Rhinitis

100micrograms (2 sprays) daily, increased if necessary up to 200micrograms (4 sprays) daily, dose to be sprayed into each nostril; reduced to 50micrograms (1 spray) daily, dose to be reduced when control achieved, dose to be sprayed into each nostril.

100micrograms (2 sprays) twice daily, dose to be administered into each nostril, reduced to 50micrograms (1 spray) twice daily, dose to be administered into each nostril, dose to be reduced when symptoms controlled; max 400micrograms (8 sprays) per day.

55micrograms (2 sprays) once daily, dose to be sprayed into each nostril, reduced to 27.5micrograms (1 spray) once daily, to be sprayed into each nostril, dose to be reduced once control achieved; use minimum effective dose.

Dymista nasal spray contains 50micrograms/dose of fluticasone propionate and 137micrograms/dose of azelastine hydrochloride.

1 spray twice daily, dose to be administered into each nostril.

Prescribing Notes:

For seasonal allergic rhinitis, prophylaxis should begin 2-3 weeks before the start of the pollen season and continue throughout.
Dymista (fluticasone propionate and azelastine hydrochloride) nasal spray is available for use for the relief of symptoms of moderate to severe seasonal and perennial allergic rhinitis if monotherapy with either intranasal antihistamine or glucocorticoid is not considered sufficient. For patients in whom the combination of azelastine hydrochloride and steroid nasal spray is an appropriate choice of therapy, Dymista provides the two ingredients in a single nasal spray.
There is no convincing evidence that one steroid spray is more effective or better tolerated than another. Choice of nasal spray should be governed by cost, safety and patient preference.
For 'as-required' treatment of occasional symptoms, consider an oral antihistamine.
To control frequent or persistent symptoms a corticosteroid nasal spray is the recommended first line treatment.
Compliance is essential for efficacy so patients should be counselled on the importance of regular treatment for 2-3 months and good nasal spray technique in controlling symptoms. Patients should only be referred to secondary care after an adequate trial of at least one once daily nasal spray has proved ineffective in relieving symptoms. Clinicians are directed to further information, such as Lothian RefHelp, and local guidance in Borders and Fife which may support prescribing and referral information.
If symptoms persist, consider combining an oral antihistamine with an intranasal steroid and increase the steroid dose up to the maximum licensed dose.
Failure to respond to treatment may indicate the presence of nasal polyps. These require treatment for 6-12 weeks with corticosteroid drops followed by long term treatment with a corticosteroid nasal spray.
Ipratropium may be useful in vasomotor rhinitis with watery rhinorrhoea.
Systemic antihistamines may be used alone or with topical nasal corticosteroids to control symptoms of mild allergic rhinitis.
Short term use of topical nasal decongestants may relieve congestion and facilitate penetration of topical nasal corticosteroid.
Sodium chloride 0.9% solution can be used as a nasal douche. NeilMed Sinus Rinse kit is an appropriate device with nasal irrigation sachets which may be purchased for this purpose.

History Notes

15/06/2022

East Region Formulary content agreed.

Prescribing Notes:

A pathway containing general notes on prescribing in pregnancy is available in the Obstetrics & Gynaecology chapter of the formulary.
Intranasal preparations are preferred to oral therapy for hay fever in pregnancy. For seasonal allergic rhinitis, prophylaxis should begin 1 week before the start of the pollen season and continued throughout.
If an antihistamine is required, then chlorphenamine may be prescribed in pregnancy. Cetirizine is an alternative in the 2nd and 3rd trimesters if chlorphenamine is not tolerated.

History Notes

15/06/2022

East Region Formulary content agreed.