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.