Over-the-Counter Nasal Steroids: Pros and Cons

Woman using nasal spray in bed

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Nasal corticosteroid sprays reduce swelling and mucus in the nasal passages to relieve sneezing, runny nose, and other allergy symptoms.

Unlike oral steroids, which treat allergy symptoms throughout the body, nasal sprays only treat nasal symptoms.

Nasacort Allergy 24 Hour (triamcinolone) was the first intranasal corticosteroid nasal spray over-the-counter (OTC) made available without a prescription.

Soon after, Flonase (fluticasone) Rhinocort (budesonide) also became available as an OTC as an effective corticosteroid spray.

Deciding whether to use a nasal corticosteroid spray or an oral OTC antihistamine like Zyrtec or Allegra can be confusing.

This article discusses the pros and cons of using OTC nasal sprays.

Nasal Sprays vs. Antihistamines

The intranasal corticosteroids—Nasacort, Flonase, and Rhinocort—are probably the most effective OTC medications for treating nasal allergy symptoms.

How Quickly Do They Work?

Intranasal corticosteroids take time to work.

They may begin to relieve allergy symptoms after about six to 10 hours, but complete relief may not be obtained for three to six weeks with daily use.

A Closer Look at Antihistamines

Antihistamines, such as Zyrtec (cetirizine), Allegra (fexofenadine), and Claritin (loratadine) work quickly, usually within a couple of hours (or less) of taking the medication.

Therefore, these medications work well when taken on an as-needed basis.

Antihistamines work best for treating itchy nose, itchy eyes, and sneezing—and are less healthy for symptoms of nasal congestion or a runny nose.

Of the three newer (and less sedating) oral antihistamine options, Zyrtec and Allegra work exceptionally well in relieving nasal allergy symptoms, usually within an hour.

On the other hand, Claritin doesn't work either and takes about three hours to take effect.

Which Antihistamine Should I Choose?

All three antihistamines are a good choice for spring allergy relief and are generally preferred over a sedating antihistamine such as Benadryl.

Another antihistamine option is Astepro (azelastine hydrochloride), a nasal spray approved for nonprescription use in adults and children over 6.

The only other medicated nasal sprays available OTC are nonsteroidal decongestants like Afrin (oxymetazoline) and NasalCrom (cromolyn).

Controversies and Considerations

Another aspect to consider is that many professional organizations of allergists, pediatricians, and otolaryngologists were against intranasal corticosteroids being made available as OTCs.

They previously opposed the antihistamine Claritin becoming available without a prescription.

However, during the 1990s, the FDA labeled allergic rhinitis as a disease that could be recognized and treated without a healthcare professional.

This means the FDA felt it safe to have the general public self-diagnose and treat allergic rhinitis using OTC products.

Intranasal corticosteroids may not be as safe as antihistamines. However, the risks and benefits should be considered.

OTC nasal decongestants should not be used for more than two days to avoid rebound nasal congestion and worsening nasal obstruction.

Pros

Nasal corticosteroid sprays have been available on the market by prescription for more than 30 years, with large amounts of safety data collected during that time.

Side effects are usually mild.

The most common types include:

  • Nasal irritation
  • Sneezing
  • Throat irritation
  • Headaches

Overuse or misuse of nasal sprays can damage the cartilage in the septum, eventually leading to nosebleeds.

Although rare, people with damaged septum cartilage who continue to use nasal sprays may develop septum perforations.

Septum perforations won't heal on their own and require surgery.

Septal perforation risk increases if you spray into the middle of your nose rather than toward the outer wall of the nasal passage.

Instead, spray one spray straight back and parallel to the hard palate and one up and out towards the eye/ear on the same side.

Outside of localized symptoms, intranasal corticosteroids rarely cause whole-body side effects.

Review of Past Studies

Studies investigating intranasal corticosteroids have yet to show evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression in which excessive use of corticosteroids affects the body's cortisol production.

What Role Will Health Insurance Play?

Insurance coverage may vary, but medical insurance providers usually do not cover the cost of OTC drugs. However, there are some exceptions for Medicare Advantage OTC cardholders.

Medicare Advantage OTC offers allowances for some non-prescription drugs, including generic fluticasone nasal sprays.

Cons

Some medical organizations believe that using OTC intranasal corticosteroids is an unwise choice—the reasons mainly concern product safety, particularly in young children and elderly adults.

There have been concerns about growth suppression in children using intranasal corticosteroids, although these effects are considered minor and inconsistent.

Despite this, a medical professional should monitor children using intranasal or inhaled corticosteroids.

Potential Risk of Glaucoma, Cataracts and Osteoporosis

The more significant concern is the use of intranasal corticosteroids in older people who are already at risk of glaucoma.

The use of nasal and oral steroids is known to increase eye pressure and contribute to the disease.

There is no clinical evidence of an increased risk of cataracts in elderly corticosteroid users.

While the drugs can increase the risk of osteoporosis if overused, no evidence exists that they increase the risk of fractures.

What Do Critics Say?

Opponents of OTC intranasal corticosteroids also believe that consumers won’t understand that this medication needs to be used routinely for it to work.

Unlike topical nasal decongestants, which bring relief in minutes, intranasal corticosteroids take hours to days to work.

Therefore, people might use higher doses than recommended, leading to more side effects.

Many of the side effects and misunderstandings of how intranasal corticosteroids work could be avoided by having these medications remain prescription only, which allows for frequent monitoring by a healthcare professional.

Summary

Nasal corticosteroid sprays can effectively reduce symptoms of allergic rhinitis, like runny nose, nasal irritation, and sneezing.

But it can take hours, days, or even weeks for their effects to set in.

Nasal sprays may cause side effects, like headache and throat irritation, but they tend to be mild. More severe side effects can also occur.

OTC nasal sprays should be used with caution in children and older adults.

Never use more than the recommended dosage to reduce the risk of side effects.

Frequently Asked Questions

  • What nasal steroid sprays are available without a presription?

    Over-the-counter steroid nasal sprays include Flonase (fluticasone), Nasacort (triamcinolone), and Rhinocort (budesonide).

  • Are intranasal corticosteroids better than oral medications for seasonal allergies?

    Nasal sprays and oral antihistamines treat allergies in different ways. Nasal steroids are sometimes preferred because they work directly on the source of the problem—the sinuses. 

    However, nasal sprays can take longer to become effective.

    It takes six to 10 hours on average before a nasal spray relieves symptoms. Antihistamines tend to work faster and start to provide relief within an hour or so.

  • Is it safe to use nasal spray like Flonase daily?

    Yes.

    Intranasal corticosteroids take time to build up in your system before they are fully effective.

    It can take three to six weeks of daily use to relieve nasal allergy symptoms completely.

3 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Brake D, Hamilton S, Bansberg S. Nasal septal perforation due to desmopressin nasal spray use. Ear Nose Throat J. 2023 Dec;102(12):NP621-NP624. doi:10.1177/01455613211026425

  2. Kaiser Permanente. Repair of nasal septal perforation.

  3. Baptist AP, Nyenhuis S. Rhinitis in the elderly. Immunol Allergy Clin North Am. 2016 May; 36(2): 343–357. doi:10.1016/j.iac.2015.12.010

Additional Reading

By Daniel More, MD
Daniel More, MD, is a board-certified allergist and clinical immunologist. He is an assistant clinical professor at the University of California, San Francisco School of Medicine and formerly practiced at Central Coast Allergy and Asthma in Salinas, California.