Nasal Allergy Medications (cont.)

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Bag-like collections of fluid in the nasal membranes, called nasal polyps, are not uncommonly found in allergic rhinitis. Nasal steroids are helpful in shrinking nasal polyps and in preventing them from recurring.

Nasal steroids are available in two forms, aerosol and a spray pump (aqueous). The aerosol form resembles an asthma spray that delivers a predetermined dose of "dry" medication when activated. The more commonly used pump delivers a "water-based" spray, which may provide some moisturizing and soothing effect as well as an anti-inflammatory action. Patients who feel that the drip in their nose and throat increases when using the spray form may prefer the aerosol. In contrast, the spray is favored if the aerosol causes irritation or excessive drying of the nasal membranes.

In 1960, the first nasal steroid spray, Decadron Turbinaire, was introduced in the United States. Although very effective, too much of the drug was absorbed into the bloodstream, which resulted in side effects and limited its use. A different medication, beclomethasone (Qvar), was initially marketed in the 1970s and has been well tolerated. Others have been developed over the years, each having some variable effects on several types of cells that have a role in nasal inflammation.

Common Intranasal Steroids
Generic Name Brand Name
beclomethasone Beconase AQ
flunisolide Brands discontinued in the U.S.
triamcinolone Nasacort AQ
budesonide Rhinocort
fluticasone Flonase
mometasone Nasonex
ciciesonide Omnaris
fluticasone furoate Veramyst

Most of these intranasal steroids - budesonide, fluticasone, mometasone, ciciesonide, and fluticasone furoate - are faster acting and more potent than the other nasal steroids, with no significant difference in side effects.

The safety record of nasal steroids at the recommended dosages is excellent. Several studies conducted in the U.S., Canada, and Europe have documented the lack of significant systemic (general body) side effects. The common side effects occur locally in the nose, such as burning, stinging, dryness, and sneezing, and are usually reported with the use of dry aerosol sprays. Less common effects include headache and mild nasal bleeding. The latter can be avoided by proper spray technique. Shallow nasal ulcers are rare and can also be avoided by the use of proper technique.

Oral or injectable corticosteroids are occasionally prescribed for a few days in cases of severe allergic rhinitis with almost total obstruction of the nasal passages. In these cases, antihistamines, decongestants, and certainly nasal sprays are not likely to help. After the nasal passages have opened, however, the nasal sprays can be used to prevent further swelling.

Other nasal sprays that might help

Ipratropium bromide spray (Atrovent)

Ipratropium bromide blocks the effects of acetylcholine, which is a chemical that, among other actions, signals the mucous glands in the nose to produce mucous. Allergic reactions can trigger excessive acetylcholine activity on the mucous glands. Ipratropium bromide occupies the same receptor on the glands as does acetylcholine and in this way reduces mucous secretion because ipratropium brobide does not stimulate mucus secretion.

Ipratropium bromide is available as a spray pump and comes in two strengths. It is only effective for runny noses and can literally "turn off the faucet." The drug does not help itchy or stuffy noses and does not usually take the place of an intranasal steroid, but rather is used along with it. Typically, two sprays 3 to 4 times per day in each nostril are required to control symptoms. Once improvement is seen, the dose can often be lowered to one spray 3 to 4 times per day or two sprays 2 times per day.

Side effects of ipratropium bromide are infrequent but include dry nose, nasal irritation, and nose bleeding. If accidentally sprayed into the eyes, the drug may cause temporary blurred vision.

Ipratropium bromide nasal spray can dry up mucous, regardless of the cause. The spray may be effective in non-allergic rhinitis and even with the common cold (usually at the higher 0.06% dose).

Cromolyn sodium nasal spray (Intal, Opticrom, Gastrocrom)

Cromolyn works to reduce nasal inflammation without the use of steroids. It acts on mast cells to stabilize them, thereby preventing the release of histamine and other mediators. Since cromolyn is strictly a "controller" medication, it must be taken before allergic exposure, usually at least 2 weeks prior, due to its slow onset of effectiveness. The drug tends to be more effective in younger people with higher levels of IgE. It is given at doses of one to two sprays in each nostril 4 times per day. Cromolyn appears to be helpful in reducing runny nose, sneezing, and congestion in milder cases, but may not be effective at all in more severe cases. The medicine became available OTC in 1997. It is a particularly well tolerated medication with minimal side effects (usually sneezing, nasal irritation, or stinging. Rare cases of nasal bleeding or residual bad taste are reported.) There are no systemic, or body-wide, side effects. Cromolyn nasal spray is safe for pregnancy, lactation, and children under the age of 6 years old.

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