Many people ask for a triamcinolone injection for summer allergies. I understand that this is not the standard of care, but most of my patient population cannot afford the recommended nasal steroids and eyedrops. What are the risks of triamcinolone injections for treatment of seasonal allergies? — Lydia Miller, ARNP, Centralia, Wash.

The evidence regarding the effectiveness of steroid injections for allergic rhinitis is conflicting. A review of 18 mostly older studies concluded that a single intramuscular injection of a corticosteroid was superior to placebo in relieving subjective symptoms of nasal allergies and resulted in approximately three weeks of relief (Prim Care Respir J. 2005;14:124-130). One comparison of glucocorticoid injections and intranasal steroids noted equal efficacy between the two; a second trial showed superior effect of injected corticosteroids.

Side effects of steroid injections included tissue atrophy, gastritis, uveitis, and some mild suppression of the hypothalamic pituitary axis. All of these studies involved healthy volunteers, but pregnant women and individuals with diabetes, glaucoma, renal insufficiency, congestive heart failure and peptic ulcer disease may experience more severe side effects from corticosteroid injections.

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Other case reports describe muscle atrophy and adverse drug interactions with such classes of drugs as protease inhibitors, seizure medications and macrolide antibiotics. Steroid injections may also diminish the effect of any recent vaccines.

Given the somewhat short duration of relief provided by injectable corticosteroids, those with chronic allergy symptoms would not be good candidates for this option.

The American Academy of Allergy, Asthma & Immunology does not recommend the use of systemic corticosteroids for allergic rhinitis; nasal steroids are considered the first-line and safest treatment approach (J Allergy Clin Immunol. 2008;122:S1-S84). The nasal corticosteroids fluticasone propionate (Flonase) and flunisolide (Nasalide, Nasarel) are now available as a generic preparation at a cost of about $15 a month.

Nasal corticosteroids start to provide symptom relief within three to 12 hours and provide effective treatment for extended symptoms. These medications can also be used as preventive treatment at the start of the allergy season, with usually only local side effects (i.e., nasal irritation and bleeding). Nasal corticosteroids are considered safe for use in pregnancy and have no contraindications other than previous allergy to the compounds themselves.

Although injectable corticosteroids may provide some short-lived relief from symptoms, the risk of side effects remains problematic. Some argue that an injectable glucocorticoid would be reasonable for individuals who are not able to use nasal steroids because of total nasal obstruction from allergic rhinitis. — Kathy Pereira, MSN, FNP-BC, assistant professor, co-coordinator, family nurse practitioner program, Duke University School of Nursing, Durham, N.C. (179-2)

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