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I may be simplistic but I reserve nasal steroids as a last line treatment. I used to think, steroids were wonderful. The longer I’m in the business, the less I like them. Steroids are steroids, whatever the form.
I deal with AR a lot in my practice. When I tell them it’s AR, they look horrified and cry, “But I’ve NEVER had allergies before.” All are from other places than AZ. I tell them, “You never have allergies until you have allergies. Just like you never have a heart attack until you have a heart attack.”
I treat with the second generation antihistamines first if nasal lavage has failed. I give them a list of the top three with instructions to buy the 5 pack to try as some react or don’t react based on their body chemistry. If the fail all, I suggest diphenhydramine 25mg TABLETS cut into quarters. 1 quarter q 3hrs to effect. This, in theory, gives the patient the antihistamine effect without or less drowsiness.
Then it’s nasal steroids.
I used to use kenalog IM, but have stopped due to the, what I call the “bullet effect”. If they have a bad reaction, you can’t just stop the medication as with tablets. They are going to ride it out or go to the ER.
If the Pt. is absolutely miserable and puffy eyed, clear mucous running out their nares, I’ll give them a burst dose of prednisone 20mg-50mg for 5 days.
Is any of this backed by literature, nope.
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