General Medical Information

Corticosteroids

Shawn D. Newlands

Nasal steroids are effective in controlling the four major symptoms of allergic rhinitis—congestion, rhinorrhea, itching, and sneezing. They also are effective in the treatment of some patients with nonallergic rhinitis, especially nonallergic rhinitis with eosinophilia. Nasal steroids are first-line therapy for rhinitis medicamentosa. Nasal steroids are preferred to systemic steroids because of a better side-effect profile. The benefit of these preparations is due to the low effective dosage, localized site of action, and minimal systemic circulation (approximately 2%). All of the currently used nasal steroids are metabolized rapidly once absorbed systemically, so they do not cause suppression of the hypothalamic-pituitary-adrenal axis.

Steroid nasal sprays used on an as needed basis can be as effective at managing allergen-induced rhinitis as the steroid sprays used at regular intervals (13). The most common side effect is septal irritation, which occurs mainly with use of aerosol formulations, which can be avoided by spraying away from the nasal septum. Unlike the aerosol versions, aqueous preparations elicit little to no nasal irritation or burning and are well tolerated by most patients. Symptomatic relief from seasonal and perennial allergic rhinitis usually is apparent after 2 weeks of daily use. Although the exact mechanism of nasal steroids not fully understood, one mechanism appears to be inhibition of inflammation through inhibition of phospholipase A2 protein that controls the release of arachidonic acid (the common precursor to inflammatory mediators, such as prostaglandins and leukotrienes) from membrane phospholipids. Nasal steroids must be used with caution in the treatment of children, because these agents can have a short-term adverse effect on growth. There drugs are considered second-line therapy for allergic rhinitis among children and should be used at the lowest effective dose, although overall they are considered safe and effective. Athletes are permitted to use nasal steroids, but systemic steroids are banned.

Oral corticosteroids are used to reduce edematous nasal mucosa and gain control over sinonasal polyposis before surgical excision or prolonged therapy with a nasal steroid spray. Oral administration of corticosteroids should be performed in a high burst with a rapid tapering of dosage. Prolonged use (more than 2 weeks) of oral steroids can cause substantial suppression of the hypothalamus, pituitary, and adrenal systems, and may be contraindicated in the care of patients with diabetes, tuberculosis, pregnancy, peptic ulcer, renal disease, emotional instability, or hypertension. Use of steroids can hinder detection of additional symptoms and infectious processes by masking additional sites of inflammation.

Injection of a corticosteroid, such as methylprednisolone, into the turbinate produces local antiinflammatory control with reduced systemic effects. This corticosteroid preparation must be injected slowly and submucosally with a small-gauge needle to avoid intravascular injection and blindness through retrograde involvement of the ophthalmic artery. Even with precautions, this procedure can cause cavernous sinus thrombosis and blindness and is not generally recommended. Topical steroid treatment is effective and safer.