Systemic absorption may occur from any nasal steroid particularly if the doses are high and prolonged.

The CSM recommends that on the rare occasion that children are receiving prolonged treatment with nasal corticosteroids the height of the child should be monitored. If growth is slowed, then paediatric referral should be considered.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include mild to moderate hay fever/seasonal allergic rhinitis.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Beclometasone dipropionate

• Nasal spray 50micrograms/dose (£4.39 = 200 doses)

Indications and dose

• Allergic rhinitis:
  • Use one or two sprays each nostril twice daily

Notes

1. Beclometasone nasal spray should be prescribed in 200 dose containers as other sizes cost considerably more per dose.
2. Beclometasone is licensed for both allergic and vasomotor rhinitis.

Mometasone

• Nasal spray 50micrograms/dose (£8.64 = 140 doses)

Indications and dose

• Allergic rhinitis (following treatment failure of first line agent):
  • Initially 2 sprays each nostril once daily. Dose can be titrated, maintenance treatment should be with the lowest effective dose which can include 1 spray once daily

Fluticasone furoate

• Nasal spray 27.5micrograms/dose (£6.44 = 120 doses)

Indications and dose

• Allergic rhinitis:
  • Initially two sprays into each nostril once daily

Fluticasone propionate

• Nasal drops 400microgram/unit dose (£15.99 = 30 unit dose)

Indications and dose

• Nasal polyps:
  • 200micrograms (approx. 6 drops) into each nostril once or twice daily

Fluticasone propionate and azelastine hydrochloride

• Nasal spray 50 micrograms fluticasone and 137 micrograms azelastine per actuation (£14.80 = 120 dose unit) 

Indications and dose

• Adults and children aged ≥12 years: Moderate to severe symptoms of allergic rhinitis only following failure of combination therapy (antihistamine and nasal corticosteroid) which has been optimised by a secondary care allergy specialist (see notes):
  • One actuation in each nostril twice daily (morning and evening).

Notes

1. Treatment must be initiated by a secondary care allergy specialist (adult immunology services, or specialists in paediatric allergy management). Initiation of treatment by other specialist services is not supported.
   1. Specialist to prescribe and assess treatment response. If the product results in a sustained reduction in symptoms primary care may be asked to continue prescribing.
   2. The initiating specialist should communicate to the primary care prescriber the expected frequency of review and how / when discontinuation of the product should be considered.
2. Fluticasone and azelastine nasal spray is not recommended for use in children below 12 years of age as safety and efficacy has not been established in this age group.
3. Pregnancy and breast feeding: The SmPC notes that there are no or limited data reported for the use of this product during pregnancy and breast feeding. Therefore, fluticasone and azelastine nasal spray should be used only if the potential benefit justifies the potential risk.
4. The routine commissioning of fluticasone propionate and azelastine combination nasal spray is accepted in Devon for the treatment of allergic rhinitis when allergy specialists have optimised treatment with standard combination therapies. (see Commissioning Policy for more details).