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

• Nasal spray 50micrograms/dose (£4.39 = 200 doses)

Indications and dose

• Prophylaxis and treatment of allergic and vasomotor rhinitis:
  • 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 50micrograms/dose (£8.64 = 140 doses)

Indications and dose

• Prophylaxis and treatment of allergic rhinitis:
  • Adults and children aged ≥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
  • Children aged 3–11 years: 1 spray into each nostril once daily
• Nasal polyps:
  • Adults aged 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 27.5micrograms/dose (£6.44 = 120 doses)

Indications and dose

• Prophylaxis and treatment of allergic rhinitis and perennial rhinitis: 
  • Adults and children over 12 years: 2 sprays into each nostril once daily; when control achieved reduce to minimum effective dose
  • Children aged 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 50micrograms/dose (click here for preferred brand)
• Nasal drops 400micrograms/unit dose (£15.99 = 30 unit dose)

Indications and dose

• Prophylaxis and treatment of allergic rhinitis and perennial rhinitis in children aged 4-6 years:
  • Nasal spray: 1 spray into each nostril once daily, preferably in the morning, increased to twice daily if required (maximum)
  • Beclometasone is the first-line treatment for patients over 6 years of age
• Nasal polyps in adults and adolescent over 16 years:
  • Nasal drops: 200micrograms (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).

Fluticasone propionate and azelastine hydrochloride

• Nasal spray 50 micrograms fluticasone and 137 micrograms azelastine per actuation (£14.80 = 120 dose unit)

Indications and dose

• Adults and children aged ≥12 years: Moderate to severe symptoms of allergic rhinitis only following failure of combination therapy (antihistamine and nasal corticosteroid) which has been optimised by a secondary care allergy specialist (see notes):
  • One actuation in each nostril twice daily (morning and evening).

Notes

1. Treatment must be initiated by a secondary care allergy specialist (adult immunology services, or specialists in paediatric allergy management). Initiation of treatment by other specialist services is not supported.
   1. Specialist to prescribe and assess treatment response. If the product results in a sustained reduction in symptoms primary care may be asked to continue prescribing.
   2. The initiating specialist should communicate to the primary care prescriber the expected frequency of review and how / when discontinuation of the product should be considered.
2. Fluticasone and azelastine nasal spray is not recommended for use in children below 12 years of age as safety and efficacy has not been established in this age group.
3. Pregnancy and breast feeding: The SmPC notes that there are no or limited data reported for the use of this product during pregnancy and breast feeding. Therefore, fluticasone and azelastine nasal spray should be used only if the potential benefit justifies the potential risk.
4. The routine commissioning of fluticasone propionate and azelastine combination nasal spray is accepted in Devon for the treatment of allergic rhinitis when allergy specialists have optimised treatment with standard combination therapies. (see Commissioning Policy for more details).