From the Guidelines
For allergies that do not respond to oral antihistamines, the most effective alternative treatment is intranasal corticosteroids, such as fluticasone (Flonase), mometasone (Nasonex), or budesonide (Rhinocort), which can significantly reduce nasal symptoms. According to the 2017 joint task force on practice parameters 1, intranasal corticosteroids are the most effective medication class for controlling symptoms of seasonal allergic rhinitis.
Treatment Options
- Intranasal corticosteroids: 1-2 sprays per nostril daily, effective for nasal symptoms
- Leukotriene modifiers: montelukast (Singulair), 10mg tablet once daily for adults, helps with nasal and respiratory symptoms
- Antihistamine eye drops: ketotifen (Zaditor) or olopatadine (Pataday), 1-2 drops twice daily, provides relief for eye symptoms
- Decongestants: pseudoephedrine, temporary relief for nasal congestion, but not recommended for long-term use due to rebound effects
- Immunotherapy: allergy shots or sublingual tablets, gradually desensitizes the immune system over 3-5 years, suitable for severe cases
- Biologics: omalizumab (Xolair), prescribed for severe cases
Recommendation
The best option depends on specific symptoms, allergy triggers, and medical history. As stated in the 2015 clinical practice guideline for allergic rhinitis 1, clinicians should recommend intranasal steroids for patients with allergic rhinitis whose symptoms affect their quality of life. Intranasal corticosteroids are the preferred treatment for moderate to severe seasonal allergic rhinitis, as they have been shown to be more effective than leukotriene receptor antagonists 1.
Considerations
When considering treatment options, it is essential to assess the patient's symptoms, medical history, and potential allergies. As recommended in the 2015 guideline 1, clinicians should assess patients with allergic rhinitis for associated conditions such as asthma, atopic dermatitis, and sleep-disordered breathing. Combination therapy, including intranasal corticosteroids and intranasal antihistamines, may be recommended for patients with moderate to severe seasonal allergic rhinitis 1.
From the FDA Drug Label
For allergic states, prednisone is indicated for the control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment: Seasonal or perennial allergic rhinitis. The treatment options for allergies that do not respond to oral antihistamines include prednisone (PO), as it is indicated for the control of severe or incapacitating allergic conditions, including seasonal or perennial allergic rhinitis, intractable to adequate trials of conventional treatment 2.
- Key points:
- Prednisone is used for severe or incapacitating allergic conditions.
- It is an option when conventional treatments, such as oral antihistamines, are not effective.
- The use of prednisone should be considered under the guidance of a healthcare professional due to its potential side effects and the need for careful patient monitoring.
From the Research
Treatment Options for Allergies Not Responding to Oral Antihistamines
- Intranasal corticosteroids are a viable treatment option for allergies that do not respond to oral antihistamines, as they have been shown to be effective in treating seasonal allergic rhinitis and as prophylaxis for perennial allergic rhinitis 3.
- Several intranasal corticosteroids are available, including beclomethasone dipropionate, budesonide, flunisolide, fluticasone propionate, mometasone furoate, and triamcinolone acetonide, all of which have been found to be efficacious in relieving nasal congestion and itching, rhinorrhea, and sneezing 3.
- A study comparing the efficacy of intranasal steroid spray (mometasone furoate) with oral corticosteroids found that both treatments were effective in reducing nasal symptoms in patients with seasonal allergic rhinitis, but intranasal corticosteroids had fewer side effects 4.
- Intranasal corticosteroids have been shown to be the most effective form of pharmacologic treatment for allergic rhinitis, and are considered the drug of choice for pediatric allergic rhinitis due to their improved risk-benefit ratio compared to oral antihistamines and corticosteroids 5.
- A review of randomized, controlled trials found that intranasal corticosteroids offered superior relief in allergic rhinitis compared to antihistamines, and that combining antihistamines and intranasal corticosteroids did not provide additional beneficial effects 6.
Comparison of Treatment Options
- Intranasal corticosteroids have been found to be more effective than oral antihistamines in treating allergic rhinitis, with a faster onset of action and fewer side effects 7.
- Oral corticosteroids are also effective in treating allergic rhinitis, but have more systemic side effects compared to intranasal corticosteroids 4.
- The choice of treatment should be based on the individual patient's needs and medical history, as well as the severity of their symptoms 5.
Safety and Efficacy
- Intranasal corticosteroids have been found to be safe and effective in treating allergic rhinitis, with minimal systemic side effects 3, 5.
- The most common side effects of intranasal corticosteroids are local, such as dryness, burning, and stinging of the nasal mucosa, and are generally mild and transient 3.
- Oral corticosteroids, on the other hand, can have more systemic side effects, such as weight gain, mood changes, and increased blood pressure 4.