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Allergies > Doctors: Corticosteroids
Corticosteroids
Corticosteroids are available in topical and systemic preparations.
- Topical corticosteroids are considered a highly effective first-line treatment for patients with moderate or severe allergic rhinitis and/or persistent symptoms
- Systemic corticosteroids are considered a last resort treatment in patients with severe allergic rhinitis refractory to first-line treatment
Topical Corticosteroids
Intranasal corticosteroids have been shown to be the most effective pharmacological treatment for allergic rhinitis.
Because of their good anti-inflammatory activity, poor absorption, and first-pass hepatic metabolism, second-generation topical corticosteroids are the treatment of choice in allergic rhinitis.
Mode of Action
Corticosteroids have potent vasoconstrictor and anti-inflammatory properties. They inhibit early-phase and late-phase allergic responses, and increase the threshold dose for a positive response to allergen.
Corticosteroids reduce cytokine and chemokine release, and can decrease the cellular infiltration of antigen-presenting cells, T cells, eosinophils, and mast cells within the nasal mucosa.
Efficacy
Placebo-controlled studies have demonstrated the effectiveness of topical corticosteroids in treating seasonal allergic rhinitis and perennial allergic rhinitis. They are beneficial in over 90% of patients and exhibit better overall symptom control than any other monotherapy including systemic and topical antihistamines, and topical cromoglicate.
- A meta-analysis of randomised, controlled trials found that intranasal corticosteroids were better at relieving nasal blockage, rhinorrhoea, sneezing, nasal itch, postnasal drip, and total nasal symptoms in patients with allergic rhinitis compared with oral antihistamines (the treatments were comparable for treating eye symptoms).
Topical corticosteroids typically have a slow onset of action (12 h) and maximum efficacy develops over days and weeks when used regularly. They may be used in the long-term for treating perennial allergic rhinitis and may reduce the symptoms of seasonal allergic rhinitis if taken before the pollen season begins.
Safety
Topical steroids are associated with local side effects such as dryness, irritation of the nose and throat, and epistaxis, but these are usually mild.
They can be used on a long-term basis without atrophy of the mucosa, but patients should be instructed not to spray the medication directly onto the nasal septum. This should be examined periodically to check for mucosal erosions that may precede perforations.
Systemic steroids are associated with systemic side effects including suppression of growth, of bone metabolism, and of the hypothalamic-pituitary-adrenal axis. As a result, there are concerns regarding potential systemic effects of topical corticosteroids.
In fact, older topical corticosteroids (eg dexamethasone and betamethasone) were found to exert systemic effects, but newer drugs (eg mometasone furoate, beclomethasone dipropionate, triamcinolone acetonide, flunisolide, fluticasone propionate, and budesonide) are considered safe. However, two studies have highlighted systemic effects in children given newer topical corticosteroids:
- In a randomised, double-blind, parallel-group study, 168 mg intranasal beclomethasone given twice daily for 1 year was found to suppress growth rate in children.
- Decreased bone growth was found in children given 200 mg intranasal budesonide twice daily for 6 weeks.
As a result of these concerns, it is recommended that only low doses of topical corticosteroids should be given to children and long-term treatment should be avoided. Care must also be taken with patients who have rhinitis and asthma and/or eczema and who may receive topical corticosteroids at several sites, as this increases the possibility of an additive effect and steroid-loading.
There have been case reports of increased intraocular pressure in patients taking topical corticosteroids, but in elderly patients no relationship was found between ocular hypertension or glaucoma and previous use of nasal corticosteroids.
Current Practice
Intranasal corticosteroids appear to be the most effective pharmacological treatment for allergic rhinitis, and their topical application makes them convenient to use.
They are generally recommended for adults with moderate to severe persistent symptoms. When the nose is very congested, nasal corticosteroids may not get to the mucosa, in which case a nasal decongestant or a week’s course of systemic corticosteroids may be used. Topical corticosteroids may be used with oral antihistamines.
Some health care providers have been reluctant to prescribe topical corticosteroids, particularly to children, because of potential systemic side effects. Certainly in children, therapy must be weighed against the risks of long-term treatment.
There are a number of methods by which steroid-load can be minimised.
- Dosing in the morning reduces any impact on the hypothalamic-pituitary-adrenal axis
- Once daily regimens can reduce systemic exposure compared with twice daily regimens
- It is more effective to use high doses to effectively reduce acute symptoms, and then decrease the dose to a maintenance level, rather than to use moderate or low doses throughout treatment. If acute symptoms flare up, doubling the dose for a few days can provide control without clinically significant systemic effects
- Prophylatic use may delay the onset of symptoms and decrease the need for higher dosage therapy when the pollen season begins
Patients themselves may be reluctant to comply with topical corticosteroid treatment because of confusion between anabolic steroids and corticosteroids, and the differences between oral and topical corticosteroids. It is important to explain the differences between these treatments.
Drug Information
The following table lists some common topical corticosteroids available in the US, Canada and UK. Links to prescribing information or summary of product characteristics are provided for most drugs. Only brand name drugs are given, but generic versions may be available.
| Active ingredients | Brand name and country where approved |
| Beclomethasone dipropionate |
Beconase (UK and US), Beconase AQ (US), Vancenase (US and Canada), Vancenase AQ (US) |
Budesonide |
Rhinocort Aqua (UK, US and Canada), Rhinocort (US) |
| Flunisolide | Syntaris (UK), Nasalide (US), Nasarel (US), Rhinalar (Canada) |
| Fluticasone furoate | Flixonase (UK), Flixonase Napsule (UK), Flonase (US and Canada) |
| Mometasone | Nasonex (UK, US, Canada), Elocon (US) |
| Triamcinolone | Nasocort (UK, US, Canada), Nasacort AQ (US and Canada) |
| Dexamethasone isonicotinate | Dexa-Rhinospray Duo (UK), Dexacort Turbinaire (US) |
Betamethasone sodium phosphate |
Betnesol (UK), Vista-methasone (UK) |
Systemic Corticosteroids
Systemic steroids have potent anti-inflammatory properties and are effective in controlling most symptoms of allergic rhinitis.
Because of the risk of systemic side effects, they should only be used for short-term treatment of severe allergic rhinitis, and should be avoided in children, pregnant women, and patients with known contraindications.
Please click on the relevant link below for further information on systemic corticosteroids.
Mode of Action
Corticosteroids have potent vasoconstrictor and anti-inflammatory properties. They inhibit early-phase and late-phase allergic responses, and increase the threshold dose for a positive response to allergen.
Corticosteroids reduce cytokine and chemokine release, and can decrease the cellular infiltration of antigen-presenting cells, T cells, eosinophils, and mast cells within the nasal mucosa.
Efficacy
Systemic corticosteroids are effective in the treatment of severe acute allergic rhinitis, but there is a lack of comparative studies on the preferred dose, route of administration, and the dose–response relationship.
Safety
Short-term use of systemic corticosteroids is generally well tolerated, but the risk of adverse events increases with duration of use. The side effects from 3-week courses are few and mild, but such courses may only be done once every 3 months.
The major systemic side effects associated with systemic corticosteroids include the suppression of: growth, bone metabolism, and the hypothalamic-pituitary-adrenal axis.
Other adverse events include osteoporosis, aseptic necrosis of bone, hypertension, centripetal obesity, peptic ulceration, glaucoma and cataracts, diminished immune response, impaired wound healing, diabetes mellitus, mental disturbance, and proximal myopathy.
Contraindications are glaucoma, herpes keratitis, diabetes mellitus, psychological instability, advanced osteoporosis, severe hypertension, tuberculosis, or other chronic infections. Systemic corticosteroids should be avoided in children and pregnant women.
Systemic corticosteroids are given orally or as a depot injection. Rarely, depot injections may cause a depression over the injection site owing to tissue atrophy. Depot injections into swollen nasal tubinates and polyps should be avoided as this may cause blindness. Continuous release of corticosteroids during the day from a depot injection will suppress the hypothalamic-pituitary-adrenal axis more than a single oral dose given in the morning.
Current Practice
Systemic corticosteroids may be used as a last resort for the treatment of severe allergic rhinitis in adults. Short-term courses (3 weeks maximum) are advised because of the risk of side effects. They are not recommended for use in children, pregnant women, and patients with known contraindications.
Oral administration is often preferred over depot injection because it is cheap, and the dosage can be adjusted to the changing need for treatment.
When a patient is suffering from allergic rhinitis and eczema or asthma, long-term topical corticosteroid treatment on the nose, lungs, and skin may be replaced with short-term systemic treatment.
References
van Cauwenberge P, Bachert C, Passalacqua G, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy 2000;55:116–134.
Nelson HS. Mechanisms of intranasal steroids in the management of upper respiratory allergic diseases. J Allergy Clin Immunol 1999;104:S138–S143.
Virant FS. Allergic rhinitis. Immunol Allergy Clin North Am 2000;20:265–282.
Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317:1624–1629.
Scadding GK. Corticosteroids in the treatment of pediatric allergic rhinitis. J Allergy Clin Immunol 2001;108:S59–S64.