose gently in advance of medication administration.

Explain purpose and side effects of medication to patient. Advise patient to read Patient Information before starting therapy. Advise to take as directed. Take missed doses as soon as remembered unless almost time for next dose.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications.
Advise patient not to exceed maximal daily dose of nasal spray.
Educate patient on correct technique for administering nasal spray (see Medication Administration Techniques). Most nasal sprays include directions with pictures. Instruct patient to read patient information sheet prior to use. Most nasal sprays require priming before 1st use or use after 7 days. Shake well before use. Warn patient that temporary nasal stinging may occur.
Advise patient to gently blow nose to clear nostrils prior to administering dose.
Advise patient to stop medication and notify health care provider immediately if signs/symptoms of anaphylaxis (rash, hives, difficulty breathing, swollen lips or throat) or if changes in vision occur.
Advise patient to notify health care provider if symptoms do not improve within 1 mo, if symptoms worsen, or if sneezing or nasal irritation occurs.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

↓in symptoms of allergic or nonallergic rhinitis.
↓in symptoms of nasal polyps.

beclomethasone: ~~Beconase AQ,~~ QNASL,

budesonide: Rhinocort Allergy,

ciclesonide: Omnaris, ~~Zetonna,~~

fluticasone: Flonase Allergy Relief, Flonase Sensimist Allergy Relief, Xhance,

mometasone: ~~Nasonex,~~

triamcinolone: Nasacort Allergy 24 HR

beclomethasone: ~~Rivanase AQ,~~

budesonide: Rhinocort Aqua,

fluticasone: Avamys,

triamcinolone: Nasacort AQ

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆