Which Intranasal corticosteroids (INCS) to recommend? Who nose!

Which INCS do you recommend? And why? A pharmacy student recently asked if I could write about this. The short answer is, it probably doesn’t matter. After all the AMH writes, ‘All INCS have similar efficacy and onset of action, with optimum effect after several days of regular use.’ But they do differ. So if I had to tell one to recommend for real life and in exam situations, I would say mometasone. Here’s why.

INCS available in Australia. And INCS have the following 3 indications: allergic rhinitis (AR), rhinosinusitis (RS) and nasal polyps (NP). Most likely you can recommend any INCS for these 3 indications. But only one of them has all 3 LISTED as its indications. And that one is mometasone.

Beclomethasone and ciclesonide only have allergic rhinitis as it’s indication. Plus, beclomethasone requires bd dosing and nobody has time for that.

Budesonide and fluticasone have the indication of allergic rhinitis and nasal polyps. And budesonide has the benefit of being pregnancy CAT A, but INCS, in general, are considered safe in pregnancy (AMH). Plus it has the drawback of the OTC version requiring up to 4 sprays daily (starting dose: 128mcg daily. OTC strength: 32mcg/dose).

So mometasone is easier to remember in an exam situation. You can write it for 3 indications and its dosage is easier to remember. Though if you have a picky examiner, write budesonide if the patient is pregnant.What about real life?

Rhinosinusitis aka sinusitis, refers to inflammation of the nose and the paranasal sinuses. This can be acute or chronic and bacterial or viral. And it usually occurs concurrently with inflammation of the nasal mucosa (rhinitis) – this could be allergic rhinitis.

In pharmacy, you most likely will treat allergic rhinitis more than rhinosinusitis. But patients with allergic rhinitis will often have rhinosinusitis. Allergic rhinitis causes your nose to block, and that can block the sinuses.

So it makes sense that we recommend an INCS that has both allergic rhinitis and rhinosinusitis as listed indications. Also, about a third of chronic rhinosinusitis case will have nasal polyps.


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