Introduction
QNASL (beclomethasone dipropionate) is an inhaled corticosteroid nasal spray approved for the treatment of seasonal and perennial allergic rhinitis in patients 4 years of age and older. It delivers a metered-dose aerosol formulation directly to nasal passages, providing localized anti-inflammatory effects with minimal systemic absorption.
Mechanism of Action
Beclomethasone dipropionate is a synthetic corticosteroid that exerts potent anti-inflammatory and immunomodulatory effects. The drug binds to cytoplasmic glucocorticoid receptors, forming complexes that translocate to the cell nucleus. This interaction modulates gene transcription, resulting in:
- Inhibition of inflammatory cytokine production
- Decreased recruitment of eosinophils and other inflammatory cells
- Reduction in vascular permeability
- Stabilization of mast cell membranes
The net effect is reduced nasal inflammation, decreased mucus production, and relief of allergic rhinitis symptoms.
Indications
- Management of seasonal allergic rhinitis symptoms in adults and children 4 years of age and older
- Management of perennial allergic rhinitis symptoms in adults and children 4 years of age and older
Dosage and Administration
Adults and adolescents 12 years and older:- 1-2 sprays (80-160 mcg) in each nostril twice daily
- Maximum recommended dose: 320 mcg daily
- 1 spray (40 mcg) in each nostril twice daily
- Maximum recommended dose: 80 mcg daily
- Prime the device before first use by spraying into the air until a fine mist appears
- Shake well before each use
- Blow nose gently to clear nasal passages
- Insert nozzle into nostril while keeping the bottle upright
- Breathe in gently through the nose while spraying
- Avoid spraying directly toward the nasal septum
- Clean actuator weekly with warm water
- Hepatic impairment: No dosage adjustment recommended
- Renal impairment: No dosage adjustment recommended
- Geriatric patients: No specific dosage recommendations
Pharmacokinetics
Absorption: Minimal systemic absorption following intranasal administration. Approximately 44% of the delivered dose reaches systemic circulation primarily through gastrointestinal absorption. Distribution: Plasma protein binding is moderate (40-50%). Volume of distribution is approximately 20 L/kg. Metabolism: Undergoes extensive first-pass metabolism in the liver via cytochrome P450 3A4 to weakly active metabolites (beclomethasone-17-monopropionate and beclomethasone-21-monopropionate). Elimination: Primarily eliminated in feces (60%) with lesser amounts in urine (12%). Terminal half-life is approximately 2.8 hours.Contraindications
- Hypersensitivity to beclomethasone dipropionate or any component of the formulation
- Recent nasal surgery or nasal trauma until healing has occurred
- Active or quiescent untreated tuberculosis infections
- Untreated fungal, bacterial, or viral infections
Warnings and Precautions
Local Effects: Nasal septum perforation has been reported with intranasal corticosteroid use. Monitor patients periodically for signs of nasal irritation. Immunosuppression: Patients using corticosteroids may be more susceptible to infections. Avoid use in patients with active or quiescent respiratory infections. Ophthalmic Effects: Glaucoma and cataracts may occur with prolonged use of corticosteroids. Regular ophthalmologic examinations are recommended. Adrenal Suppression: Systemic corticosteroid effects may occur, particularly at higher doses. Monitor for signs of adrenal insufficiency during stress or trauma. Growth Suppression: Monitor growth in pediatric patients receiving prolonged therapy. Hypersensitivity Reactions: Anaphylaxis and other hypersensitivity reactions have been reported.Drug Interactions
Strong CYP3A4 Inhibitors: Ketoconazole, itraconazole, clarithromycin, ritonavir, and other strong CYP3A4 inhibitors may increase systemic corticosteroid exposure. Use with caution and consider dose reduction. Other Corticosteroids: Concurrent use with other systemic or inhaled corticosteroids may increase the risk of systemic corticosteroid effects.Adverse Effects
Common (≥2%):- Nasal discomfort (11%)
- Epistaxis (6%)
- Headache (5%)
- Nasopharyngitis (4%)
- Pharyngolaryngeal pain (3%)
- Anaphylaxis and hypersensitivity reactions
- Nasal septum perforation
- Vision changes (glaucoma, cataracts)
- Adrenal suppression
- Impaired wound healing
Monitoring Parameters
- Nasal examination for signs of irritation or septal damage
- Growth monitoring in pediatric patients
- Ophthalmologic examinations with prolonged use
- Signs and symptoms of adrenal suppression during stress or trauma
- Clinical response to therapy
- Adverse effects
Patient Education
- Use regularly as prescribed for optimal effect; not for immediate symptom relief
- Prime the device before first use and if not used for 7 days
- Aim spray away from the nasal septum
- Rinse mouth after administration to minimize systemic absorption
- Report any signs of nasal irritation, bleeding, or vision changes
- Do not discontinue abruptly if using for prolonged periods
- Keep regular follow-up appointments with healthcare provider
- Inform all healthcare providers about QNASL use, especially before surgery
- Store at room temperature; do not freeze
References
1. QNASL [package insert]. Raleigh, NC: Meda Pharmaceuticals Inc; 2021. 2. Meltzer EO, Jacobs RL, LaForce CF, et al. Safety and efficacy of once-daily treatment with beclomethasone dipropionate nasal aerosol in allergic rhinitis. Ann Allergy Asthma Immunol. 2012;109(2):137-142. 3. Ratner PH, Jacobs RL, Hampel FC, et al. Effectiveness of beclomethasone dipropionate nasal aerosol in children with allergic rhinitis. Ann Allergy Asthma Immunol. 2012;109(4):279-284. 4. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63(10):1292-1300. 5. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy. 2008;63(Suppl 86):8-160.