Over-the-Counter Nasal Steroids Pros and Cons

Woman using nasal spray in bed

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Nasacort Allergy 24 Hour (triamcinolone) was the first intranasal corticosteroid nasal spray available over-the-counter (OTC) without a prescription. Soon after, Flonase (fluticasone) and Rhinocort (budesonide) also became available OTC as effective corticosteroid sprays.

Deciding whether to use a nasal corticosteroid spray or an oral OTC antihistamine like Zyrtec or Allegra can be confusing. Which is more effective? Which is longer lasting? Which causes the fewest symptoms? The choice depends largely on the type and severity of your symptoms.

Nasal Sprays vs. Antihistamines

The intranasal corticosteroids, Nasacort, Flonase, and Rhinocort, are probably the most effective OTC medications for the treatment of nasal allergy symptoms. A downside to them is that they will not work on an as-needed basis. Intranasal corticosteroids take the time to work—they may begin to give relief to allergy symptoms after about six to 10 hours, but full relief may not be obtained for days.

Antihistamines, such as Zyrtec (cetirizine), Allegra (fexofenadine) and Claritin (loratadine), on the other hand, tend to work fairly quickly, usually within a couple of hours (or less) of taking the medication. Therefore, these medications work well when taken on an as-needed basis.

Antihistamines work best for the treatment of itchy nose, itchy eyes and sneezing—and less well for symptoms of nasal congestion or a runny nose.

Of the three newer (and less sedating) oral antihistamine options, Zyrtec and Allegra work especially well in relieving nasal allergy symptoms, usually within an hour.

Claritin, on the other hand, doesn't work as well and takes about three hours to take effect. All three of these antihistamines are a good choice for spring allergy relief and are generally preferred over a sedating antihistamine such as Benadryl.

The only other medicated nasal sprays available OTC are nonsteroidal decongestants like Afrin (oxymetazoline) and NasalCrom (cromolyn).

Controversies and Considerations

Another aspect to consider is that many professional organizations of allergists, pediatricians, and otolaryngologists were against intranasal corticosteroids being made available OTC. They previously opposed the antihistamine Claritin becoming available without a prescription.

However, during the 1990s, the FDA labeled allergic rhinitis as a disease that could be recognized and treated without a healthcare professional. This means that the FDA felt that it was safe to have the general public self-diagnose and treat allergic rhinitis using OTC products.

Intranasal corticosteroids may not be as safe as antihistamines, however, and therefore the risks and benefits should be considered.

Pros

Nasal corticosteroid sprays have been available on the market by prescription for more than 30 years, with large amounts of safety data collected during that time. The most common side effects include nasal irritation, sneezing, throat irritation, headaches, and noseblood, which are usually mild.

The most concerning side effect of nasal corticosteroid use is a septal perforation, although this is extremely rare given that most people will stop using a spray once pain and nosebleeds occur.

The risk of septal perforation is increased if you spray into the middle of your nose rather than toward the outer wall of the nasal passage.

Outside of localized symptoms, intranasal corticosteroids rarely cause whole-body side effects. Studies investigating the use of intranasal corticosteroids have yet to show any evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression in which the excessive use of corticosteroids affects the body's own cortisol production.

There are some concerns about the cost of intranasal corticosteroids given that OTC brands are not covered by medical insurance. Generally speaking, the cost of seeing a doctor all but mitigates that concern. In the end, people are more likely to try an OTC spray than going through the effort of obtaining a prescription with essentially the same results.

Cons

Some medical organizations believe that OTC intranasal corticosteroids are a bad idea. The reasons are mostly related to product safety, particularly in young children and elderly adults.

There have been concerns about growth suppression in children use intranasal corticosteroids, although these effects are considered small and inconsistent. Despite this, children using intranasal or inhaled corticosteroids should be monitored by a medical professional.

The greater concern is the use of intranasal corticosteroids in the elderly who are already at risk of glaucoma. The use of nasal and oral steroids are known to increase eye pressure that contributes to the disease.

At present, there is no clinical evidence of an increased risk of cataracts in elderly corticosteroid users. While the drugs can increase the risk of osteoporosis in overused, there is no evidence that they increase the risk of fractures.

Opponents to OTC intranasal corticosteroids also believe that consumers won’t understand that this medication needs to be used routinely for it to work. Unlike topical nasal decongestants, which bring relief in a matter of minutes, intranasal corticosteroids take hours to days to work. Therefore, people might use higher doses than recommended, which may lead to more side effects.

Many of the side effects and misunderstandings of how intranasal corticosteroids work could be avoided by having these medications remain by prescription only, which allows for frequent monitoring by a healthcare professional.

A Word From Verywell

Understanding the proper use of OTC medications for the treatment of allergic rhinitis can help you avoid the potential side effects. You may want to discuss your choices with your doctor, especially if considering using them for children or older adults.

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Article Sources

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  1. Baptist AP, Nyenhuis S. Rhinitis in the elderly. Immunol Allergy Clin North Am. 2016 May; 36(2): 343–357. doi:10.1016/j.iac.2015.12.010


Additional Reading

  • Blaiss MS. Over-the-Counter Intranasal Corticosteroids: Why the Time is Now. Ann Allergy Asthma Immunol. 2013;111:316-8.
  • Friedlander SL, et al. Risk of Adverse Effects, Misdiagnosis, and Suboptimal Patient Care With the Use of Over-the-Counter Triamcinolone. Ann Allergy Asthma Immunol. 2013;111:319-22.