What alternative treatments can be considered for patients with allergic rhinitis who do not respond to Zyrtec (cetirizine) and Flonase (fluticasone)?

From the Guidelines

For patients with allergic rhinitis who don't respond to Zyrtec and Flonase, the most effective alternative treatment option is combination therapy with Dymista (azelastine/fluticasone) 1 spray per nostril twice daily, as it offers both antihistamine and corticosteroid benefits, as recommended by the 2017 Joint Task Force on Practice Parameters 1. Other options to consider include:

• Other second-generation antihistamines like Allegra (fexofenadine) 180mg daily, Claritin (loratadine) 10mg daily, or Xyzal (levocetirizine) 5mg daily, which may be effective as they work differently for individual patients.
• Nasal antihistamines such as Astepro (azelastine) 1-2 sprays per nostril twice daily, which can provide rapid relief.
• For severe cases, oral corticosteroids like prednisone (short course of 20-40mg daily for 5-7 days) may be necessary.
• Leukotriene modifiers such as Singulair (montelukast) 10mg daily can help, especially for patients with concurrent asthma, although they are not recommended as primary therapy 1.
• Immunotherapy (allergy shots or sublingual tablets) provides long-term desensitization for specific allergens over 3-5 years and may be offered to patients with inadequate response to pharmacologic therapy 1.
• Nasal anticholinergics like Atrovent (ipratropium) 0.03% 2 sprays per nostril 2-3 times daily help with runny nose. These alternatives work through different mechanisms, targeting histamine receptors, inflammatory pathways, or immune response modification, providing options when first-line treatments fail. Combination pharmacologic therapy may also be offered to patients with inadequate response to monotherapy 1.

From the FDA Drug Label

XOLAIR is indicated for adults and pediatric patients 6 years of age and older with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. XOLAIR is indicated for add-on maintenance treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) in adult patients 18 years of age and older with inadequate response to nasal corticosteroids. XOLAIR is indicated for the treatment of adults and adolescents 12 years of age and older with chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment.

For patients with allergic rhinitis who do not respond to Zyrtec (cetirizine) and Flonase (fluticasone), alternative treatments can be considered, including:

• Omalizumab (XOLAIR), an anti-IgE antibody, for patients with moderate to severe persistent asthma or chronic rhinosinusitis with nasal polyps who have inadequate response to nasal corticosteroids 2.
• Omalizumab (XOLAIR) for patients with chronic spontaneous urticaria who remain symptomatic despite H1 antihistamine treatment 2.
• Omalizumab (XOLAIR) for patients with IgE-mediated food allergy for the reduction of allergic reactions (Type I), including anaphylaxis, that may occur with accidental exposure to one or more foods 2.

Key considerations for the use of omalizumab include:

• Initiation of therapy in a healthcare setting with close observation for anaphylaxis
• Patient education on signs and symptoms of anaphylaxis and instruction to seek immediate medical care if symptoms occur
• Selection of patients for self-administration based on criteria to mitigate risk from anaphylaxis.

From the Research

Alternative Treatments for Allergic Rhinitis

When Zyrtec (cetirizine) and Flonase (fluticasone) do not provide adequate relief for allergic rhinitis, several alternative treatments can be considered.

• Combination therapy with montelukast and levocetirizine has been shown to be effective in treating nasal symptoms of allergic rhinitis complicated with asthma 3.
• Montelukast plus cetirizine has been found to be effective in the prophylactic treatment of seasonal allergic rhinitis, reducing clinical symptoms and nasal allergic inflammation 4.
• Fluticasone propionate aqueous nasal spray (FPANS) in mono-therapy or combined therapy with cetirizine or montelukast has been compared, and results suggest that FPANS is highly effective for treating patients affected by allergic rhinitis, with efficacy exceeding that of cetirizine plus montelukast in combined therapy 5.

Prescription Allergy Pills

Some prescription allergy pills that can be considered as alternatives or additions to Zyrtec and Flonase include:

• Montelukast (Singulair) - an antileukotriene that can be used alone or in combination with antihistamines like cetirizine or levocetirizine 3, 4.
• Levocetirizine (Xyzal) - an antihistamine that can be used in combination with montelukast for treating allergic rhinitis with asthma 3.

Key Findings

Key findings from the studies suggest that:

• Combination therapy with montelukast and levocetirizine is effective in improving symptoms of allergic rhinitis 3.
• Montelukast plus cetirizine is effective in preventing AR symptoms and reduces allergic inflammation in nasal mucosa during natural allergen exposure 4.
• FPANS is highly effective for treating patients affected by allergic rhinitis, with efficacy exceeding that of cetirizine plus montelukast in combined therapy 5.