What is the best antihistamine (anti-histaminic) for allergic rhinitis?

From the Guidelines

The best antihistamine for allergic rhinitis is a second-generation antihistamine like cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra), or levocetirizine (Xyzal), as they are generally recommended as first-line treatments and have been shown to be effective in relieving symptoms with minimal sedation 1.

Key Considerations

• Second-generation antihistamines are preferred over first-generation antihistamines due to their minimal sedation and performance impairment compared to first-generation options like diphenhydramine (Benadryl) 1.
• These medications are typically taken once daily at doses of 5-10mg for cetirizine, 10mg for loratadine, 180mg for fexofenadine, or 5mg for levocetirizine.
• For persistent symptoms, these medications can be used daily during allergy season or year-round if needed.
• If antihistamines alone don't provide adequate relief, adding an intranasal corticosteroid spray like fluticasone propionate may help with nasal congestion.

Treatment Options

• Second-generation antihistamines: cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra), or levocetirizine (Xyzal)
• Intranasal corticosteroid sprays: fluticasone propionate
• Combination therapy: intranasal antihistamine and intranasal corticosteroid in separate devices or as a single combination spray 1

Important Notes

• Consult with a healthcare provider for personalized treatment, especially for severe cases.
• The 2017 Joint Task Force on Practice Parameters recommends the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Antihistamines for Allergic Rhinitis

• Second-generation oral antihistamines, such as cetirizine, loratadine, and fexofenadine, are commonly used to treat allergic rhinitis 2, 3, 4.
• These antihistamines are considered first-line therapy for mild-to-moderate allergic rhinitis and are available over the counter in many countries 2, 3.
• Intranasal antihistamines, such as azelastine and olopatadine, are also effective in treating allergic rhinitis and can be used in combination with oral antihistamines 3.

Efficacy of Specific Antihistamines

• Loratadine has been shown to be effective in relieving symptoms of seasonal allergic rhinitis, including nasal discharge, sneezing, and itching/burning eyes 5.
• Cetirizine has been found to be effective in reducing symptoms of allergic rhinitis, including nasal congestion, and is considered a good option for patients with mild-to-moderate symptoms 2, 3, 4.
• Fexofenadine has also been shown to be effective in relieving symptoms of allergic rhinitis, including nasal congestion, and is considered a good option for patients with mild-to-moderate symptoms 3, 4.

Safety and Tolerability

• Second-generation antihistamines, such as cetirizine, loratadine, and fexofenadine, are generally well-tolerated and have a lower incidence of adverse effects compared to first-generation antihistamines 2, 3, 4.
• Intranasal antihistamines, such as azelastine and olopatadine, are also generally well-tolerated and can be used in combination with oral antihistamines 3.
• The safety and efficacy of second-generation antihistamines and montelukast have been established in pediatric patients, including infants and children 6.