Treatment Option

Intranasal Corticosteroids

  • Reduce nasal blockage, rhinorrhea, sneezing, and itching
  • Onset: 12 hrs to days
    • Max Effect: 2-4 weeks
    • Most effective when used daily
  • Do not blow nose for a minimum of 10 minutes after use
  • Side effects: headache, dry nose, epistaxis, bitter taste,  nose and pharynx infections, nasal septal perforation (rare), nasal mucosal ulceration (rare)
  • Counsel patients to shake the container gently before use and to prime the medication with one spray if it has not been used for two consecutive days
    • If the medication has not been used for 14 days, reprime with two sprays
  • Do not use more often than recommended (risk of HPA axis suppression)
  • Use with caution in patients who are already immunosuppressed or those with a history of glaucoma and cataracts, or those who recently have had nasal surgery (poor wound healing)
  • They may reduce growth velocity in pediatric patients
  • OTC: Do not use for more than 6 months unless instructed by a health care provider 
  • RX: Pregnancy Category C and No lactation data available, use with caution in nursing mothers (budesonide is the exception)
  • Use with caution in children between the ages of 2 and 4

OTC

  • Administer once daily

Budesonide

  • Approved for children 6 and above
    • Dosing 6-11: 1 spray in each nostril once daily, max 2 sprays in each nostril once daily
    • Dosing >12: Maximum 4 sprays per nostril once daily

Fluticasone Propionate

  • Approved for children 4 and above
    • Dosing 4-17: 1 spray in each nostril once daily, max 2 sprays in each nostril once daily

Fluticasone Furoate

  • Approved for children 2 and above
    • Dosing 2-11: 1 spray in each nostril once daily, max 2 sprays in each nostril once daily
    • Dosing > 12: 2 sprays in each nostril once daily

Mometasone Furoate

  • Approved for children 2 and above
    • Dosing 2-11: 1 spray in each nostril once daily
    • Dosing > 12: 2 sprays in each nostril once daily

Triamcinolone  Acetonide

  • Approved for children 2 and above
    • Dosing 2-5: 1 spray each nostril once daily
    • Dosing 6-12: 1 spray in each nostril once daily, max 2 sprays each nostril
    • Dosing > 12: 2 sprays in each nostril once a day

Prescription (Rx)

Flunisolide (Rx only)

  • Approved for children 6 and above
    • Dosing 6-14: 1 spray in each nostril tid
    • Dosing > 14: 2 sprays in each nostril bid
  • Administer twice or three times daily

Ciclesonide (Rx only)

  • Approved for children 12 and above
  • Administer one dose daily per nostril

Beclomethasone Dipropionate (Rx only)

  • Approved for children 6 and above
    • Dosing 6-12: 1 spray in each nostril bid-tid
    • Dosing > 12: 1 spray in each nostril bid-qid



Intranasal Antihistamines

  • Indicated for rhinorrhea, sneezing, and nasal pruritus
  • Moderate effect on nasal congestion
  • Rapid onset (15-30 mins)
  • Side effects: somnolence, bitter taste, headache, drowsiness, rhinitis exacerbation, epistaxis, nasal mucosal ulceration (rare)
  • Counsel patients to avoid hazardous activities due to the risk of somnolence after administration
  • Pregnancy Category C
  • Lactation: No lactation data available; use with caution in nursing mothers

Prescription (Rx)

Azelastine 

  • Approved for children above the age of 12

Olopatadine 

  • Approved for children 6 and above
    • Dosing 6-11 one spray per nostril per day



2nd Generation Oral Antihistamines

    • Class side effects: headache, cough, tiredness, sore throat, nausea, dizziness, fatigue, dyspepsia
    • Each agent in this class is present in the breast milk of lactating women; drowsiness and irritability has been reported in exposed infants.  Infants should be monitored while mothers are on antihistamine therapy
  • Use with caution in children between the ages of 2 and 4

OTC

Fexofenadine

  • Dosing depends on the specific formulation; refer to the formulation for dosing information.
  • Pediatric dosing and approval age depend on the formulation; refer to the product for specific dosing.
  • The patient should avoid taking concurrently with aluminum- or magnesium-containing antacids or fruit juices within 30 min before or after taking the  drug
  • Pregnancy Category C

Loratadine

  • Approved for children 2 and over
    • Dosing children 2-5: 5 mg daily
    • Dosing children > 6: 10 mg daily
  • Side effects: xerostomia, headache, somnolence, or fatigue
  • It may be taken with or without water
  • Pregnancy Category B

Cetirizine

  • Pediatrics
    • Dosing 2-5: 2.5 mg daily, may increase to 2.5 bid or 5 daily if tolerated
  • Patients may experience sedation and should avoid activities requiring mental alertness or coordination until drug effects are realized
  • Counsel patients not to take concurrently with alcohol and other CNS depressants
  • Dosing considerations:
    • Renal Impairment
      • CrCl 11-31: 5 mg daily
      • CrCl </=10 5 mg q48h initially, increase to 5 mg daily if tolerated
      • Pediatrics:
        • CrCl 10-29: Reduce dose by 50%
        • CrCl < 10: Do not use
    • Hepatic impairment
      • 5 mg once daily
  • Pregnancy Category B

Levocetirizine

  • Patients may experience sedation and should avoid activities requiring mental alertness or coordination until drug effects are realized
  • Counsel patients not to take concurrently with alcohol and other CNS depressants
  • Pregnancy Category B

Prescription (Rx)

Desloratadine 

  • Pediatric dosing
    • Children 2-5: 1.25 mg daily
    • Children 6-11: 2.5 mg daily
  • Pregnancy category B
  • Use with caution in renal impairment
    • May need every other day dosing in these patients



Oral Decongestants

  • Mild-moderate nasal decongestant 
  • Side effects: irritability, restlessness, insomnia, tremors, increased blood pressure, tachycardia, urinary retention in BPH, headache
  • Do not use within 14 days of MAOi therapy
  • Do not use for more than one week without physician direction
  • Use with caution in patients with cardiovascular disease, diabetes, glaucoma, BPH, seizure disorders, and spinal cord disorders/autonomic dysfunction (exaggerated increase in blood pressure), and elderly patients (increased risk of side effects)
  • Avoid use with antidepressants or antihypertensive medication unless approved by a healthcare professional (risk of increased blood pressure)
  • Use with caution in children between the ages of 2 and 4
  • Do not use with other OTC stimulants

OTC

Phenylephrine 

  • Pediatric dosing:
    • Children 4-5: 2.5 mg q4h, max 15 mg/24h
    • Children 6-11: 5 mg q4h, max 30 mg24h
  • Should avoid activities requiring mental alertness or coordination until drug effects are realized
  • Pregnancy Category C
  • Lactation: It is unknown if phenylephrine reaches breast milk; caution is advised, and the risks and benefits should be weighed.

Pseudoephedrine

  • Has significant diversion potential
  • Dosing depends on the formulation; please see the specific formulation for adult and pediatric dosing
  • Take with water to decrease GI issues
  • Pregnancy Category C
  • Lactation: Pseudoephedrine is present in breast milk, and irritability and agitation have been reported in exposed infants. Pseudoephedrine may also suppress milk production. Caution is advised

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