What treatment can be given to a patient with severe seasonal allergic symptoms, currently taking Zyrtec (cetirizine) and Flonase (fluticasone), without relief, 11 days after completing a 7-day course of amoxicillin for a sinus infection?

From the Guidelines

For a patient with severe seasonal allergies not responding to Zyrtec and Flonase, I recommend adding a nasal antihistamine such as azelastine (Astelin) 1-2 sprays in each nostril twice daily, as this combination has been shown to provide additional benefit in patients with moderate-to-severe seasonal allergic rhinitis 1. This approach is supported by the 2017 Joint Task Force on Practice Parameters, which suggests that the addition of an intranasal antihistamine to an intranasal corticosteroid can be beneficial for patients with moderate-to-severe seasonal allergic rhinitis 1. Some key points to consider when implementing this treatment plan include:

• Ensuring the patient is using Flonase correctly (1-2 sprays in each nostril daily) and consistently, as intranasal steroids take several days to reach full effectiveness.
• Considering alternative treatments, such as switching to a stronger oral antihistamine like levocetirizine (Xyzal) 5mg once daily or fexofenadine (Allegra) 180mg once daily, if the patient does not respond to the addition of azelastine.
• Using saline nasal irrigation with a neti pot or similar device to help clear allergens and mucus.
• Implementing environmental modifications, such as keeping windows closed, using air purifiers, and showering after outdoor exposure, to reduce allergen exposure. It is also important to note that the patient has recently completed a course of amoxicillin for a sinus infection, and it is essential to monitor for any potential interactions or side effects with the new treatment plan. Overall, the goal of this treatment plan is to provide relief from severe seasonal allergy symptoms while minimizing the risk of adverse effects and interactions.

From the FDA Drug Label

In 4 randomized, doubleblind, vehicle placebo-controlled, parallel- group allergic rhinitis studies and 2 studies of patients in an outdoor “park” setting (park studies), a decrease in nasal symptoms in treated subjects compared to placebo was shown to occur as soon as 12 hours after treatment with a 200-mcg dose of Fluticasone Propionate Nasal Spray, USP. Maximum effect may take several days Regular-use patients who have responded may be able to be maintained (after 4 to 7 days) on 100 mcg/day (1 spray in each nostril once daily). Some patients (12 years of age and older) with seasonal allergic rhinitis may find as-needed use of Fluticasone Propionate Nasal Spray, USP (not to exceed 200 mcg daily) effective for symptom control

The patient is already taking the maximum recommended dose of Fluticasone Propionate Nasal Spray, USP (200 mcg/day). No dose adjustment is recommended. Consider adding or substituting other treatments for seasonal allergic rhinitis, such as:

• Antihistamines (the patient is already taking Zyrtec, cetirizine)
• Decongestants
• Immunotherapy
• Other nasal corticosteroids are not recommended as the patient is already taking Fluticasone Propionate Nasal Spray, USP at the maximum dose. 2

From the Research

Treatment Options for Severe Seasonal Allergic Symptoms

• The patient is currently taking Zyrtec (cetirizine) and Flonase (fluticasone) without relief, and has completed a 7-day course of amoxicillin for a sinus infection 11 days ago 3.
• Considering the patient's lack of response to current treatment, alternative medications with unrelated chemical structures may be substituted 3.
• Additional therapy for severe seasonal allergic symptoms may include topical corticosteroids, oral antihistamines, and in severe cases, systemic corticosteroids 3.

Consideration of Other Treatment Options

• Omalizumab may be considered as a treatment option for adult patients with severe asthma and food allergies, as it has been shown to improve asthma control and induce pharmacological remission of food allergy 4.
• Biologics and allergy immunotherapy may also be considered for the treatment of allergic diseases, as they can provide lasting benefits after discontinuation 5.
• Cetirizine has been shown to be effective in reducing symptoms of seasonal allergic rhinitis, perennial allergic rhinitis, and chronic idiopathic urticaria, and may be considered as an alternative treatment option 6, 7.

Important Considerations

• Diagnosis of drug allergy or other conditions should be made through a careful history and physical examination, and may require referral to an allergist 3.
• Cross-reactivity among drugs should be taken into consideration when choosing alternative agents 3.
• The patient's recent completion of a 7-day course of amoxicillin for a sinus infection should be considered when evaluating their current symptoms and treatment options 3.