From the Guidelines
If seasonal allergies are not controlled with antihistamines and inhaled steroids, the next treatment option is typically allergen immunotherapy (allergy shots or sublingual tablets). This treatment involves gradually exposing your body to increasing amounts of the allergen to build tolerance over time. Allergy shots are administered in a doctor's office, starting with 1-2 weekly injections during a 3-6 month build-up phase, followed by monthly maintenance injections for 3-5 years. Sublingual immunotherapy tablets, taken daily at home, are available for specific allergens like grass, ragweed, and dust mites. Before starting immunotherapy, allergy testing is necessary to identify your specific triggers. This treatment works by modifying your immune system's response to allergens, potentially providing long-term relief even after treatment ends. It's particularly beneficial for patients who have identifiable allergens, experience significant symptoms despite medication, or cannot tolerate the side effects of multiple medications. While immunotherapy requires a significant time commitment, it's the only treatment that addresses the underlying cause of allergies rather than just managing symptoms, as supported by the 2017 Joint Task Force on Practice Parameters 1.
Some key points to consider when evaluating the effectiveness of allergen immunotherapy include:
- The treatment's ability to provide long-term relief from symptoms, even after treatment ends
- The importance of identifying specific allergens through testing before starting immunotherapy
- The potential benefits for patients with identifiable allergens, significant symptoms despite medication, or intolerance to multiple medications
- The time commitment required for immunotherapy, which can be significant but may be worth it for the potential long-term benefits.
Overall, allergen immunotherapy is a viable option for patients with seasonal allergies that are not controlled with antihistamines and inhaled steroids, and it should be considered as part of a comprehensive treatment plan, as recommended by the 2017 Joint Task Force on Practice Parameters 1.
From the FDA Drug Label
What is XOLAIR XOLAIR is an injectable prescription medicine used to treat: moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids.
The next treatment for seasonal allergies not controlled with antihistamines and inhaled steroids is XOLAIR (omalizumab), which is used to treat moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids 2.
- Key points:
- XOLAIR is an injectable prescription medicine
- Used to treat moderate to severe persistent asthma
- For people 6 years of age and older
- Whose asthma symptoms are not well controlled with inhaled corticosteroids
- Note: The FDA label does not explicitly address the use of XOLAIR for seasonal allergies, but it does mention its use for asthma, which can be related to seasonal allergies. However, another option could be montelukast (PO), which is used to treat seasonal allergic rhinitis 3.
From the Research
Treatment Options for Seasonal Allergies
If seasonal allergies are not controlled with antihistamines and inhaled steroids, the next treatment options may include:
- Immunotherapy, which is considered for patients who require medications for more than 6 months per year, have two or more seasons of unacceptable pollinosis, or have intolerable side effects from pharmacotherapy, especially those with co-morbid conditions 4
- Combination therapy with an intranasal corticosteroid and various agents, such as antileukotrienes or nasal decongestants 5, 6
- New formulations, such as MP29-02, which combines the nasal glucocorticosteroid fluticasone propionate with azelastine in one single spray, and has achieved greater improvements than those under monotherapy with modern glucocorticosteroids or antihistamines 6
- Allergen-specific immunotherapy alone or in combination with modern monoclonal antibodies, which is considered a causal treatment option 6
Efficacy of Intranasal Medications
A systematic review and meta-analysis found that most intranasal medications, including corticosteroids and antihistamines, are effective in improving rhinitis symptoms and quality of life, with some medications having a higher probability of resulting in moderate or large improvements 7
- Azelastine-fluticasone, fluticasone furoate, and fluticasone propionate were found to be the most effective medications in improving the Total Nasal Symptom Score and Rhinoconjunctivitis Quality-of-Life Questionnaire in seasonal allergic rhinitis 7
- Azelastine-fluticasone displayed the highest probability of resulting in moderate or large improvements of Total Ocular Symptom Score 7