What is the best treatment for seasonal allergies?

Treatment of Seasonal Allergies

For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, an intranasal corticosteroid should be prescribed as monotherapy rather than in combination with an oral antihistamine. 1

First-Line Treatment Recommendations

Adults and Adolescents (12+ years)

• First choice: Intranasal corticosteroid (INCS) 1
  • Example: Fluticasone propionate 200 mcg once daily (two 50-mcg sprays in each nostril) 2
  • Alternative dosing: 100 mcg twice daily (one 50-mcg spray in each nostril twice daily) 2
  • Onset of action can be as soon as 12 hours, with maximum effect taking several days 2

Children (4-11 years)

• Start with 100 mcg INCS once daily (one spray in each nostril) 2, 3
• Reserve 200 mcg dosing for children not adequately responding to 100 mcg daily 2
• Fluticasone propionate 100 mcg is as effective as 200 mcg in children and well-tolerated 3

Treatment Algorithm Based on Severity

Mild to Moderate Symptoms

1. Intranasal corticosteroid monotherapy 1
   • More effective than leukotriene receptor antagonists (strong recommendation) 1
   • More effective than oral antihistamines for nasal congestion 4

Moderate to Severe Symptoms

1. Consider combination of intranasal corticosteroid + intranasal antihistamine 1
   • This combination provides greater symptom reduction than either agent alone
   • Particularly effective for patients with TNSS ≥ 8/12 and congestion score ≥ 2/3 1
   • Note: This is a weak recommendation, but clinically meaningful 1

Comparative Effectiveness

• Intranasal corticosteroids are superior to:
  • Leukotriene receptor antagonists (montelukast) 1, 5
  • Combination of montelukast and loratadine for nighttime symptoms 5
• Once-daily dosing of fluticasone propionate is as effective as twice-daily dosing 2, 6

Common Pitfalls to Avoid

1. Adding oral antihistamines to intranasal corticosteroids

   • No proven additional benefit for nasal symptoms 1
   • May increase risk of sedation and other adverse effects

2. Using leukotriene receptor antagonists as first-line therapy

   • Less effective than intranasal corticosteroids 1, 5
   • Consider only for patients who cannot tolerate intranasal corticosteroids or have concurrent mild persistent asthma 1

3. Inadequate duration of therapy

   • Maximum effect may take several days to achieve 2
   • Regular scheduled use provides better symptom control than as-needed use 2

Special Considerations

• Ocular symptoms: Oral antihistamines may provide better relief for eye symptoms than intranasal corticosteroids alone 4
• Combination therapy side effects: Dysgeusia (altered taste) is the most common adverse event with intranasal antihistamine combinations (2.1%-13.5% of patients) 1
• Children: Fluticasone propionate at 100 mcg daily does not appear to interfere with hypothalamic-pituitary-adrenal axis function 3

Dosing Flexibility

• Some patients (12+ years) with seasonal allergic rhinitis may benefit from as-needed use of intranasal corticosteroids (not exceeding 200 mcg daily) 2
• After 4-7 days of regular use, maintenance with 100 mcg/day may be sufficient for patients who have responded well 2