As-needed fluticasone furoate for allergic rhinitis appears beneficial

Abstract

Use of fluticasone furoate nasal spray on an as-needed basis for patients with moderate-to-severe, persistent perennial allergic rhinitis yielded similar improvements in nasal symptoms compared with scheduled once daily use, according to findings of a recent randomized controlled trial. “These results may not apply to other nasal steroids,” said Leslie Hendeles, PharmD, professor emeritus from the College of Pharmacy at the University of Florida, Gainesville. Fluticasone furoate (i.e., OTC Flonase Sensimist Allergy Relief—Glaxo-SmithKline) has greater affinity for the glucocorticoid receptor and has a longer duration of effect than fluticasone propionate (e.g., Flonase Allergy Relief nasal spray and various generic store names). In asthma, for example, Hendeles said that fluticasone furoate is more effective than placebo with once daily administration, whereas fluticasone propionate is no more effective than placebo when given once a day. Fluticasone propionate requires daily dosing twice a day. Allergic rhinitis is a common condition affecting nearly 50% of children and 40% of adults worldwide. Current guidelines for the management of patients with allergic rhinitis recommend the daily use of intranasal corticosteroids. However, previous data have suggested that intermittent or as-needed use of an intranasal corticosteroid may be an effective option for those with seasonal allergic rhinitis. This idea of as-needed use of therapies follows the most recent asthma guideline update. In December 2020, the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee released a focused update to its 2007 asthma guidelines. One of the biggest changes is that NAEPP now recommends that patients aged 12 years and older with mild persistent asthma use low-dose inhaled corticosteroids either once daily or as needed along with a short-acting beta-agonist. Authors of the new study, published in the Journal of Allergy and Clinical Immunology: In Practice, conducted a single-blinded, randomized controlled trial with 108 adults who had moderate-to-severe, persistent perennial allergic rhinitis. The goal was to evaluate the efficacy of as-needed use compared with daily use of fluticasone furoate nasal spray (27.5 mcg/spray). In the as-needed group, patients ad-ministered two sprays once daily for 1 week, followed by as-needed use for 5 additional weeks. In the daily group, patients used two sprays once daily for 6 weeks. Study participants were instructed to record their 24-hour reflective nasal symptoms, such as congestion, rhinorrhea, sneezing, and itching, on a daily diary card using a 4-point rating scale from 0 (no symptoms) to 3 (severe, and sufficiently troublesome to interfere with normal daily activity or sleep). The summation of the four individual nasal symptoms comprised the total nasal symptom score (TNSS). After 6 weeks, researchers found that the mean change in the TNSS from baseline was not significantly different between the two groups from the first week to the sixth week. When assessing individual symptom scores, although the daily group showed more improvement in nasal congestion and sneezing at week 6, there was no difference in nasal itching and rhinorrhea between the groups. Both groups showed similar improvements in quality-of-life scores and the as-needed group used about half as much steroid as the daily cumulative group. Adverse events were comparable in both groups. This new research supports the use of as-needed fluticasone furoate for the management of moderate-to-severe, persistent perennial allergic rhinitis as a reasonable alternative to daily corticosteroids. Since adherence is often an issue with regularly scheduled use of intranasal corticosteroids for allergic rhinitis, the concept of as-needed use may be appealing to both patients and providers as a safe and effective treatment option. Additional studies are needed to confirm the efficacy of other intranasal corticosteroids used on an as-needed basis for those with moderate-to-severe, persistent perennial allergic rhinitis.