5.1.4. Glucocorticosteroids
Intranasal steroids (INS) as a maintenance treatment are the first
therapy of choice in moderate/severe and persistent AR, CRS and most
forms of NAR 20, 21, 60. In athletes specifically,
they have shown to reduce symptoms and improve QOL significantly for AR66. Furthermore, they are known to have a beneficial
effect on asthma symptoms 20. Interestingly, the use
of INS has been reported to revert the paradoxical increase in nasal
resistance upon isometric exercise which is seen in NAR43 and might therefore be the ideal treatment for
athletes with NAR and/or exercise-induced rhinitis.
The use of INS is presently permitted by WADA without a therapeutic use
exemption (TUE) 61. However, literature suggests that
athletes may not be fully aware of those regulations since several
studies show that athletes with rhinitis are much less adherent to their
INS compared to non-athletes; Surda showed that chronic nasal medication
was significantly less taken by elite swimmers with nasal symptoms (18
%) compared to symptomatic non-sporting controls (67 %)3 and Walker showed that elite hockey players were
much less adherent to their INS compared to non-elite players and
sedentary controls 14. Adverse effects of INS include
minor epistaxis, crusting, nasal dryness and irritation of the throat
and nose, however, most of these side-effects are transient and rarely
require stopping INS treatment, even on a long-term base.
It is worthwhile mentioning that WADA allows physicians to treat severe
AR with systemic glucocorticosteroids under the TUE rule. However, in
view of the possible side effects, indications for treating AR with oral
or depot steroids are extremely rare and preserved for uncontrolled AR
with severe symptoms not responding to any other medical therapy
including allergen immunotherapy 67.