Generic Name

Nasacort

Mechanism

• Receptor Activation: Triamcinolone acetonide binds glucocorticoid receptors in nasal epithelial cells.
• Gene Regulation: Induces synthesis of anti‑inflammatory proteins (e.g., lipocortin‑1) and represses pro‑inflammatory cytokines (IL‑4, IL‑5, IL‑13, TNF‑α).
• Resulting Effects: ↓ Vascular permeability, ↓ eosinophil migration, ↓ mucosal edema, ↓ mucus viscosity – alleviating sneezing, rhinorrhea, congestion, and itching.

Pharmacokinetics

• Absorption: Rapid local uptake; minimal systemic absorption (~0.5 % of dose).
• Distribution: Fails to reach significant plasma concentrations due to first‑pass metabolism.
• Metabolism: Primarily hepatic via CYP3A4/5; metabolic profile is similar to other glucocorticoids.
• Elimination: Excreted largely as metabolites (urine, feces); half‑life ≈ 3–4 h (local), systemic ~10–13 h.
• P‑gp Influence: Not a substrate for P‑gp; low drug–drug interaction risk.

Indications

• Allergic Rhinitis: Seasonal and perennial rhinitis in adults and adolescents ≥ 12 y.
• Nasal Polyps: Adjunctive therapy for polyposis when medical control is required.
• Rhinitis medicamentosa: Reverses congestion if used correctly.

Contraindications

• Contraindicated: Known hypersensitivity to triamcinolone acetonide or other components.
• Warnings:
• Chronic use may cause nasal septal perforation or atrophy, especially in patients with existing septal disease.
• Use cautiously in patients with uncontrolled systemic diseases (e.g., diabetes, hypertension) if long‑term or high‑dose regimen intended.
• Avoid in pregnancy unless benefit outweighs risk—C‑class but data limited.
• Potential for systemic exposure with overuse or in patients with significantly compromised mucosa.

Dosing

*Maximum of 4 sprays per nostril per day; use at interval ≥ 12 h.
• Start low, titrate: Many patients achieve control on 100 µg; escalation to 200 µg only if needed.
• Avoid over‑use: ≥ 12 sprays daily increases systemic risk.

Adverse Effects

• Common (≤1 %):
• Local nasal irritation, burning, dryness.
• Mild epistaxis or nosebleed.
• Headache.
• Serious (≤0.001 %):
• Nasal septal perforation or atrophy.
• Ophthalmic complications: increased intraocular pressure, glaucoma, cataracts (rare).
• Systemic glucocorticoid effects if high dose/long‑term: adrenal suppression, hyperglycemia, hypertension.
• Other: Rare reports of depression, insomnia, or mood changes.

Monitoring

• Baseline: Assess nasal mucosa, check for septal abnormalities.
• Follow‑up (≥3 months):
• Monitor symptom control; adjust dose or discontinue if inadequate.
• Evaluate for mucosal atrophy or bleeding.
• In chronic users: annual ophthalmologic evaluation if risk factors for glaucoma.
• Adrenal Function: If patient is on >4 weeks of high‑dose therapy or has comorbid systemic steroid use, assess serum cortisol or perform ACTH stimulation test.

Clinical Pearls

1. Start Low, Go Slow – 100 µg for most patients → reduce side‑effect profile and cost.

2. Avoid “All‑Day” Spraying – Limit use to ≤4 sprays/nostril; patient education reduces inadvertent over‑use.

3. Adjunctive Humidification – Adds mucosal hydration; beneficial in dry climates or during winter months.

4. Combination with Antihistamines – Frequently used to control late‑phase allergic symptoms—consider potential additive sedation.

5. Use in Polyps – Effective as primary medical therapy; can reduce need for systemic steroids or surgical intervention.

6. Patient Counseling – Emphasize intranasal delivery – “sneeze after use to clear excess spray.”

7. Pregnancy Consideration – While transplacental transfer is low, still classify as pregnancy category C; use only if benefits outweigh potential risks.

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• References

1. FDA Label – Nasacort (Triamcinolone Acetonide, Spray, 0.1 mg/mL) 2009.

2. UpToDate: Intranasal corticosteroids for allergic rhinitis.

3. W. H. K. Tao, *Journal of Allergy and Clinical Immunology*, 2023.