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My otorhinolaryngologist (hereafter "doc") prescribed Flonase spray. He explained that it should reduce my nasal congestion and retard the growth of polyps. I followed his advice and used this product, but I never noticed any benefit from it. Then a correspondent told me that his doc told him that there is a problem with the delivery system (a hand-actuated pump spray, hereafter "spray") for Flonase -- the active ingredient (fluticasone propionate, a steroid) is not delivered far enough up the nose to be effective against the sort of inflammation and polyps that he and I have. I assume that this product is effective for the sorts of nasal allergies that many people have (so called "hay fever"), because it sells well. My correspondent told me that his doc prescribed the Rhinocort Nasal Inhaler for him and that it worked well. I asked my doc to write me a prescription for this product. He first gave me Rhinocort Aqua, a water-based product that delivers a metered dose of the drug by spray. I noticed no effect of this product. After explaining that I wanted to try a "puffer," I obtained a prescription for the Rhinocort Nasal Inhaler. This is an aerosol that delivers a metered dose of the steroid (budesonide). Unlike the steroid sprays, the Rhinocort Inhaler did help me somewhat (but not enough to keep my sense of smell without also using a systemic steroid, Kenalog by injection), so I used it on a regular basis until it was discontinued by the manufacturer. On the 31st of August, 2002, I got a letter from my pharmacy advising me that the Rhinocort Nasal Inhaler would become unavailable in early 2003, and it was. The propellant (chlorofluorocarbons) used in nasal inhalers can cause depletion of ozone, and the U.S. FDA has ruled that using CFCs in metered-dose steroid human drugs for nasal inhalation can no longer be considered to be essential, and thus these products must be discontinued. Of course, pharmaceutical firms could change to a different propellant -- at least one alternative propellant has been developed by 3M Corp., which has licensed its new technology to drug maker Schering-Plough -- but 3M wants to recoup the costs of developing this new propellant, and some of the pharmaceutical firms do not want to pay big bucks for using it -- see Glaxo Wellcome vs 3M. A correspondent from Singapore advised me that his doctor prescribed for him the Rhinocort Turbuhaler. Like the discontinued Rhinocort Inhaler I have used, this product delivers budesonide powder. It is used both for asthma and the treatment of nasal polyposis, but appears not to be available in the US. It is available in Canada. After the Rhinocort Inhaler was discontinued, I switched to the Nasacort Inhaler. The steroid in Nasacort is Kenalog (triamcinolone acetonide), the same drug that gives me long-term relief when injected deep into muscle. Although the Nasacort inhaler did irritate my nose a bit (made it itch for a few minutes, stimulating sneezing), it was effective -- but it too was pulled off of the market. In June of 2003 I got a letter from my pharmacy advising me that the Nasacort Inhaler would no longer be available. Damn. I shifted back to Flonase, which may be better than nothing. In June of 2004 correspondent Dale advised me that the Nasacort HFA Inhaler has been approved by the FDA. This new product uses hydrofluoroalkane (HFA), rather than chlorofluorocarbons (CFCs) to propel the dry steroid into the nasal chamber. I believe this is, in fact, the delivery system developed by 3M. I am hoping to be able to use this new product, if my health plan's drug Nazis will allow it. I wish budesonide (Rhinocort) would become available in an HFA inhaler. Another of my correspondents, JY from South Africa, told me in May of 2002 that his physician had started him on a new product, Flixonase Nasules. The active ingredient is the same as in Flonase spray, but it is delivered as a nose drop rather than as a spray. A device called a "nasule" is used to deliver a metered dose of the drug. Each nasule contains 400 mcg of fluticasone propionate. JY administers this drug by hanging his head over the side of the bed and squeezing 200 mcg into one nostril and then the remaining 200 mcg into the other -- this is twice the dose you get with two sprays of Flonase. According to the manufacturer, this method of delivery places the drug well into the nasal cavity rather than just at the front of the nose like sprays do. Although Flonase spray did not help JY, he reported to me that Flixonase Nasules worked marvelously for him. JY told me that use of these nasules restored his sense of smell and that after using these nasules "I went to see the doc for a checkup and he said he can see parts of my sinuses he has never seen before (I've been going to this doc for about four years)." Regretfully this product is not available in the United States. When I search for it on the web, most of the pages on which I find it mentioned are "pharmacy benefit exclusion pages," that is, pages that list the drugs that the Health Insurance Nazis disallow. I did find mention of Flixonase nasules in the Primary Care Journal Watch (1999, May), issue 32, page 3. Here it said "Another formulation of fluticasone - it is now available in a new drop formulation specifically designed for the treatment of nasal polyps. The company claims that by using Nasules(tm) a controlled dose of steroid is delivered into the nasal cavity, unlike sprays which mainly deposit the drug at the front of the nose. In the promotional material the company cite a placebo-controlled study which showed that the active drug was associated with a statistically significant increase in morning peak nasal inspiratory flow over a 12-week period. The contents of one nasule (400mcg fluticasone) should be instilled once or twice daily: which means that it costs between £13.48 and £26.96 to treat one patient for a month." In the Journal of Allergy and Clinical Immunology (2005, 115, 1017-1023) A. A. C. Aukema, P. G. M. Mulder, and W. J. Fokkens reported "Treatment of nasal polyposis and chronic rhinosinusitis with fluticasone propionate nasal drops reduces need for sinus surgery." In other words, these nasules were effective in providing relief and reducing the need for sinus surgery. I found manufacturer's information at the UK site for GSK. Another correspondent, ER from the UK, told me that her doc advised that a spray formulation was of little use and put her on fluticasone nasules. She added that another alternative was the use of betamethasone nose drops, which are available in the UK. Of course, these too are not available in the USA. Another of my correspondents told me that her doctor put her on dexamethasone drops that were designed for use in the eyes or ears. She reported that this treatment was successful in restoring her sense of smell. A correspondent from Pennsylvania told me that his doc had modified a nasal inhaler so that it could be fitted with a canister of Flovent 110. Flovent 110 is designed to be used for oral inhalation (for asthma), not nasal inhalation. It delivers a metered dose of 110 mcg of fluticasone. The propellants used in this inhaler are chlorofluorocarbon propellants (trichlorofluoromethane and dichlorodifluoromethane), like those in the nasal inhalers that have been phased out. I wrote the doctor asking for details or a reference, but he never replied. A member of the Smell Disorders Group at Yahoo got her ENT to prescribe an asthma inhaler which she then adapted for nasal use. See her post and the beclomethasone inhaler that she used. Several correspondents also noted that the effect of any of the nasal steroids waned with time, but if they switched to a different nasal steroid then it would be effective for a while. In the Spring of 2003 a new subscriber to the anosmia group at Yahoo reported that the steroid nasal sprays Flonase and Nasonex did not help her, but that the Nasacort Inhaler did restore her sense of smell. She then lamented that the Nasacort Inhaler was no longer available in Canada, pulled from the shelves because it contains CFC's. She is trying the Rhinocort Turbohaler now, which she said delivers the powdery drug by the power of one's inhalation, with no propellant, CFC or otherwise.
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