What is the recommended treatment and dosage for allergic rhinitis using Ryaltris (azelastine and fluticasone)?

Ryaltris (Azelastine and Fluticasone) for Allergic Rhinitis Treatment

For moderate to severe allergic rhinitis in patients 12 years and older, Ryaltris (azelastine and fluticasone combination) is recommended at a dosage of 1 spray per nostril twice daily. 1

Medication Information

Ryaltris is a combination nasal spray containing:

• Azelastine hydrochloride (137 μg per spray): intranasal antihistamine
• Fluticasone propionate (50 μg per spray): intranasal corticosteroid

This fixed-dose combination provides several advantages:

• Superior efficacy: Combination therapy shows greater symptom reduction compared to either agent alone, with clinical trials demonstrating 37-40% relative improvement with combination therapy versus 24-29% for individual components 1, 2
• Rapid onset: Azelastine provides quick symptom relief (within 15 minutes) 3
• Comprehensive coverage: Addresses multiple allergic rhinitis pathways simultaneously

Dosing Recommendations

• Adults and adolescents (≥12 years): 1 spray per nostril twice daily 1
• Children (<12 years): Not FDA approved for this age group

Clinical Evidence

The combination of azelastine and fluticasone in a single device has demonstrated:

• Greater reduction in Total Nasal Symptom Score (TNSS) compared to monotherapy with either agent 1, 2
• Improvement in both nasal and ocular symptoms 1
• Enhanced quality of life measures, though not consistently exceeding the minimal clinically important difference compared to monotherapies 1

Common Side Effects

• Bitter taste (dysgeusia): 2.1-13.5% of patients 1
• Epistaxis (nosebleed)
• Headache
• Somnolence: 0.4-1.1% (similar to placebo in most studies) 1

Treatment Algorithm

1. For mild, intermittent symptoms:

   • Consider second-generation oral antihistamine

2. For moderate to severe or persistent symptoms:

   • First-line: Intranasal corticosteroid alone (fluticasone or mometasone) 4
   • Second-line: Combination therapy with azelastine/fluticasone (Ryaltris) when monotherapy is inadequate 2

3. For patients with both allergic rhinitis and asthma:

   • Consider adding a leukotriene receptor antagonist 1

Administration Technique

For optimal efficacy:

• Gently blow nose before administration
• Shake bottle well before use
• Tilt head slightly forward
• Insert spray tip into nostril, pointing away from nasal septum
• Breathe in gently while spraying
• Avoid sniffing forcefully after spraying

Clinical Pearls

• Patient satisfaction with Ryaltris may be influenced by sensory attributes, with some studies showing patients prefer the sensory profile of alternative combination products 5
• Combination therapy is particularly beneficial for patients with moderate-to-severe symptoms not adequately controlled with monotherapy 2
• The combination provides faster onset of action than intranasal corticosteroids alone, making it useful for patients needing rapid symptom relief 3
• Somnolence rates with intranasal antihistamines are much lower than previously thought (0.4-3%) and similar to placebo in recent studies 1