Ask Dr Gary: Use the lowest dose for the shortest time

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Q: In a prior article, you discussed injecting steroids into joints and said "you can only do this for so long before the cartilage breaks down". I'm a bit concerned as I use Telnase nose spray for my hayfever. One 55mcg spray in each nostril once a day. I've been using it for about two years throughout the warmer months, and it's very effective but I'm concerned as I'm keen to continue using it for many years ahead. Look forward to hearing from you. — J.

A: Steroids are really fascinating chemicals. They can shut down inflammation, weaken the immune system, keep you up all night and cause jitters, or keep autoimmune diseases at bay. People have gone psychotic on steroids, developed fatty deposits on their backs and faces, suffered thinned skin and spider veins ... all due to corticosteroids.

Not to mention the other kind of steroids, the "anabolic" steroids that build muscle mass sometimes at the price of mood disorders, testicle shrinkage, heart problems and reduced bone growth.

Steroids can be life-saving, or dangerous. But not the ones you spray in your nose. They generally are neither.

Like Paracelsus said 500 years ago, the dose makes the poison. The reality is that for all the many effects of steroid hormones on our bodies the amount being sprayed in our nose for hay fever control is miniscule. And more importantly, the amount absorbed into our bloodstream and distributed to all our tissues is even lower. You'll find this general rule to be true: topical and locally applied medications are less potent than oral or injected ones.

Injected steroids, high-potency steroids and oral steroids are a completely different story. Doctors typically are very careful with those classes of steroids, making sure that people are on them for as short a period as possible (typically days or weeks) unless there is truly no other alternative. In some extremely severe disease states patients are literally living from steroid dose to dose. That is a horrible situation to be in.

In your case though, the risks are on a whole different level.

Nasal triamcinolone acetonide is not completely without risk however. It can stunt kid's growth and cause nosebleeds to worsen, delay healing after Nasal surgeries, or make nose and eye infections worse. People who already have endocrine problems usually wouldn't be prescribed it, nor those pregnant or breastfeeding, or those with glaucoma, which it can make worse.

But for most people, the risks will be negligible. And it is undeniably effective in the treatment of allergic rhinitis.

A couple of caveats, though: steroids don't usually "fix" a disease, they suppress the immune reaction (or overreaction) to a trigger. So it pays to first eliminate triggers: Hepa filtration of your air at home, closed windows especially overnight and in the mornings, bare floors instead of allergen-holding carpets, and staying away from mould, pets and smokers, all allergy triggers.

And the second caveat: the Medsafe data sheet on Telnase recommends its use for no more than six months without a doctor's advice.

As with any medicine that has side effects (and that's pretty much all of them), you should strive for the lowest dose that is effective, for the shortest course of time necessary. Best wishes.

• Gary Payinda is an emergency doctor who would like to hear your medical questions. Email him at drpayinda@gmail.com. This column provides general information, and is not a substitute for the medical advice of your own doctor.