Pregnant women

In women with asthma in whom effective management of allergic rhinitis is likely to help control asthma, the potential benefits of using INCS might outweigh concerns about potential treatment-related adverse effects.

• Intranasal budesonide spray is rated Category A for pregnancy*, and can be considered for use by pregnant women where necessary. Other INCS (beclomethasone dipropionate, fluticasone propionate, mometasone furoate) are rated Category B3.*
• Intranasal antihistamines levocabastine (Livostin) and azelastine (Azep) are classified Category B3.* Avoid deliberate use in pregnancy, but reassure women who have inadvertently taken them short-term during the first trimester that this exposure is unlikely to harm the foetus.
• If a non-sedating oral antihistamine is required during pregnancy, loratidine (Claratyne) is appropriate (Category B1).*

Lactation*²⁸

• Intranasal azelastine should be avoided
• Intranasal corticosteroids (budesonide, fluticasone, mometasone, triamcinolone) may be used.
• Ipratropium may be used
• Newer, less sedating oral antihistamines may be used.

Young children

Intranasal corticosteroids are appropriate first-line treatment in children with moderate-to-severe intermittent allergic rhinitis or persistent allergic rhinitis. Intranasal corticosteroids are more effective than antihistamines²⁹ or leukotriene receptor antagonists³⁰ in children.

• Mometasone furoate nasal spray can be used in children over 3 years old; budesonide nasal spray can be used in children over 6 years old*
• Growth rate in children does not appear to be affected by treatment with newer intranasal INCS.^{31, 32}

Oral antihistamines are appropriate first-line therapy in children with mild allergic rhinitis or intermittent allergic rhinitis.

• Newer (less sedating) oral antihistamines e.g. cetirizine (Zyrtec), loratadine (Claratyne) are appropriate first-line treatment in very young children. There is a large body of safety data supporting the use of cetirizine in very young children.³³ Cetirizine and loratidine can be used in children over 1 year old. Fexofenadine (Telfast) can be used in children over 6 years old.
• Older (more sedating) antihistamines should be avoided.
• Topical antihistamines should be used with caution in children under 5 years old.*

Patients with allergic rhinitis and asthma

• The use of INCS for allergic rhinitis might help improve control of asthma.¹³
• Concurrent treatment with INCS and ICS does not appear to affect function of the hypothalamic–pituitary–adrenal axis, based on studies of fluticasone propionate.³⁴ Consider the total corticosteroid dose, especially in children.
• In children with asthma and allergic rhinitis, treatment guidelines for both conditions should be followed concurrently, according to severity.³⁵

*Refer to Approved Product Information and for individual agents.

Practice points

• Many children do not tolerate intranasal medications. Oral antihistamines may provide an alternative with better adherence.
• In children with asthma and allergic rhinitis, do not hesitate to prescribe INCS and ICS concurrently.
• For children using high-dose ICS for asthma, choose lower-bioavailability INCS formulations (e.g. budesonide, mometasone or fluticasone).^{24, 36}