A manic episode in a patient with stable bipolar disorder triggered by intranasal mometasone furoate

Sir,

Intranasal corticosteroid sprays are a mainstay treatment for allergic rhinitis and other conditions. The usual drug prescription textbooks, such as the Physicians’ Desk Reference, do not mention mania as a possible adverse event. Confronted with a bipolar patient who developed a hypomanic episode after taking mometasone furoate, we briefly reviewed the literature on the topic of mania and nonsystemic corticosteroid therapy. We found three case reports published in the 1980s: one of an asthmatic child aged 5 who developed mania on inhaled budenoside [Lewis and Cochrane, 1983]; one of a 69-year-old patient who had previously presented prednisone-induced manic symptoms and developed mania on intranasal beclomethasone [Phelan, 1989]; and one of a 28-year-old known bipolar patient, who was stable and developed mania on intranasal beclomethasone [Goldstein and Preskorn, 1989]. We found two other studies reporting a possible link between intranasal corticosteroid sprays and mania: one was an online survey of 192 bipolar patients about possible triggers of affective episodes; antiallergic medication was a rarely reported possible trigger of mania [Proudfoot et al. 2012]; the other was a report of the International Pharmacovigilance Programme of the World Health Organization and reported seven cases of manic reactions attributed to intranasal corticosteroids, which were not described in further details [Pokladnikova et al. 2008]. We contribute to the literature with our case report.

Case report

Ms A is a 53-year-old White woman, married and the mother of three children, who worked as a nurse until her first depressive episode at age 30, which occurred in the post-partum period of her first pregnancy. She presented a first manic episode, with psychotic symptoms, while on fluoxetine, at age 35. Between the age of 35 and 50, she experienced fluctuating mixed symptoms with several acute episodes of either mania or depression, often accompanied by psychotic symptoms (paranoid delusions). She was treated with numerous drugs and found most responsive to valproate and sertindole. Over the past 3 years, she has been mostly well, with fluctuating subthreshold depressive symptoms. The medication and an intensive individual and family psychotherapy allowed her to enter a few voluntary activities and she is planning to partially opt out of invalidity benefits to engage in a rehabilitation program, hoping to be able to get back to work.

Ms A had previously noted that the intranasal corticosteroids she had been prescribed every spring for an allergic rhinitis tended to induce irritability, and was somewhat wary of them. This spring, however, she experienced a rather severe bout of rhinitis and took mometasone furoate, twice, two puffs per nostril per day, a daily dose of 400 µg (twice the recommended dosage for treating allergic rhinitis, but within the dose range for nasal polyps). Ten days later, she developed irritability, psychomotor agitation, paranoid ideation, sleeplessness, talkativeness, flight of ideas with difficulties concentrating. She spontaneously stopped taking the spray and began to feel gradually better 5 days later. 20 days after the apex of the manic symptoms, she was perfectly euthymic.

This is to our knowledge the first report of a manic episode likely to have been induced by mometasone furoate. Considering the available evidence, it seems that intranasal corticosteroids should be used only with caution in bipolar patients.