Nasal Sprays for Allergies
ALLERGYOTC
For this part of my blog series on over-the-counter (OTC) allergy medications, I’ll be focusing on nasal sprays. If you missed my previous blog on oral antihistamines, you can find it here. As always, feel free to visit me at Wellcome Pharmacy if you have any questions about any OTC medications.
Nasal sprays are a good option for those with allergic rhinitis, the medical term for allergy symptoms associated with the inside of the nose. Using a spray is less popular than oral allergy medications because it requires us to put something up our noses and nearly always leave a strange or bitter aftertaste.
Also, most OTC Nasal sprays use a type of corticosteroid called glucocorticoids as an active ingredient, whereas oral allergy medications tend to be antihistamines. I wanted to call this out because corticosteroids tend to have higher risk of negative side effects compared to antihistamines when misused.
To help you decide on the best OTC nasal spray for your allergy symptoms, I've created the following table.
As with oral antihistamines, there are no lack of options to choose from. As with my previous blog, I've provided answers to some of the more common questions that I have been asked relating to nasal sprays:
Why can’t I use corticosteroid nasal sprays (Flonase, Nasacort, Nasonex, budesonide) long term?
To be fair, all of the corticosteroid sprays I have listed in table are FDA approved and considered safe for most people to use at the smallest recommended dose for long periods of time. So, you will find plenty of other online resources that will state that they are safe for long term use.
My recommendation in this blog is based on a comparison with other nasal spray options and considering the type and severity side effects that is common to corticosteroids, namely:
Increased risk of infections
More potential for drug interactions
Potential decrease in children’s growth rate
Damage to inside of nose
Some people that used these nasal sprays have also raised concerns about increased risk of glaucoma due to potential increases in intraocular pressure, but the latest studies have mixed results on this.
My explanation for the seeming contradictory safety recommendations is that corticosteroids as a drug have some pretty negative side effects, but when used by patients as a nasal spray, very little should be absorbed into the bloodstream.
Unfortunately, many people don’t quite use the nasal sprays correctly allowing the drug to run down the throat and eventually into their bloodstream. If enough of it gets into the blood, side effects can come into play.
What is the proper way to use a nasal spray?
The nasal sprays I have mentioned in this blog all come in pump bottles meaning that you need to push down the “pump” mechanism for the medication to come out. When using these types of nasal sprays, I recommend following these general guidelines for best results:
1. Prime the pump
If you haven’t used the spray in a week or so, you may need to prime it. This just means you have to pump it a few times until see a mist come out.
2. Clear your nose
Any lingering mucus your nose is going to get in the way of the spray reaching the areas it needs to go. So, make sure your nasal passage Is clear by gently blowing your nose to clear things out.
3. Lean forward
The medication in nasal sprays is meant to stay in your airways and not go into your stomach. By leaning forward, any extra spray will run out of your nose rather than down your throat.
4. No need to push the tip all the way in
Many of us remember the COVID test swabs that went so deep it almost touched our brains. There’s no need to go that far with the nasal spray tip. Insert a quarter or a half inch is sufficient because you will need some space for air to flow past the tip when you inhale.
5. Close the other nostril
For many of us on the go, we prefer to do things with one hand, but proper use of nasal sprays require you to use your other hand to close the other nostril. This helps the spray goes to the right place as you inhale.
6. Inhale gently as you spray
You many have noticed that the pump on the spray bottles is not strong, so you will have to help it along by inhaling gently as you spray. The best way to do this is to exhale just before you are ready to use the medication.
7. Breath out through your mouth after spraying
Since you did all that work to make sure the medication got to the right place, pushing it all back out by exhaling through your nose would be a shame. So, exhale through your mouth the first time after you spray. You can resume normal breathing afterwards, but try to avoiding blowing your nose for at least 15 minutes after spraying.
Why does it take a week or more for some nasal sprays to fully work?
How quickly a drug works has a lot to do with their mechanism of action and their delivery mechanism. In the case of nasal sprays, most work slower because the active ingredient is a glucocorticoid. The primary way this type of drug works is by regulating gene expression, an early step in the biological processes leads to an allergic reaction.
Put it another way, using glucocorticoids is like turning off the faucet with a long hose connected to it. The water might slow down at the end of the hose, but it doesn’t immediately stop. It takes a little time for the rest of water in the hose to flow through.
Can I use both oral antihistamines and a nasal spray?
Using OTC nasal sprays with oral antihistamines is generally safe and can often provide more relief for your allergy symptoms. I wouldn’t recommend using an antihistamine nasal spray like Astepro with an oral antihistamine just because they are the same class of drug and won’t provide much additional benefit when used together.
Which nasal spray should you choose?
Just like oral antihistamines, there’s no single right answer since everyone has a fundamentally different physiology. So, I will repeat what did in my last blog and provide some general suggestions:
If your allergy symptoms tend to last for a few days or more, don’t use Afrin (oxymetazoline). It can feel like a godsend if you are extremely congested, but the rebound congestion that typically occurs after 3 days will make you feel much worse.
There’s not a lot of difference between the different glucocorticoids (Flonase, Nasacort, Nasonex, etc.) for the purposes of treating allergy symptoms. I mentioned in the table that Nasonex worked a bit better for those with running nose, but that had more to do with the other ingredients in the spray which dries out your airway a bit to keep the drug around longer.
If you want quick relief, Astepro (azelastine) is probably your best bet. If that doesn’t work, you can use it with conjunction with Flonase (fluticasone) to get more relief. The combination of those two active ingredients is actually another prescription drug call Dymista.
Many of the nasal sprays can cause a dry, burning, or stinging sensation in your nose. If that is bothering you, a common trick is to use the nasal spray right after you shower. You can also achieve the same effect by hovering your face over some warm steaming water for 5 or so minutes before using the nasal spray. Another option that often works is to use a saline nasal spray just before you use your allergy nasal spray.
If you do use one of the glucocorticoids for long periods of time, please check for any damage to the inside of your nose at least once a year. Also, if you ever get any sort of infection, you should stop using any glucocorticoid nasal sprays.