Corticosteroids
A number of agents are available for reducing the inflammatory response in allergies and so preventing an attack in the first place.
Corticosteroid Nasal Sprays
Benefits of Corticosteroid Nasal Sprays. Nasal-spray corticosteroids, most commonly called steroids, are the most effective agents currently available for treating allergic rhinitis. Corticosteroids suppress important stress and other hormones in a specific region in the brain called HPA axis. This, in turn, blocks the inflammatory response that triggers an allergic attack. They do not relieve symptoms immediately but may take several hours before their effects are felt. Nasal spray steroids are proving to be safe and have the following benefits:
- They reduce inflammation and mucus production.
- They improve night sleep and daytime alertness in patients with perennial allergic rhinitis.
- They appear to be beneficial in treating polyps in the nasal passages. It is not clear if they are useful for other forms of nonallergic rhinitis, although a 2002 study with fluticasone (Flonase, Flounce) reported benefits in patients with such conditions.
Comparison studies are reporting that nasal steroid sprays are more effective than the second generation antihistamines, such as loratadine (Claritin) and cetirizine (Zyrtec), and possibly even more effective than allergy shots.They have no effect on itchy eyes, however.
Nasal-Spray Brands. Corticosteroids available in nasal spray form include the following:
- Triamcinolone (Nasacort). Approved for children over six.
- Mometasone furoate (Nasonex). Approved for use in patients as young as three.
- Fluticasone (Flonase, Flounce). Approved for children over four.
- Beclomethasone (Beconase, Vancenase), flunisolide (Nasalide), and budesonide (Rhinocort). Approved for children over six.
These agents have some differences in their effects. For example, in one 2002 study, patients preferred triamcinolone over either fluticasone or mometasone. Furthermore, in another study fluticasone reduced stress hormone levels significantly compared to triamcinolone, which might over time produce more adverse side effects. Some experts then suggest that triamcinolone may be a better first choice than others for many patients.
One caution, triamcinolone (Nasacort) and Nasonex (among others) contain a preservative, benzalkonium chloride (BKC), which may impair one of the defense systems in the nose that wards of infections. Studies are mixed, however, on whether this effect is significant. Not all preparations use BKC. For example, Rhinocort does not contain it.
Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas, and the risk for wide spread side effects is very low unless the drug is used excessively.
- Dryness, burning, stinging in the nasal passage.
- Sneezing.
- Headaches and nosebleed. These side effects are uncommon but should be reported to your doctor immediately.
Possible Long-Term Complications. Corticosteroids suppress stress hormones, which is known to produce some serious long-term complications in people who take oral steroids. Researchers have found far fewer concerns with nasal administration or inhaled forms, but there may be certain problems.
- Effect on growth. The major concern for children is whether nasal steroids, like other forms of steroids, will adversely affect growth. Studies report either only a temporary and slight (about half an inch) early effect on growth or no effect at all.
- Effect on eyes. Of some concern is the possible risk for adverse effects in the eyes, particularly glaucoma, which is a known side effect with oral steroids. Some ophthalmologists have observed higher pressure in the eye (a sign of glaucoma) in some patients taking nasal steroid sprays. (Studies have found no increased risk for cataracts in young people who have taken intranasal steroids.) All the conditions resolve after stopping the steroid, although periodic eye examinations are advised.
- Use during pregnancy. These agents are most likely safe during pregnancy, but pregnant women should discuss all options carefully before taking them.
- Nasal passage injury. Steroid sprays may injure the nasal septum (the bony area that separates the nasal passage) if the spray is directed onto it. This complication is very rare.
- Lower resistance to infection. People with any infectious disease or injury in the nose should not take these drugs until the disease or wound has been treated and cured. People should avoid steroids that have not been vaccinated or had chicken pox or measles.
Cromolyn
Cromolyn serves as both an anti-inflammatory drug and a specific blocking agent for allergens. The standard cromolyn nasal spray (Nasalcrom) is not as effective as steroid nasal sprays but is effective for many people with mild allergies. It is one of the preferred first-line therapies for pregnant women with mild allergic rhinitis. It may take up to three weeks for a person to experience full benefit.
Side Effects. Cromolyn has no major side effects, but minor ones include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. The spray can cause burning or irritation.
Leukotriene-Antagonists
Leukotriene-antagonists are oral drugs that block leukotrienes, powerful immune system factors that are important in causing airway constriction and mucus production in allergy-related asthma. The leukotriene-antagonists include zafirlukast (Accolate), montelukast (Singulair), zileuton (Ziflo), and pranlukast (Ultair, Onon). They are currently being used for asthma and are being investigated for treatment of allergic rhinitis. Evidence to date suggested that they are equal to the non-sedating antihistamines but are not as effective as the steroid nasal sprays. At this time, they do not seem to have any advantages over the current choices for allergic rhinitis.
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