The Medical Letter. on Drugs and Therapeutics. Drug Some Formulations OTC/Rx Usual Dosage Comments Class Comments Cost 1

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1 The Medical Letter publications are protected by US and international copyright laws. Forwarding, copying or any other distribution of this material is strictly prohibited. For further information call: Last updated: April 25, 2017 The Medical Letter on Drugs and Therapeutics Comparison Table: Some Nasal Sprays for Seasonal Allergic Rhinitis Comparison Table: Some Nasal Sprays for Seasonal Allergic Rhinitis Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 H1-Antihistamines Azelastine Astelin 0.1% (Meda) generic Astepro 0.15% (Meda) generic Olopatadine 0.6% generic Patanase (Alcon) (137 mcg/spray) 200 sprays (30 ml bottle) (205.5 mcg/spray) 200 sprays (30 ml bottle) (665 mcg/spray) 240 sprays (30.5 g bottle) 5-11 yrs: 1 spray per 12 yrs: 1-2 sprays per yrs: 1 spray per 4 12 yrs: 1-2 sprays per or 2 sprays per yrs: 1 spray per Some patients complain of bad or bitter taste Astelin is also approved for vasomotor rhinitis in patients 12 years old Astepro is also approved for perennial allergic rhinitis in patients 6 years old Astelin: prime before first use by releasing 4 sprays or until a fine mist appears and reprime with 2 sprays if it has not been used for 3 days Astepro: prime before first use by releasing 6 sprays or until a fine mist appears and reprime with 2 sprays if it has not been used for 3 days Some patients complain of bad or bitter taste Patanase: prime before first use by releasing 5 sprays or until a fine mist appears and reprime with 2 sprays if it has not been used for >7 days Intranasal H1-antihistamines have a rapid onset of action Efficacy is equal or superior to that of oral H1-antihistamines Nasal discomfort, epistaxis, headache, and somnolence can occur $ e85

2 Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 Corticosteroids Beclomethasone dipropionate Beconase AQ (GSK) Qnasl (Teva) Qnasl Children's Budesonide Rhinocort Allergy Spray (Johnson & Johnson) Children s Rhinocort Allergy Spray (42 mcg/spray) 180 sprays (25 g bottle) HFA metered-dose aerosol (80 mcg/actuation) 120 sprays (8.7 g bottle) HFA metered-dose aerosol (40 mcg/actuation) 60 sprays (4.9 g bottle) (32 mcg/spray) (5, 8.43 ml bottles) (32 mcg/spray) 60 sprays (5 ml bottle) 6-11 yrs: 1-2 sprays per 5 12 yrs: 1-2 sprays per 4-11 yrs: 1 spray per 6-11 yrs: 1-2 sprays per 5,6 5,7 No generic beclomethasone dipropionate nasal sprays are available Contain alcohol, which may cause dryness Qnasl and Qnasl Children's have a strong odor and bitter aftertaste, which could reduce patient compliance and may lead to discontinuation Beconase AQ is also approved for perennial allergic rhinitis and vasomotor rhinitis in patients 6 years old Qnasl and Qnasl Children's are also approved for perennial allergic rhinitis in patients 4 years old Beconase AQ: prime before first use by releasing 6 sprays or until a fine mist appears and reprime until a fine mist appears if it has not been used for >7 days Qnasl and Qnasl Children's: prime before first use by releasing 4 sprays or until a fine mist appears and reprime with 2 sprays if it has not been used for >7 days Individual retailers may have their own generic products Lower volume per spray than Flonase Allergy Relief Rhinocort Allergy Spray and Children s Rhinocort Allergy Spray: prime before first use by releasing 8 sprays and reprime until a fine mist appears if it has not been used for >2 days Onset of action typically occurs within 12 hours, but may take 1 week to achieve maximum effect Intranasal corticosteroids are the most effective drugs available for prevention and relief of allergic rhinitis symptoms Drugs of choice for moderate-to-severe allergic rhinitis Intranasal corticosteroid sprays can decrease concomitant Mild dryness, irritation, burning or bleeding of the nasal mucosa, sore throat, epistaxis, and headache Nasal mucosal ulceration, mucosal atrophy, and septal perforation with longterm use Use in children for 12 months may slow growth rate $ e86

3 Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 Ciclesonide Omnaris (Sunovion) Zetonna (Sunovion) Flunisolide generic Fluticasone furoate Flonase Sensimist Allergy Relief (GSK) 120 sprays (12.5 g bottle) HFA metered-dose aerosol (37 mcg/actuation) 60 sprays (6.1 g bottle) (25 mcg/spray) 200 sprays (25 ml bottle) (27.5 mcg/spray) (9.9, 15.8 ml bottles) 6 yrs: 2 sprays per nostril once/d 9 12 yrs: 1 spray per nostril once/d yrs: 1 spray per nostril tid or 2 sprays per >14 yrs: 2 sprays per -tid 2-11 yrs: 1 spray per 6 x 7d, then 1-2 sprays per nostril once/d 7 No generic ciclesonide nasal sprays are available Omnaris does not contain alcohol Zetonna contains alcohol, which may cause dryness Zetonna has a strong odor and bitter aftertaste, which could reduce patient compliance and may lead to discontinuation Omnaris is also approved for perennial allergic rhinitis in patients 12 years old Zetonna is also approved for perennial allergic rhinitis in patients 12 years old Omnaris: prime before first use by releasing 8 sprays and reprime with 1 spray if it has not been used for >4 days Zetonna: prime before first use by releasing 3 sprays and reprime with 3 sprays if it has not been used for >10 days Does not contain alcohol Contains propylene glycol, which may be irritating Prime before first use by releasing 5-6 sprays and reprime if it has not been used for 5 days No generic fluticasone furoate nasal sprays are available Approved for itchy, watery eyes in patients 12 years old Does not contain alcohol Flonase Sensimist Allergy Relief: prime before first use by releasing 6 sprays or until fine mist appears and reprime if it has not been used for 30 days Onset of action typically occurs within 12 hours, but may take 1 week to achieve maximum effect Intranasal corticosteroids are the most effective drugs available for prevention and relief of allergic rhinitis symptoms Drugs of choice for moderate-to-severe allergic rhinitis Intranasal corticosteroid sprays can decrease concomitant Mild dryness, irritation, burning or bleeding of the nasal mucosa, sore throat, epistaxis, and headache Nasal mucosal ulceration, mucosal atrophy, and septal perforation with longterm use Use in children for 12 months may slow growth rate $ e87

4 Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 Fluticasone propionate Clarispray Nasal Allergy Spray (Bayer) Flonase Allergy Relief (GSK) Children s Flonase Allergy Relief Mometasone furoate generic Nasonex (Merck) Triamcinolone acetonide Nasacort Allergy 24 HR (Chattem) Children s Nasacort Allergy 24HR (9.9, 15.8 ml bottles) 60 sprays (9.9 ml bottle) 120 sprays (17 g bottle) (55 mcg/spray) (10.8, 16.9 ml bottles) (55 mcg/spray) 60 sprays (10.8 ml bottles) 4-11 yrs: 1 spray per 6 x 7d, then 1-2 sprays per nostril once/d yrs: 1 spray per 2-5 yrs: 1 spray per nostril once/d yrs: 1-2 sprays per 5,6 5,7 Individual retailers may have their own generic products Flonase Allergy Relief and Children s Flonase Allergy Relief are also approved for itchy, watery eyes in patients 4 years old Some patients complain Flonase Allergy Relief products have a light floral scent Contain alcohol, which may cause dryness Clarispray Nasal Allergy Spray: prime before first use and reprime if it has not been used for 7 days Flonase and Flonase Children's: prime before first use by releasing 6 sprays or until fine mist appears and reprime if it has not been used for 7 days Nasonex is also approved for prophylaxis of seasonal allergic rhinitis in patients 12 years old Nasonex: prime before first use by releasing 10 sprays and reprime with 2 sprays if it has not been used for >7 days Individual retailers may have their own generic products Some patients prefer taste of Nasacort over Flonase Allergy Relief or Nasonex Nascort Allergy 24HR and Children s Nasacort Allergy 24 HR: prime before first use and reprime with 1 spray if it has not been used for >14 days Onset of action typically occurs within 12 hours, but may take 1 week to achieve maximum effect Intranasal corticosteroids are the most effective drugs available for prevention and relief of allergic rhinitis symptoms Drugs of choice for moderate-to-severe allergic rhinitis Intranasal corticosteroid sprays can decrease concomitant Mild dryness, irritation, burning or bleeding of the nasal mucosa, sore throat, epistaxis, and headache Nasal mucosal ulceration, mucosal atrophy, and septal perforation with longterm use Use in children for 12 months may slow growth rate $ e88

5 Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 H1-Antihistamine/Corticosteroid Azelastine/Fluticasone propionate Dymista (Meda) (137 mcg azelastine/ 50 mcg fluticasone propionate/spray) 120 sprays (23 g bottles) 6 yrs: 1 spray per nostril bid No generic azelastine/fluticasone nasal sprays are available Onset of action typically occurs within 12 hours, but may take 1 week to achieve maximum effect Improves symptoms more than each of the individual components alone Combination may decrease concomitant Contains alcohol, which may cause dryness Mild dryness, irritation, burning or bleeding of the nasal mucosa, sore throat, epistaxis, and headache Nasal mucosal ulceration, mucosal atrophy, and septal perforation with long-term use Use in children for 12 months may slow growth rate Some patients complain azelastine has a bad or bitter taste Dymista: prime before first use by releasing 6 sprays and reprime with 1 spray if it has not been used for 14 days See H1-antihistamine class comments See corticosteroid class comments $ Mast Cell Stabilizer Cromolyn sodium generic Nasalcrom (Prestige) (5.2 mg/spray) 13, 26 ml bottles 2 yrs: 1 spray per nostril tid-qid 10 Less effective than an intranasal corticosteroid May take 1-2 weeks to achieve maximum effect Start treatment 1-2 weeks before exposure to allergen Nasal stinging and/or sneezing may occur after use Nasalcrom: no priming required None e89

6 Drug Some Formulations / Usual Dosage Comments Class Comments Cost 1 Anticholinergic Ipratropium bromide generic (21, 42 mcg/spray) 15 (42 mcg/spray), 30 ml bottles (21 mcg/spray) 5 yrs: 2 sprays per nostril qid 11 Does not relieve sneezing, itching, or congestion Also approved for perennial allergic rhinitis in patients 6 years old Dryness, epistaxis, and pharyngeal irritation Ipratropium bromide: prime before first use by releasing 7 sprays and reprime with 2 sprays if it has not been used for >24 hours None $30.00 HFA = hydrofluoroalkane 1. Approximate WAC for the smallest size bottle available.wac = wholesaler acquisition cost or manufacturer s published price to wholesalers; WAC represents a published catalogue or list price and may not represent an actual transactional price. Source: AnalySource Monthly. April 5, Reprinted with permission by First Databank, Inc. All rights reserved drug-pricing-policy. 2. Dosage for vasomotor rhinitis is 2 sprays per. 3. Lowest price available according to Accessed April 27, Dosage for perennial allergic rhinitis is 1 spray per for patients 6-11 years old and 2 sprays per for patients 12 years old. 5. A dose of 2 sprays per nostril should be used only until symptoms improve, then the dose should be reduced to 1 spray per nostril. 6. corticosteroids should not be used for >2 months/year in children <12 years old without the supervision of a physician. 7. corticosteroids should not be used for >6 months without the supervision of a physician. 8. Cost according to cvs.com. 9. Dosage for perennial allergic rhinitis is the same as the dosage for seasonal allergic rhinitis. 10. Should not be used for >12 weeks without consulting a physician. 11. Dosage of 0.06% formulation for seasonal allergic rhinitis. Dosage of 0.03% formulation is 2 sprays (42 mcg) per -tid in patients 6 years old with perennial allergic rhinitis. e90

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