Nasonex Nasal Spray

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Nasonex is a prescription nasal spray containing mometasone furoate 50 micrograms per actuation.

It is classified as an intranasal corticosteroid and is used to treat the symptoms of allergic rhinitis (commonly known as hay fever), perennial (year-round) rhinitis, and nasal polyps.

Nasonex is one of the most commonly prescribed nasal steroid sprays in the United Kingdom and has been available since 1997.

It is manufactured by Organon (formerly Merck Sharp and Dohme). Nasonex is a prescription-only medicine (POM) in the UK and is available on the NHS.

Allergic rhinitis affects approximately 10 to 30 per cent of the UK population.

Symptoms include nasal congestion, sneezing, nasal itching, and a watery runny nose, often accompanied by itchy, watery eyes.

These symptoms can significantly impair quality of life, affecting sleep, concentration, work productivity, and school performance.

Intranasal corticosteroids are considered the most effective single-agent treatment for moderate to severe allergic rhinitis and are recommended as first-line therapy by both NICE and the BSACI (British Society for Allergy and Clinical Immunology).

This page provides a comprehensive clinical overview of Nasonex, including how it works, dosage guidance, side effects, important safety information, and how to obtain a prescription in the United Kingdom.

Important safety information about Nasonex

• Nasonex is a prescription-only medicine. Use it only as directed by your prescriber.
• Do not use Nasonex if you have an untreated nasal infection or have recently had nasal surgery or injury.
• Nosebleeds are the most common side effect. They are usually mild and self-limiting.
• Systemic corticosteroid effects are very unlikely at recommended doses because less than 1% of the drug is absorbed into the bloodstream.
• Tell your prescriber if you are taking ritonavir or other strong CYP3A4 inhibitors, as these may increase systemic exposure to mometasone.

Understanding intranasal corticosteroids

Intranasal corticosteroids are the cornerstone of treatment for allergic rhinitis.

They work by reducing inflammation in the nasal mucosa, which is the tissue lining the inside of the nose.

Unlike oral antihistamines, which primarily block the histamine-mediated itch and sneeze reflex, intranasal corticosteroids address the full spectrum of nasal symptoms, including congestion, which is often the most bothersome symptom and the one least responsive to antihistamines alone.

Mometasone furoate is a potent synthetic corticosteroid with high topical activity and very low systemic bioavailability, making it one of the safest corticosteroids available for nasal use.

Several intranasal corticosteroids are available in the UK, including beclometasone (Beconase, available over the counter), fluticasone propionate (Flixonase, also available over the counter in some formulations), fluticasone furoate (Avamys, POM), budesonide (Rhinocort), and triamcinolone (Nasacort).

Mometasone is distinguished by its very low systemic bioavailability (less than 1%), rapid onset of action (some patients notice improvement within 12 hours), and favourable safety profile in both adults and children.

The BSACI guideline on rhinitis does not recommend one intranasal corticosteroid over another, as clinical efficacy is broadly comparable across the class at recommended doses.

How Nasonex works: mechanism of action

Mometasone furoate exerts its anti-inflammatory effects by binding to intracellular glucocorticoid receptors in the nasal mucosa.

This activates anti-inflammatory gene transcription and suppresses the production of pro-inflammatory mediators, including cytokines (interleukins IL-1, IL-4, IL-5, and IL-13), chemokines, prostaglandins, and leukotrienes.

The result is a reduction in the number and activity of inflammatory cells in the nasal tissue, including eosinophils, mast cells, basophils, lymphocytes, and macrophages.

In allergic rhinitis, exposure to an allergen (such as pollen, house dust mites, or animal dander) triggers an IgE-mediated immune response.

Mast cells in the nasal mucosa degranulate, releasing histamine and other mediators that cause the immediate symptoms of sneezing, itching, and rhinorrhoea.

This is followed by a late-phase response, characterised by the influx of eosinophils and other inflammatory cells, which causes sustained nasal congestion, mucosal thickening, and ongoing symptoms.

Mometasone is particularly effective at suppressing the late-phase response, which is why it is superior to antihistamines for controlling nasal congestion.

In nasal polyposis, chronic inflammation leads to the formation of benign, grape-like growths (polyps) in the nasal passages and sinuses.

These polyps cause nasal obstruction, loss of smell, facial pressure, and postnasal drip.

Mometasone reduces polyp size by suppressing the underlying inflammatory process, improving nasal airflow and symptom control.

It is the first-line medical treatment for nasal polyps and may reduce the need for surgical intervention (polypectomy) in some patients.

Clinical evidence and UK prescribing guidance

The efficacy of mometasone furoate nasal spray in allergic rhinitis has been demonstrated in numerous randomised controlled trials.

In a pivotal trial involving 289 patients with seasonal allergic rhinitis, mometasone 200 micrograms once daily significantly reduced total nasal symptom scores (congestion, rhinorrhoea, sneezing, and itching) compared with placebo, with improvement evident within the first 24 hours and sustained throughout the treatment period.

Similar results have been demonstrated in perennial allergic rhinitis and in paediatric studies.

For nasal polyps, clinical trials have shown that mometasone 200 micrograms twice daily significantly reduces nasal congestion scores and polyp grading compared with placebo over 4 months of treatment.

Bilateral polyp scores were reduced, and patients reported improved quality of life and sense of smell.

NICE Clinical Knowledge Summary (CKS) on allergic rhinitis recommends intranasal corticosteroids as first-line treatment for moderate to severe symptoms or when nasal congestion is the predominant symptom.

The guideline notes that intranasal corticosteroids are more effective than oral antihistamines at controlling nasal symptoms and can also improve eye symptoms in some patients.

The BSACI guideline similarly recommends intranasal corticosteroids as first-line therapy, noting that regular use is more effective than intermittent use.

Nasonex compared with other treatments

Oral antihistamines (cetirizine, loratadine, fexofenadine) are effective for sneezing, itching, and rhinorrhoea but are less effective at relieving nasal congestion.

They are appropriate for mild symptoms or when congestion is not a major concern. Non-sedating second-generation antihistamines are preferred over older sedating antihistamines such as chlorphenamine.

Intranasal antihistamines (azelastine) have a faster onset of action than intranasal corticosteroids and can be useful for intermittent symptoms.

Combination sprays containing both an intranasal corticosteroid and an intranasal antihistamine (fluticasone-azelastine, marketed as Dymista) are available for patients who do not respond adequately to either agent alone.

Leukotriene receptor antagonists (montelukast) may be used as add-on therapy in patients with concomitant asthma and rhinitis but are less effective than intranasal corticosteroids as monotherapy for rhinitis.

Nasal decongestants (xylometazoline, oxymetazoline) provide rapid relief of congestion but must not be used for more than 7 days because of the risk of rebound congestion (rhinitis medicamentosa).

Saline nasal irrigation (nasal douching) can be used as an adjunct to other treatments and is safe for long-term use.

Dosage and administration

The standard adult dose for allergic rhinitis is two sprays into each nostril once daily, delivering a total daily dose of 200 micrograms.

Once symptoms are controlled, the dose may be reduced to one spray in each nostril once daily (100 micrograms total) as a maintenance dose.

For nasal polyps in adults, the recommended starting dose is two sprays into each nostril twice daily (400 micrograms total), reducing to twice daily in each nostril once polyp size and symptoms improve.

For children aged 3 to 11 years with allergic rhinitis, the dose is one spray into each nostril once daily (100 micrograms total).

There is no dose adjustment for elderly patients.

Nasonex is not recommended for allergic rhinitis in children under 3 years or for nasal polyps in patients under 18 years.

Proper technique is essential for effectiveness. Shake the bottle gently before each use.

If the spray has not been used for 14 or more days, reprime by pressing and releasing the pump until a fine mist appears.

Blow your nose gently before use.

Tilt your head slightly forward and insert the nozzle into one nostril, pointing it away from the nasal septum (towards the outer wall of the nose).

Close the opposite nostril, spray while breathing in gently, and breathe out through the mouth. Repeat for the other nostril.

Do not blow your nose vigorously for several minutes after use. Clean the nozzle and dust cap regularly with warm water.

Side effects of Nasonex

Common side effects

The most commonly reported side effect is epistaxis (nosebleed).

In clinical trials, epistaxis occurred in approximately 10 to 15 per cent of patients using mometasone nasal spray, compared with 8 to 11 per cent of patients using a placebo nasal spray.

Nosebleeds are usually mild, self-limiting, and more common in the first few weeks of use.

To reduce the risk, aim the spray towards the outer wall of the nostril rather than the nasal septum. Headache and pharyngitis (sore throat) are also commonly reported.

Uncommon and rare side effects

Uncommon side effects include nasal irritation, burning or stinging, sneezing after application, and a sensation of dryness in the nose. Some patients notice an unpleasant taste or smell.

Very rarely, nasal septal perforation has been reported, typically with prolonged use at high doses or in patients with pre-existing nasal conditions (including previous nasal surgery or cocaine use).

Raised intraocular pressure (which may lead to glaucoma) and posterior subcapsular cataracts have been reported rarely with intranasal corticosteroids, including mometasone.

If you have a personal or family history of glaucoma, your prescriber should arrange regular ophthalmic monitoring.

Seek medical advice if you develop blurred vision or other visual changes while using Nasonex.

Hypersensitivity reactions, including urticaria, angioedema, bronchospasm, and anaphylaxis, are very rare. If you experience facial swelling, difficulty breathing, or widespread rash after using Nasonex, stop using the spray immediately and call 999.

Systemic effects

Because the systemic bioavailability of intranasal mometasone is less than 1%, systemic corticosteroid effects (adrenal suppression, osteoporosis, growth retardation) are not expected at recommended doses.

However, if you are also using other corticosteroid preparations (inhaled corticosteroid for asthma, topical steroid creams, steroid eye drops, or oral steroids), the total corticosteroid burden should be assessed.

Growth velocity should be monitored in children receiving prolonged treatment.

Clinical studies using recommended paediatric doses of mometasone nasal spray have not shown a statistically significant effect on growth over one year.

When to seek urgent medical advice

Stop using Nasonex and seek urgent medical help if you experience sudden wheezing, facial swelling, difficulty breathing, severe nosebleed that does not stop within 20 minutes, or visual changes including blurred vision.

Call 999 in an emergency.

Contact your GP or call NHS 111 if you develop persistent nasal crusting, pain, or an unpleasant smell from the nose, as these may indicate nasal septal damage or infection.

Report suspected adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Do not use Nasonex if you have an untreated localised infection of the nasal mucosa, such as nasal herpes simplex or nasal candidiasis.

Do not use the spray if you have recently undergone nasal surgery or sustained a nasal injury until the wound has healed.

Nasonex is contraindicated in patients with known hypersensitivity to mometasone furoate or any of the excipients.

Special precautions

If you have active or quiescent pulmonary tuberculosis, untreated systemic fungal, bacterial, or viral infections, or ocular herpes simplex, discuss the risks and benefits with your prescriber before starting Nasonex. Intranasal corticosteroids may mask or worsen certain infections.

Patients being transferred from systemic corticosteroids (such as prednisolone) to Nasonex should be monitored for signs of adrenal insufficiency. Withdrawal of oral steroids may unmask allergic conditions (eczema, conjunctivitis) that were previously controlled by systemic therapy.

If localised nasal candidiasis (thrush) develops during treatment, the infection should be treated with an appropriate antifungal, and discontinuation of Nasonex may be necessary.

Drug interactions

Potent inhibitors of cytochrome P450 3A4 (CYP3A4), including ritonavir, ketoconazole, itraconazole, cobicistat, and clarithromycin, may increase systemic exposure to mometasone by reducing its metabolism.

Co-administration should be avoided unless the expected benefit outweighs the risk of systemic corticosteroid effects.

If concurrent use is necessary, patients should be monitored for signs of adrenal suppression.

Pregnancy and breastfeeding

There are limited human data on the use of Nasonex during pregnancy. Animal studies have shown reproductive toxicity at high systemic doses, as is typical for corticosteroids.

Nasonex should be used in pregnancy only if the expected benefit to the mother justifies the potential risk to the foetus.

If you are pregnant or planning pregnancy, discuss treatment options with your GP or midwife. It is not known whether mometasone furoate is excreted in human breast milk.

Given the very low systemic absorption of intranasal mometasone, exposure via breast milk is expected to be negligible, but a risk-benefit discussion with your prescriber is recommended.

How to get Nasonex in the UK

Nasonex requires a prescription and is available through the NHS.

You can obtain a prescription from your GP, an allergy clinic, or an authorised online prescriber registered with the General Pharmaceutical Council (GPhC).

The standard NHS prescription charge of 9.90 pounds applies in England; prescriptions are free in Scotland, Wales, and Northern Ireland.

If you prefer an over-the-counter option, nasal sprays containing beclometasone (Beconase) or fluticasone propionate (Pirinase) are available from pharmacies without a prescription and may be suitable for mild to moderate hay fever symptoms.

Your pharmacist can advise on whether an OTC product is appropriate for your needs.

Lifestyle advice for managing allergic rhinitis

In addition to using Nasonex, practical measures can help reduce allergen exposure and improve symptom control.

For pollen allergy, check pollen forecasts daily (available from the Met Office), keep windows closed during high pollen counts, shower and change clothes after outdoor activities, and use wraparound sunglasses.

For house dust mite allergy, use allergen-proof mattress and pillow covers, wash bedding at 60 degrees Celsius or above weekly, and remove soft furnishings from the bedroom where practical.

For pet allergy, keeping animals out of bedrooms and washing hands after contact can help, though complete allergen avoidance is difficult if the pet lives in the home.

Sources

• Nasonex Nasal Spray, Summary of Product Characteristics (EMC)
• Mometasone furoate, British National Formulary (BNF)
• Allergic rhinitis, NICE Clinical Knowledge Summary
• Allergic rhinitis, NHS
• MHRA Yellow Card Scheme