What is the recommended management for chronic allergy symptoms?

From the Guidelines

The recommended management for chronic allergy symptoms typically involves a multi-faceted approach starting with allergen avoidance and medication therapy, with intranasal corticosteroids being the most effective medication class for controlling symptoms, as supported by the most recent and highest quality study 1.

Key Considerations

• First-line medications include second-generation antihistamines such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), which provide relief with minimal sedation.
• For nasal symptoms, intranasal corticosteroids like fluticasone propionate (1-2 sprays per nostril daily) or mometasone furoate (2 sprays per nostril daily) are highly effective and can be used long-term.
• For eye symptoms, antihistamine eye drops such as olopatadine (1-2 drops twice daily) may provide relief.
• Leukotriene modifiers like montelukast (10mg daily for adults) can help patients with both allergies and asthma.
• For severe or persistent symptoms, allergen immunotherapy (allergy shots or sublingual tablets) may be considered for long-term desensitization, as recommended by the latest clinical practice guideline 1.

Environmental Modifications

• Using allergen-proof bedding covers
• Removing carpets
• Using HEPA air filters
• Keeping windows closed during high pollen seasons These treatments work by blocking histamine receptors, reducing inflammatory responses, or gradually desensitizing the immune system to specific allergens, addressing the underlying immunological mechanisms of allergic reactions rather than just masking symptoms, as discussed in 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Patients should use Fluticasone Propionate Nasal Spray, USP, at regular intervals for optimal effect. The recommended starting dosage in is 2 sprays (50 mcg of fluticasone propionate each) in each nostril once daily (total daily dose, 200 mcg). Some patients (12 years of age and older) with seasonal allergic rhinitis may find as-needed use of 200 mcg once daily effective for symptom control

The recommended management for chronic allergy symptoms includes the use of fluticasone propionate nasal spray at a dosage of 200 mcg once daily for optimal effect, with the option to reduce to 100 mcg once daily for maintenance therapy in some patients.

• For adults, the recommended starting dosage is 2 sprays (50 mcg each) in each nostril once daily.
• For patients with seasonal allergic rhinitis, as-needed use of 200 mcg once daily may be effective for symptom control 2.

DOSAGE AND ADMINISTRATION Dosage Information The dosage for adults and adolescents 15 years of age and older is one 10-mg tablet. For allergic rhinitis SINGULAIR should be taken once daily

Alternatively, montelukast can be used for the management of chronic allergy symptoms, with a recommended dosage of 10 mg once daily for adults and adolescents 15 years of age and older 3.

• The dosage for pediatric patients varies by age, with options including 5-mg chewable tablets and 4-mg oral granules.
• Montelukast should be taken once daily, with the time of administration individualized to suit patient needs.

From the Research

Management of Chronic Allergy Symptoms

The management of chronic allergy symptoms involves a combination of allergen avoidance, pharmacotherapy, and immunotherapy 4, 5, 6.

• Allergen Avoidance: Patients with allergic rhinitis should avoid inciting allergens to reduce symptoms 4, 7.
• Pharmacotherapy:
  • First-line treatment for mild intermittent or mild persistent allergic rhinitis may include a second-generation H1 antihistamine (e.g., cetirizine, fexofenadine, desloratadine, loratadine) or an intranasal antihistamine (e.g., azelastine, olopatadine) 4, 6.
  • Patients with persistent moderate to severe allergic rhinitis should be treated initially with an intranasal corticosteroid (e.g., fluticasone, triamcinolone, budesonide, mometasone) either alone or in combination with an intranasal antihistamine 4, 5.
• Immunotherapy: May be considered for selected cases of allergic rhinitis 5, 6.
• Environmental Controls: Measures such as frequently washing cats and dogs, encasing bedding within impermeable covers, air filtration, and chemicals can effectively reduce levels of allergens in the home 7.

Treatment Selection

Treatment selection should be based on the severity and frequency of symptoms, patient preference, and comorbidities 4, 5.

• Oral Antihistamines: Second-generation oral antihistamines are recommended over first-generation antihistamines due to their nonsedating properties 6.
• Intranasal Corticosteroids: Are first-line therapy for patients with more severe symptoms 4, 5, 6.
• Combination Therapy: May be considered for patients with persistent moderate to severe allergic rhinitis 5.