Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.
(Nasal steroid sprays or drops)
Why have you been prescribed this medication?
Your physician has prescribed this treatment because you have been diagnosed with chronic rhinosinusitis with or without nasal polyps.
Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and sinuses and intranasal corticosteroids (INCS) are the treatment of choice because they are demonstrated to have an anti-inflammatory effect. INCS might come as a nasal spray, nasal drops, or a solution to add to your nasal saline irrigation.
Drops and solutions have a higher dosage of corticosteroid medications than nasal sprays. INCS can have a beneficial effect on all of your nasal symptoms including nasal blockage, excessive nasal secretions, and reduced smell. They have an excellent safety record and they can be used on a long-term basis.
How it works
Intranasal corticosteroids have an anti-inflammatory action on the lining of the nose. Inflammation causes the nasal lining to become thickened and swollen; increases the number of cells that make mucus; and can lead to polyps being formed. Nasal steroids act to soothe the lining and reverse some of the effects of inflammation. The tissues become less swollen and there is reduced production of nasal secretions. Your symptoms should start to improve and hopefully, you will find that breathing through the nose becomes easier, your sense of smell may improve, and you have less troublesome nasal discharge. If present, they can reduce the size of nasal polyps with additional beneficial effects on nasal breathing, sinus blockage and sense of smell. These changes take time, as the body accommodates to the positive influence of steroids and gradually restores normal nasal function after months of inflammation. Therefore, nasal steroids may take quite some weeks or months before you notice their positive effects. However, most patients with CRS will notice that nasal steroids significantly improve their quality of life.
How, when and for how long you should use it
It is important to use nasal steroids in exactly the way your doctor describes, and to use them every day at the prescribed dose. Before each dose, it is helpful to rinse with saline irrigation. This helps to clear mucus and debris from the nose that might block the uptake of the medication.
If you have been prescribed a spray, shake the bottle first and point your head slightly downward, looking at your feet, as shown below. Apply one or two puffs in each nostril, as instructed, using your right hand for your left nostril and your left hand for your right nostril, while aiming the spray inside the nostril but slightly to the side - as if pointing it towards your ears. By using this technique, you can prevent the spray from landing on the cartilage in the middle of the nose (the nasal septum) and reduce the risk of nosebleeds.
If you have been prescribed nasal drops, it is recommended to tip your head back in a 90° position as shown below to allow the drops to spread into the sinuses and the higher parts of the nostrils.
It is also possible that your doctor prescribed a corticosteroid that should be added to your daily nasal saline douching. This can be in the form of drops, powder, liquid or ointments. Your doctor will have explained the process of adding this medication to your wash bottle, and always make sure the medication is thoroughly mixed through irrigation.
It is important to use your medication on a regular basis as directed by your doctor or pharmacist to gain the maximum benefit.
Using a nasal spray – head tilted forward, spray angled outwards towards ear, inhale the mist nice and gently.
Using nose drops – lie on the bed with your head tipped backwards over the end of the bed.
Side effects (and what to do if they occur)
Corticosteroid sprays do not have the same risks or effects as oral corticosteroids. This is because they have been specially engineered to target the lining of the nose only, and only a negligible is absorbed into the bloodstream.
Most side effects of nasal steroids are quite mild and related to the method of application. Dryness of the nasal lining with
crusting and nosebleeds are the most frequently reported side effects. When this occurs, just check again the instructions given above on how to effectively use the spray using the opposite hand for each nostril. Sometimes, you may need to take a brief break from the medication to allow healing and then restart with the proper technique afterwards. If case these side-effects recur, please let your doctor know as there are different spray applicators and types of steroids that can be used. Almost all patients find they can use nasal steroids with a minimum of side effects.
Adding corticosteroids to your nasal saline irrigations is a relatively new way of treating CRS and there is currently not a lot of data on the side effects of long-term use of this treatment. However, it is likely they will be broadly the same as when steroids are used directly and not added to the wash bottle.
Several scientific studies have shown that nasal corticosteroid sprays and drops do not affect the pressure in your eye or cause a cataract. But if you have pre-existing glaucoma – particularly a type of glaucoma called “closed-angle” - you should mention this to your doctor before starting this treatment.
Patient’s experience with intranasal corticosteroids
Patient 1 reports:
“Because of my problem of chronic rhinosinusitis, I use a nasal spray (INCS) that my doctor prescribed, daily; 2 puffs in each nostril. For me, it reduces very effectively the amount of nasal secretions I had been producing. For many years, I had so many secretions at the back of my throat that I had the impression that air could not pass anymore/ to lack air. Since using INCS daily, I do not have this feeling anymore. When I forget the spray, for example on holiday, the postnasal drip recurs and reminds me to restart. When I have a cold, I double the dose to prevent it from evolving into acute sinusitis. In general, I have more symptoms in winter and therefore I sometimes try to stop the INCS spray during summer.”
Patient 2 reports:
“I used to have a blocked nose, all year long, with regular exacerbations (headache and coloured secretions) for which my GP pre- scribed oral steroids. Since I started using an INCS, I can breathe better through my nose, my sense of smell is better and I have no exacerbations anymore. The use of oral steroids could be heavily reduced. I still have episodes of increased secretions, but overall, I feel a lot better controlled than before. “
Frequently asked questions
Why do my symptoms come back when I stop using the spray?
Chronic rhinosinusitis is, as the name suggests, a chronic condition and up until now, no ‘cure’ is available to avoid the need for ongoing treatment. Good symptom control can usually be achieved by using a nasal spray in the long term. Intranasal corticosteroids reduce the inflammation, but when you stop them, unfortunately, inflammation of the sinus mucosa will reappear and symptoms will recur.
Is it safe to keep using nasal sprays as they have steroids in them?
Yes, it is safe and it’s even recommended/mandatory to use them for long(er) periods. Corticosteroid sprays (and drops) contain only a low dose corticosteroids and there is only very minor uptake into the bloodstream. They do not have the same side effects as oral corticosteroids. Most reported adverse events of INCS are mild in severity and related to the application method, such as minor bleeding. See the pictures above for the recommended application method.
What should I do if I notice any blood in the mucus when I blow my nose?
Mild nosebleed or blood in the mucus is the most frequently reported side effect of the use of intranasal corticosteroid spray and is in part related to the application method. (Be sure to spray in the direction of the ears, away from the nasal midline/septum.) If this occurs, a brief break will allow the mucosal lining of the nasal septum to heal. You can just restart afterwards. In case of frequent recurrence, please inform your physician, who can prescribe a nasal ointment to smoothen and hydrate the nasal mucosa.
I’ve heard that steroids damage the lining of the nose – is this true?
No. It can sometimes cause dryness of the nasal mucosa with crusting and mild nosebleeds as a consequence. When this occurs, a brief break will allow the mucosa of the nasal septum to heal and you can just restart afterwards. In case these side-effects reoccur on a regular basis, please inform your physician, who can prescribe a nasal ointment to moisturise the nasal mucosa.