Linda Abe, APRN
Influenza treatment options are always in a state of flux. Two new nasal medications have been in the news recently. The first is the nasal influenza vaccine, which is not new but will now be offered for home administration. The second is nasal epinephrine, which can be used for anaphylaxis. Both of these medications offer an additional treatment option for some patients that does not involve injections.

Nasal influenza vaccine
The influenza vaccine has been around for over 20 years now. FluMist is the name brand for the vaccination and is made by AstraZeneca. For some that have been practicing as long as I have, we remember when this medication came out in the early 2000s and was the vaccination of choice for children. Then, in 2016, the Centers for Disease Control recommended against its use during the 2016- 2017 influenza season due to its ineffectiveness against one influenza strain. It remained off the market for 2 years until it returned in 2018 (Fox, 2018). It was reformulated and has been back in use since 2018. More recently, it has been shown that the nasal influenza vaccine is as effective as the intramuscular influenza injection (Macmillan, 2024).
The big difference between the nasal influenza vaccine and the traditional intramuscular influenza vaccine is that the nasal influenza vaccine is a live-attenuated vaccine. Intramuscular influenza vaccines are either inactivated viruses or recombinant viruses. Because the nasal influenza vaccine is a live- attenuated vaccine, it is not recommended to give it to immunocompromised patients.
The nasal influenza vaccine is recommended in pa.ents 2 to 49 years of age. It has been shown to be less effective for pa.ents younger than 2 or older than 50, which prompted this recommendation. Additionally, pregnant patients or children with a history of asthma or wheezing should not receive the nasal influenza vaccine. Pa.ents who have taken antiviral therapy in the past 5 days should also not receive the nasal influenza vaccine.
New Home Use Approval for Influenza Vaccination
The nasal influenza vaccine has traditionally been administered in a medical setting, such as a pharmacy, medical office, or vaccination drive. In September 2024, the FDA also approved the nasal influenza vaccine for home use. This could mean that more patients could be vaccinated. However, if a patient isnโt aware of this option for vaccination, they wonโt be able to choose this option. It also does require planning and effort from the patient. AstraZeneca has discussed a plan to have a website available for patients to fill out a questionnaire to verify eligibility and put in insurance information. If the patient meets the criteria, a prescription for the nasal influenza vaccine is given, and the medication is mailed to the patient.
One issue with this new option is the lack of cold chain storage during the nasal influenza vaccine delivery. It is required to be refrigerated and kept at the recommended temperature. Additional shipping costs and requirements would be needed. Another issue is the inability to administer the vaccine correctly. While most adults will have minimal issues with administration, many children will fight a substance squirting up their nose. This may lead to a false confidence that the patient is protected against influenza, but they received an inadequate dose and needed to build up sufficient immunity to flu.
The nasal influenza vaccine presents a new alternative to providers to vaccinate patients at home. However, it is still up to providers to educate patients on this option and ensure that this is the best alternative for the patient.
Nasal Epinephrine for Influenza Treatment
Epinephrine autoinjectors have been in the news over the past several years for the high cost that made them unaffordable for many patients. With all the negative press, there is now some good news for patients with a history of anaphylaxis. In August of this year, the FDA approved a new nasal epinephrine to treat anaphylaxis.
The new nasal epinephrine is called neffy by ARS Pharmaceuticals. This will be the first-ever nasal epinephrine treatment option for anaphylaxis. The nasal epinephrine spray is comparable to the commonly used autoinjectors for anaphylaxis (Presnall, 2020). This is good news for patients who may not be comfortable with self-injecting with the autoinjector.
The nasal epinephrine spray is approved for patients who weigh > 66 lbs. Hopefully, more research will be done in the future, and a lower dose version will be available for those under 66 lbs. The dose of nasal epinephrine is 2mg, more than the 0.3 mg for patients > 30 kg and 0.15 for patients < 30 kilograms. A higher dosage is required to obtain the same blood levels of circulating epinephrine based on the studies that need approval.
Cost-Effective and Easy to Administer
One of the most significant issues with epinephrine is the cost. ARS Pharmaceuticals currently says that pa.ents who have insurance that cover the prescription will only have a $25 copay. Pa.ents with high deductible plans or without insurance would pay $200 through pharmacy discount programs like GoodRx (Parikh, 2024). There may also be options through the company to apply for additional financial aid for patients who cannot afford the medication.
The prescription for nasal epinephrine spray is similar to autoinjectors, where the patient will receive two doses with each prescription. The patient should be instructed to administer a second dose if they have no improvement 5 minutes after the first dose. With the nasal epinephrine spray, the patient should administer the second dose in the same nostril as the first.
Some important patient instructions regarding administration should be given at the time the prescription is written to ensure that the patient is receiving the medication correctly. Patients should be instructed to administer straight into the nose, not angles like some nasal steroid sprays. The patient should also be instructed not to sniff the medication after administration.
Stable Storage
One advantage of the nasal epinephrine spray over injectable epinephrine is the stability of the medication. The medication has a shelf-life of 30 months, so patients only need to replace it every two years or so. The medication can also withstand temperatures up to 122 ยฐF for up to 3 months (ARS Pharmaceuticals, 2024). It can also be frozen and thawed (ARS Pharmaceuticals, 2024). While the recommended storage is at room temp, this adds reassurance that it can be leg in a car during extreme hot or cold and not lose potency. This may mean patients will keep it closer to them and have it more readily available during anaphylaxis.
Summary
These two new nasal medications represent some exciting new advances in medicine. These medications can mean greater patient access to the influenza vaccine and epinephrine. Clinicians can start conversing with patients about these new options as they become more widely available. The at- home nasal influenza vaccine should be widely available for the 2025-2026 influenza season, and the nasal epinephrine spray will be available around October- November 2024.
References:
ARS Pharmaceuticals. (2024). ARS Pharmaceuticals Receives FDA Approval of neffyยฎ (epinephrine nasal spray), the First and Only Needle-Free Treatment for Type I Allergic Reactions, Including Anaphylaxis. hTps://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceu.cals-receives-fda- approval-neffyr-epinephrine
Fox, M. (2018). FluMist nasal flu vaccine can come back, vaccine advisors say.
Macmillan, C. (2024). Nasal flu vaccine mist gets FDA approval for at-home use.
https://www.yalemedicine.org/news/flumist-at-home
Parikh, P. (2024). FDA approves first epinephrine nasal spray to treat anaphylaxis.
https://allergyasthmanetwork.org/news/epinephrine-nasal-spray-for-anaphylaxis
Presnall, A. (2020). Epinephrine nasal spray demonstrated bioequivalent exposure and absorption rate compared to epinephrine autoinjectors. https://www.aaaai.org/about/news/news/epinephrines