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12.2.1 Drugs used in nasal allergy

Beclometasone nasal spray - 1st line
Budesonide nasal spray - 2nd line
Betamethasone drops - short term use only e.g. 4 weeks
Fluticasone furoate nasal spray - Third line option for children with allergic rhinitis with accompanying ocular symptoms (Specialist initiation)
Fluticasone nasal drops (nasules) – for chronic rhinosinusitis (with polyps)
Fluticasone + azelastine (Dymista) nasal spray - see note
Sodium cromoglicate spray
Mometasone furoate nasal spray - restricted to third-line use for perennial rhinitis/nasal polyps (after beclometasone and budesonide nasal sprays)
When considering which agent to use, first consideration is allergen avoidance.

Link to Chronic Rhinosinusitis with or without nasal polyps Guideline

Note:

Dymista is for ENT specialist use only. Patients will have moderate to severe allergic rhinitis, refractory to or intolerant of standard therapies with either a nasal steroid +/- oral antihistamines. It is expected that such patients will have troublesome symptoms negatively impacting on quality of life and daily function.

 

Topical decongestants
Nasal Itching and Sneezing -
Rhinorrhoea -
Nasal blockage +++
Impaired smell -
 +++ very effective; ++moderately effective; +marginally effective; + / - little effect; - ineffective

Notes:

1. Oral antihistamines can control mild cases of allergic rhinitis. More severe cases may require topical therapy with corticosteroid spray or sodium cromoglicate nasal spray.

2. Generally topical corticosteroids are more effective and less expensive than sodium cromoglicate, and may also be useful in non-allergic rhinitis. Adrenal suppression does not occur at recommended doses and often the dose can be reduced once initial control of symptoms has been obtained. Regular use is essential for maximum benefit.

3. Sodium cromoglicate is of some use in allergic rhinitis. Regular use is essential. Cromoglycate is inappropriate when antigen exposure is unlikely. 

For the link to the BNF section: 12.2.1 Drugs used in nasal allergy