Episode 11 - Nose sprays

Kara Wada, MD: Are you using nasal sprays for your allergies but not getting the relief you expected? You might be making one of these common mistakes that we see as allergists all the time. Nasal sprays are a really powerful tool for managing allergy symptoms, but they have to be used correctly. And today we are debunking common myths and sharing expert tips for using allergy sprays effectively.

Amber Patterson, MD: Hi ladies.

Kara Wada, MD: Hello. So

Meaghan Shepherd, MD: How are you this morning?

Kara Wada, MD: I'm here. Got a sick kid in the other room. 

Meaghan Shepherd, MD: Same. You'll hear some dogs and kids.

Kara Wada, MD: We realized while we were meeting after our initial recording that we didn't get a chance to talk about one of the most powerful tools in our allergy toolbox, which are the nasal sprays. And I don't know about you, but in my practice with almost every single patient, even allergy veterans who have, they've been to the rodeo more than, more than once there always are some things that we can talk about to really optimize their use.

And so, I'd love to hear your experiences and also see if, if we can learn from one another as we're sharing with our listeners and viewers today all of our techniques that we like to share.

Why Nasal Sprays Are the First-Line Treatment for Nasal Allergies

Amber Patterson, MD: One thing I like to point out is the nasal steroids are the first line treatment for rhinitis or nasal allergy type symptoms. I think so many times when we go to the store to get an allergy medicine, the first thought is, "Oh, we're gonna get a pill or a liquid to treat these symptoms." And really nose spray's the first thing we should be grabbing off the shelf.

Meaghan Shepherd, MD: Yeah, that's absolutely right. I always tell people antihistamines are, are really great for itchy, watery, sneezy. But if you are congested and having a lot of nasal issues, you really have to treat that primary target right there if you want to get better specifically for all of that.

Kara Wada, MD: I think the other thing that a lot of my patients, especially kind of in, in this area of a little more holistic practice is folks are always wanting to use like the most local kind of low hanging fruit type treatments and, and really trying to simplify regimens. And I, I think there's this like struggle between, "Oh gosh, it's a steroid." There's a lot of fear around that term, but really you're using a much lower dose and using it locally. And often for many people, that can be, when used correctly, a, a single med and kind of do it all.

Amber Patterson, MD: Yeah, I totally agree. I think explaining it exactly like that, that it's local treatment, meaning, think about if you had a rash on your arm and you grabbed some hydrocortisone and you rub the hydrocortisone just topically exactly where you need it, that's exactly what you're doing with a nose spray.

You're putting that very low dose medicine right on that nasal tissue, and very little, if any, gets absorbed to the rest of the body. So it's, it's a topical, local targeted treatment.

The Difference: Non-Addictive Steroids vs. Addictive Decongestants

Meaghan Shepherd, MD: You know, one of the things my patients say a lot is, "Oh, I don't wanna get addicted to it." And so that's where we come into the discussion about, well, a nasal steroid is different from the vasoconstrictors that we all have heard about.

Amber Patterson, MD: Why do you have that in your house?

Meaghan Shepherd, MD: And so just to clarify what they mean by that is that whenever you use one of the nasal decongestants, it does definitely feel great for a little bit and it's fairly immediate and so it helps the swelling to go down pretty quickly. And it's okay for short term use. The issue is when you start to use it daily or for longer periods of time, you, it stops working quite as well and as long. And we have had patients who come in for instance and are using it every 30 minutes. And so that's not something that is sustainable long term and it's not healthy to do.

And what I tell my patients is the nasal steroid is different. It's technically, if you have symptoms, it's meant to be used every day. And I do have patients I'll instruct to do it daily, sometimes twice a day, depending on the dose, but or, and it also depends on the season as well, if they need it. But I also have a lot of people that use it as needed, which again, it's not really indicated for that, but truly they do great with the nasal steroid as needed. So they feel like they're not having to use much medication, but they can get the relief whenever they need it.

Amber Patterson, MD: That's so true. And then nasal antihistamines similarly to the steroid are not addictive, can give you some quick relief, be used as needed. So there's a few different things and these are all over-the-counter, that are right at our patient's fingertips. But I can see how as maybe a lay person going to the store and just looking at the, what's in front of you, there's so many options. It's hard to know what to pick.

Meaghan Shepherd, MD: Do you guys wanna do where we talk about, like, I'll say our favorite nasal steroid spray that's over-the-counter on the count of three. 

Amber Patterson, MD: Okay. I think I know which one I would say.

Meaghan Shepherd, MD: Okay. Ready? 1, 2, 3. Flonase Sensimist. 

Kara Wada, MD: Yeah.

Amber Patterson, MD: We did not plan that.

Meaghan Shepherd, MD: No, we did not plan that.

Kara Wada, MD: But if the Flonase Sensimist people wanna reach out and sponsor us, then you know.

Amber Patterson, MD: We can explain in great detail why we like it, but there are other ones that are good too. 

Meaghan Shepherd, MD: Yeah, absolutely.

Kara Wada, MD: And I, I think that's an important point, that there are many options out there and maybe if you've tried Triamcinolone or Nasacort or you've tried Rhinocort, which is Budesonide or regular Flonase versus Flonase Sensimist. Each of those has different properties and so just because you've tried one and maybe it hasn't been a great fit, that doesn't necessarily mean that the others aren't going to be as helpful or are not worth trying. For instance, regular Flonase has a bit of a floral smell. So often my patients who have migraines or are sensitive to stronger smells, like that's not my first choice for 'em. Or maybe they've already tried it and said, yeah, this was a trigger for my migraines. So then we opt for an, different formulation that doesn't have that floral smell.

Meaghan Shepherd, MD: Mm-hmm.

Amber Patterson, MD: Do you guys wanna show how to use some of the nose sprays?

The PROPER Technique: How to Use a Nasal Spray Correctly

Meaghan Shepherd, MD: Mm-hmm.

Amber Patterson, MD: Okay. I'll start. I received this as a sample in my office. It's called Astepro. Azelastine is the generic name, and that is in very small print underneath. This is a nasal antihistamine, so it works kind of like, cetirizine or fexofenadine that we take by mouth, but this is for the nose. And it works well for both allergic and non-allergic rhinitis, to be honest. It's really good at drying up like the goopy postnasal drip, congestion. Let me just get it out of the box. And in our house,

Kara Wada, MD: And it is one of the newer ones over-the-counter too. It's only been over-the-counter for maybe three-ish years, four years?

Amber Patterson, MD: I'll also say we have six people in our household, so when I buy nose sprays at the store, I get one for everybody. It's like toothpaste. We are not sharing a nose spray.

Kara Wada, MD: Good call.

Amber Patterson, MD: take

Kara Wada, MD: Great reason to have that Sam's or Costco membership.

Amber Patterson, MD: Alright. So the first time you use a nose spray, you want to prime it, you wanna make sure you can see the medicine coming out. So I'll just kind of close here and see if we can get the mist. So nothing came out there. Oop, did you see that? 

Kara Wada, MD: A A little bit yeah.

Amber Patterson, MD: So then when we put it in the nose, usually we'll use opposite hand, opposite nostril, straight back. And then make sure we're aiming away from the septum. So the middle of the nose is the septum. We don't wanna aim towards it. We wanna aim away, kind of like towards the eye or the ear, and then you do your squirt. I just did a little tiny twist.

Kara Wada, MD: And I'm gonna point out that you didn't do a big sniff.

Amber Patterson, MD: For sure.

Meaghan Shepherd, MD: Yep. That's why I always, I always tell my patients one thing that we learned whenever we were fellows very first, I remember Dr. Fox talking about this all the time, and you, we would say nose to the toes. And so one of the things is that you don't want to sit up and then spray your nose, spray up 'cause you really just hit the, the roof of your nostrils there, you don't actually go back into your sinuses.

So I always tell my patients "nose to the toes." So if you can imagine you're standing or sitting, you lean over a little bit. And so whenever you use the opposite hand to spray, you're already kind of pointing it in that direction.

And we're just supposed to do a nice, gentle breath in as we do it. And I have, right now, I have Ayr which is a nasal saline gel, and I recommend it on the daily and I use it multiple times a day myself. It's so soothing. But I go ahead and use it now actually, if that's

Amber Patterson, MD: And that does not contain medicine. It's just salt water, right?

Meaghan Shepherd, MD: Nope. And it feels so good. And so what we're not supposed to do at the end, we're not supposed to or anything like that. What we always tell people is that you just do a gentle breath in as you do it, and then you sit up and that's that. And if you have a little that kinda comes out, you can dab it, but most of the time you don't really even have that issue. 

Kara Wada, MD: Yeah. I'm gonna follow up the second half of that rhyme of nose to toes. "If you taste it, you waste it." Um, So especially with the Astepro or Azelastine, it does have a bit of a taste to it. And so, and, and it's not the most pleasant. So one that's a good thing to know and to be aware of, but also using this type of technique is gonna minimize how much of that is dripping down the back and getting some to the taste buds.

Meaghan Shepherd, MD: Absolutely. I tell people to do it before they brush their teeth. My nurse tells people and this is for the ones that, that have a taste or a flavor to some people. I say and, and I keep it in my toothpaste drawer, so whenever I brush my teeth I just go ahead and use that. Then I brush my teeth and I really don't taste anything after that.

My nurse tells everyone to use it and then eat an M&M, which I like that as well. And M&M is always a good idea. But there are things that you can do to mitigate the taste if it's aggravating for you. Some people will say, eat a mint, chew some gum. I just, I always hate to see people who miss out on using really effective medicines that could have a taste because they don't like it, because there are ways to kind of quickly move on from that and still get the benefit of the medication.

Kara Wada, MD: How long do you tell people to give a nose spray to really feel like they've given it like the old college try. Like that they have, like, "Okay, we've tried it, is this, is this gonna be what's right for me or what's not?"

Meaghan Shepherd, MD: I usually say two weeks minimum.

Kara Wada, MD: Mm-hmm.

Amber Patterson, MD: Yeah, I think that's,

Meaghan Shepherd, MD: I tell people, don't expect,

Amber Patterson, MD: oh, no,

Meaghan Shepherd, MD: on. Sorry.

Amber Patterson, MD: I was just agreeing with you.

Meaghan Shepherd, MD: Just tell, it doesn't mean it didn't work if you don't feel better immediately, don't expect that. It'll take at least two weeks and then we can see how you're doing.

Amber Patterson, MD: And that doesn't mean it'll take two weeks for you to feel any benefit. I mean, you might start noticing improvement pretty quickly, 

Meaghan Shepherd, MD: right away.

Amber Patterson, MD: But to really see, is this something that long-term is, is gonna help me feel better every day, breathe better through my nose, not be annoyed by drainage dripping, not be annoying other people, give it a couple weeks.

How to Prevent & Manage Nosebleeds from Nasal Sprays

Kara Wada, MD: What about, I think one of the other really common things I get asked about or kind of comes up in the conversation are, "Gosh. Those nose sprays, I get nosebleeds every time I use 'em."

Meaghan Shepherd, MD: First would be technique.

Kara Wada, MD: Yeah.

Meaghan Shepherd, MD: Are you spraying it toward the septum, so toward the middle, or are we doing it to the side, which are where the turbinates are? And I, I'll tell my patients, that's the tissue that overlies the bones, that sort of make up the inside of your sinuses there. And so that's where we want the medicine to go.

So if you're spraying it to your septum, you can often be aggravating that tissue there. That's where we have Kiesselbach's triangle, all the little arteries right there. And if we aggravate those, you can get a lot of nosebleeds, so make sure you're doing it the right direction. 

Amber Patterson, MD: Also, you can take breaks. I mean, certain times of year, people's environments are drier than others and can just naturally make your skin and mucosal tissues drier. So maybe you need to back down to, instead of two sprays, each nostril every day, maybe you're doing one in one nostril one day, one in the nostril the other day. Gotta find a balance between controlling the inflammation and any, mucus production you're having with not drying out that mucosal tissue too much.

Kara Wada, MD: I, I feel like especially with my patients with Sjogren's, which is drying and they have allergies or non-allergic inflammation, super common. We are always trying to thread the eye of a really small needle in regards to turning down the inflammation, but also keeping those tissues moist and, and, and also. So, so I am often using in combination with like the Ayr, the Ayr gel. Sometimes xylitol containing sprays, which are also moisturizing. A common brand you'll see at the store is called Xlear, kind of looks like clear, but instead of a C has an X, those also do have a taste 'cause it's it's a, a, a sweetener. But those are some other things that are sometimes helpful.

And that's, I think the other, going back to the different formulations too, where sometimes, and maybe I don't wanna speak for you all, but that's one of the reasons I like Sensimist because it does seem to be a little gentler and maybe a little less irritating for some folks.

Amber Patterson, MD: For sure. What do you say to people who are afraid of using nose sprays? They don't like the feeling of putting something in their nose or sometimes parents will make assumptions about their kids. "Oh, he would never do that. She would never do that," but maybe they haven't tried. What are some things, how do you approach that?

Overcoming the Fear of Using a Nasal Spray

Kara Wada, MD: I like to just start by asking them, "Tell me more." Like, because each person, and, and I can, I myself can go jump to assumptions as to why that may be. But usually there's a story behind it. And sometimes knowing a bit more about that story can be really helpful and, and untangling some of those like preconceived notions, limiting beliefs icky experiences. And also just thinking, "Okay, well if a nose spray isn't helpful, would we consider a, does that mean anything nasals off the table like a sinus rinse?"

Or there's even some like nebulizer type treatments for the nose or, and then symptom burden, is it something that maybe we do try orals instead? Or, lean on immunotherapy much sooner than we might in another patient.

Meaghan Shepherd, MD: I like to ask exactly what part of it do you not like? Do you not like putting something in your nose, period, which is sometimes that's a harder barrier to overcome, to be honest. But whenever people are like, "Ooh, I hate that feeling of it going down my throat, and I hate the taste of it."

Amber Patterson, MD: By the way, I can just now taste the Astepro, so go on. I can taste it now. It's, it's fine. It's fine. Go on.

Meaghan Shepherd, MD: So, but yeah, and that's what I wanna know because we could technically, I mean, you can, you can choose a formulation that probably doesn't have that. And so, and I always tell people, for instance, we talked about the Sensimist, where that doesn't have a, a smell. The other thing, I don't know if you guys remember when it was Veramyst before it was rebranded as Flonase Sensimist, the drug reps would come around and they would, that was how it was marketed. They would hold their hand up and they would be like, "Look, it doesn't drip. See?" And sure enough, it did not drip. It was kind of sticky. And so I tell them about that and I always also tell them that it's the only one my own kids will tolerate. So you know, my kids use it. I suspect your kid would not hate it as much as others they've possibly hated before.

All right. Well, I think that this has been an awesome discussion and we're really excited to share all of this knowledge in our personal tips that we use since it seems like we all frequently use a nose spray. And if you have any questions, comments, likes, anything like that, please stick them in the comments section and follow us for more information from your allergy besties at

Kara: Allergy, Actually.

​