If I had a nickel for every patient that uses a nasal spray
but cannot recall the name, I’d be a gazillionaire. “You know, doc,” is a common reply, “the
spray they have at the store for noses.”
Thus, the reason for Thomas Jefferson—the guy on our 5 cent piece—in the
title picture.
In the world of nasal sprays, there are lots to choose,
perhaps too many. What once was
available by prescription only are now over-the-counter (OTC). Scan the medicinal aisle in a store and
you’ll probably scratch your head, musing, “Hmm…what to use, what to use…” So what should you use? Below is a short synopsis of the different
sprays and their reasons for being.
But first, let’s talk about symptoms, in other words,
the specific conditions or sensations that one is experiencing.
Nasal congestion:
This is a rather vague term used differently by different folks, ranging
from a sense of fullness or pressure in the nose or face to a sense of nasal
stuffiness or plugging. A few patients I’ve
seen used “congestion” to describe a “fogginess” in the head, with an inability
to concentrate. It’s important to drill
down what the patient means by this term.
Most ENTs define congestion as impaired breathing through nose, a result
of swollen (congested) soft tissue inside the nasal passages.
Rhinorrhea is nasal drainage, namely a “runny” or
dripping nose. The type of rhinorrhea
can vary from loose and watery, to thick and discolored (i.e., yellow, brown,
green, bloody or a combination of each).
Postnasal drainage is similar to rhinorrhea, although
in the other direction. The back of the
nose communicates freely with the throat, and thus nasal drainage can run
backwards and down the throat. This
often causes throat clearing, throat irritation or itching or cough.
Nasal pruritis is the fancy medical term for “nasal itching.” This also can lead to sneezing—a means for
the nose to blow out unwanted allergens or irritants.
Sinus pressure, pain, headaches are exactly what they
mean, and often we most dive further into a patient’s history to have them more
specifically describe the location of quality of such symptoms since they often
are quite vague. The sinuses
are airspaces in the skull that drain into the nose. Blockage of these openings can lead to sinus
headaches or facial pain.
Let’s get down and dirty to the different types of nasal
sprays out there. But, as always, some
words of caution:
Note: this is not an
exhausted discussion of nasal sprays and their side-effects, risks, drug
interactions and so forth. Naturally,
you should discuss these issues with your doctor, check product information, particularly
if you have other medical problems or taking other medications from chronic
health problems.
NASAL DECONGESTANTS SPRAYS:
Nasal decongestant sprays shrink the mucosa by a process of vasoconstriction. Vaso=vessel and constriction = narrowing or
shrinking the diameter of the vessel.
Hence, the blood vessels that supply the nasal tissue are narrowed to reduce
blood flow to the target tissues. These
sprays are meant for very short-term use only, for instance, to relieve nasal
congestion from a cold or allergy flare-up.
These also can prevent a sinus-related headaches or onset of a sinus
infection by improving ventilation to and from the sinuses. If noticing facial pressure with nasal
congestion, using these sprays may be helpful to alleviate both. They have a quick onset of action, typically
within minutes. Also, for those who have
nasal congestion and/or ear pain when flying, these sprays can be helpful when
used prior to onset of the flight (especially with descent and landing of the
aircraft).
The generic names of these OTC decongestant sprays are oxymetazoline
and phenylephrine. The common
brand names are Afrin® and Neo-synephrine®, respectively. However, there are a variety of OTC sprays
with different names that contain these ingredients, so in purchasing these,
carefully review the fine print under Active Ingredients.
BEWARE!!!: These
sprays are meant for short-term use only.
Use them for no more than three days in a row. Otherwise, they can lead to rhinitis
medicamentosa, a dastardly condition also known as rebound congestion,
where the nasal tissues no longer respond as well to the nasal decongestant spray,
becoming congested shortly after the vasoconstriction wears off. Often the congestion from rhinitis
medicamentosa is worse than the initial congestion which prompted the use of
the spray in the first place. So again,
be careful, short-term use only.
SIDE NOTE: Cocaine
does the same thing along with anesthetizing the nasal tissues. Of course, cocaine is not available OTC, it’s
addicting, has potentially bad side effects, and in its purest form it’s extremely
expensive since it’s, well…illegal. I mention
it here since we often use cocaine (legally, but in a dilute 4%
solution) for nasal and sinus surgery.
Its vasoconstrictive properties reduce intraoperative bleeding and can
help with postoperative pain.
NASAL STEROID SPRAYS:
Nasal steroid sprays reduce the inflammatory
response caused by allergens or irritants.
The spray in turn reduces swelling of the mucosa that leads to nasal
congestion, drainage and itching. I’ve
listed two of the more common ones with their directions for use:
Fluticasone (brands are Flonase®, Allerflo®
(Kirkland-Costco):
Ages 4-11 years old:
1 spray each nostril once a day
Ages 12 years and older: 2 sprays each nostril once a day
Triamcinolone
(brand is Nasacort®):
Ages 2-11 years old:
1 spray each nostril once a day
Ages 12 years and older: 2 sprays each nostril once a day
Contrary
to what many people believe, nasal steroids do not have quick onset of action
like the nasal decongestant sprays. You
must use these sprays for at least two weeks consecutively; they will not work
right away. Start these sprays two weeks
prior to your peak season when you tend to have problems. Afterwards, if you are noticing improvement,
go ahead and decrease to one spray a day.
If this still keeps the nose open, then try using it every other
day. In children, consider decreasing to
one spray every other day after two weeks, and if symptoms remain improved,
then every 2-3 days.
CHROMIUM
SODIUM:
Chromium
sodium (NasalCrom®) spray is also used for allergies, but is more of a
preventative spray. It works by
stabilizing mast cells, which are part of the immune system. When activated by allergens (protein molecules
that trigger an allergic response) the mast cells release histamine. Histamine then binds to histamine
receptors (specifically, H1 receptors) in the body, causing not-so-pleasant
things such as edema (swelling), vasodilation (widening of blood vessels), increased
blood vessel permeability (which causes serum or fluid to leak into tissues)
and smooth muscle contraction (which can constrict the bronchial tubes in the
lungs—the cause of wheezing in asthma).
Chromium sodium binds to mast cells and prevents them from releasing
histamine.
NASAL ANTIHISTAMINES
Antihistamines
block the H1 receptors mentioned above.
Thus, if mast cells release histamine, the histamine molecules cannot
bind to the receptors and cause those nasty things mentioned above. Antihistamines are available in oral form
(i.e, loratadine, fexofenadine, cetirizine, and diphenhydramine) but these must
circulate through your blood to get to the targets. Antihistamine sprays work directly in the
nose with little to no absorption into the blood stream. The most common antihistamine spray is:
Azelastine
(Astelin® or Astepro®):
Ages 6-11 years old:
1 spray each nostril twice a day as needed for rhinorrhea, congestion,
postnasal drainage.
Ages 12 years and older: 1-2 sprays each nostril 1-2
times a day as needed
Azelastine
helps much more with rhinorrhea, more so than the nasal steroids. To this date, azelastine is prescription only
however. Azelastine is also indicated
for the treatment of vasomotor rhinitis (which we’ll discuss shortly).
Synergistic
combination of nasal sprays:
Sometimes
a nasal steroid with a nasal antihistamine are used together. There seems to be a synergistic action when
using them together; in other words, the effect of the combination is greater
than the sum of its parts.
Azelastine
and nasal steroid spray (i.e., fluticasone or triamcinolone): 1 spray of
Azelastine in each nostril, followed by one spray of your nasal steroid into
each nostril, 2 times a day.
Dymista®
is a combination of azelastine and fluticasone.
In my past experience, the cost of this medication was rather high
(despite it being a mix of two generic sprays).
Every time I prescribed this, it invariably was denied by the patient’s
insurance. To simplify matters and avoid
the frustration and hair-pulling time-waste trying to get pre-authorization
(which often was unsuccessful), I simply use the two sprays as above.
NASAL
ANTICHOLINERGIC SPRAY:
There
is a phenomenon called vasomotor rhinitis (VMR) which often hits people
who are older, though I’ve seen it in younger people. I sometimes suffer from this as well (though
I don’t consider myself old, but that may be just a personal
misconception). VMR causes a clear,
watery rhinorrhea, which is not triggered by allergens or pathogens such as
viruses. Oftentimes it occurs when
eating—the nose runs as a person salivates when eating. Sometimes a change in weather, or going from
one room to another with a different temperature may trigger this. I’ve experienced this during exercise or
running at times. Often there is no
trigger at all, and the nose just spontaneously runs and drips for now rhyme or
reason.
The
cause for VMR is believed to be simulation of the parasympathetic nerves in the
nasal mucosa. These nerves are
responsible for dilating blood vessels and increasing secretions from the
mucosa—thus the “runny nose” with this condition. Parasympathetic nerves also stimulate saliva
production when eating, which is the reason many folks with VMR have a runny
nose during meal time, often carrying Kleenex or tissues to the dining table. One treatment is a spray that prevents release
of acetylcholine (a neurotransmitter) from parasympathetic nerves. This anticholinergic spray is called ipratropium
bromide, which was adapted from the oral inhaler of the same name used as a
bronchodilator (to open up the bronchial tubes in the lung).
Ipratropium
bromide (Atrovent®): comes in 0.03% for longer term use, and a stronger 0.06%
for shorter term use (ie, for common cold symptoms).
Directions: 1-2 sprays up to three times a day as
needed for runny nose.
IMPORTANT
NOTE: I’ve mentioned
this before in Nasal
Sprays: Proper Technique, but I’ll mention it again. To best deliver the medications to the nose,
use the opposite hand to spray the opposite nose (i.e., right hand for the left
nose, left hand for the right). Some of the side effects of the nasal sprays
include nasal dryness, nose bleeds, sore throat, headaches. To prevent these, use nasal saline. Which then leads to our next type of nasal
spray:
NASAL
SALINE:
Nasal
saline (ie, different brands are Ocean®, Ayr®, Neil Med® bottle,
Neti Pot®) is a mild salt solution, and basically is a natural product that is
similar to what your nose normally produces.
Use 1-2 sprays each nostril 3 or more times a day to rinse and
moisturize the nasal passages. You can
also irrigate the nose, but don’t feel you must do this so vigorously such that
the solution comes out the other side.
If it does and you can tolerate it, so be it, but don’t force it too
much if it doesn’t. You can gently
irrigate or spray, and if it comes out the same side of the nose, that’s
OK. These all can be purchased OTC.
Nasal
gel (ie, Ocean®, Ayr®) is a water-based gelatinous product that keeps
the nose moist for a longer period of time.
Apply a pea-size amount 2-3 times a day to nose on both sides with clean
finger or qtip. This too is OTC.
NASAL
EMOLIENTS:
These are natural plant oils that can help to moisten and soothe
dry nasal passages. Some people of a
condition called atrophic rhinitis, which is a very dry nose, one that creates
firm crusts and thick mucous, which in turn causes nasal irritation, pain,
blockage and bleeding. This condition
can be a result of the side effects of certain medications, prior nasal surgery
(esp. when too much normal tissue is removed, resulting in turbulent nasal
airflow) and often unknown causes.
Ponaris® is an example of a nasal emollient. It comes in a bottle with a dropper. Though and OTC product, you may need to ask
the pharmacist if it is behind the counter since often this is not on display
with the other nasal sprays, or it may need to be special ordered or obtained
online. Ponaris can be used 1-3 times a
day, as needed, using as few drops as possible each time. One should use nasal saline first to rinse or
irrigate any crusting out of the nose and the apply the emollient.
That’s a brief summary of the wonderful world of nasal sprays. Sniff, breathe and enjoy.
Randall S. Fong, M.D.
www.randallfong.com
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