There are no published studies showing that any one nasal steroid is more effective than any other. Aqueous sprays tend to cause less irritation.

Ensure the patient knows how to use their nasal spray effectively.

A short course of oral prednisolone 20mg – 40mg daily for 2 weeks may be helpful for extensive nasal polyposis or resistant sinusitis.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include mild to moderate hay fever/seasonal allergic rhinitis.

Many products for these conditions are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Seasonal allergic rhinitis: short term treatment, start treatment 2-3 weeks before season starts

Perennial rhinitis: long term therapy required

There is a strong link between allergic rhinitis and asthma. Both need to be treated adequately to optimise control of symptoms of either.

Systemic absorption may follow on from any nasal steroid particularly if the doses are high and prolonged:

• When children are receiving prolonged treatment with nasal corticosteroids the height of the child should be monitored. If growth is slowed then paediatric referral should be considered.
• MHRA Drug Safety Update (September 2010) Psychological and behavioural side effects may occur in association with use of inhaled and intranasal formulations of corticosteroids. All patients (or their carers) should be informed of the important benefits of steroid treatment, and should be advised of these safety issues.
• Patients should keep using their steroid medication, but should seek medical advice in the event of worrying symptoms or illness while taking steroids

Instructions on the correct use of nasal sprays

• Gently blow your nose to try to clear it
• Shake the bottle of nasal spray well
• Put the spray nozzle into the nostril
• Tilt your head forward slightly and keep the bottle of spray upright
• Squeeze a fine mist into your nose while breathing in slowly. Do not sniff hard
• Breathe out through your mouth
• Repeat this procedure for your other nostril

Beclometasone dipropionate

• Aqueous nasal spray 50 micrograms per spray (£2.37 = 200 dose unit)

Indications

• Prophylaxis and treatment of allergic and vasomotor rhinitis

Dose

• Adult and child over 6 years, 2 sprays into each nostril twice daily; maximum 8 sprays daily; when symptoms controlled, dose reduced 1 spray into each nostril twice daily

Mometasone furoate

• Nasal spray 50 micrograms per spray (£3.05 = 140 dose unit)

Indications

• Prophylaxis and treatment of allergic rhinitis
• Nasal polyps

Dose

• Allergic rhinitis: adult and child over 12 years, 2 sprays into each nostril once daily, increased if necessary to 4 sprays into each nostril once daily (maximum); when control achieved reduce to 1 spray into each nostril once daily; child 3–11 years, 1 spray into each nostril once daily
• Nasal polyps: adult over 18 years, 2 sprays into each nostril once daily, increased if necessary after 5–6 weeks to 2 sprays into each nostril twice daily (consider alternative treatment if no improvement after further 5–6 weeks); reduce to the lowest effective dose when control achieved

Fluticasone furoate

• Nasal spray, 27.5 micrograms per spray (£6.44 = 120 dose unit)

Indications

• Prophylaxis and treatment of allergic rhinitis and perennial rhinitis in adults and children over 6 years of age

Dose:

• Adult and child over 12 years, 2 sprays into each nostril once daily; when control achieved reduce to minimum effective dose; child 6–12 years, 1 spray into each nostril once daily, increased if necessary to 2 sprays into each nostril once daily; when control achieved reduce to 1 spray into each nostril once daily

Fluticasone propionate

• Nasal spray 50 micrograms per spray (click here for preferred brand)
• Nasal drops 400 microgram/unit dose (£15.99 = 30 unit dose)

Indications

• Prophylaxis and treatment of allergic rhinitis and perennial rhinitis in children aged 4-6 years. Beclometasone is the first-line treatment for patients over 6 years of age
• Nasal polyps

Dose

• Nasal spray: Child 4–6 years, 1 spray into each nostril once daily, preferably in the morning, increased to twice daily if required (maximum)
• Nasules: nasal polyps, adult and adolescent over 16 years, 200 micrograms (approx. 6 drops) into each nostril once or twice daily; consider alternative treatment if no improvement after 4–6 weeks

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Azelastine hydrochloride and fluticasone propionate (Dymista)

The routine commissioning of Azelastine hydrochloride and fluticasone propionate (Dymista) is not accepted in Devon for allergic rhinitis (see Commissioning Policy for more details). The policy indicates that in exceptional circumstances the Trust-Managed Individual Patient Treatments process can be used for this indication.