What is the best treatment for seasonal allergies?

Best Treatment for Seasonal Allergies

For initial treatment of seasonal allergic rhinitis in adults and adolescents aged 12 years and older, intranasal corticosteroids are recommended as first-line therapy due to their superior efficacy in controlling all symptoms. 1

Treatment Algorithm

First-Line Therapy

1. Intranasal Corticosteroids
   • Most effective medication class for controlling all symptoms of seasonal allergic rhinitis
   • Superior efficacy for nasal congestion, rhinorrhea, sneezing, and itching
   • Options include fluticasone propionate, mometasone furoate, and budesonide
   • Recommended as monotherapy rather than in combination with oral antihistamines 1

The 2017 Joint Task Force on Practice Parameters strongly recommends intranasal corticosteroids over leukotriene receptor antagonists for initial treatment of seasonal allergic rhinitis in persons aged 15 years or older 1. This recommendation is based on high-quality evidence showing superior symptom control with intranasal corticosteroids.

Second-Line or Adjunctive Therapy

1. Second-Generation Oral Antihistamines

   • Effective for mild symptoms or when sneezing and itching are predominant
   • Options include cetirizine, loratadine, fexofenadine
   • Less effective than intranasal corticosteroids, especially for nasal congestion 2
   • Studies show cetirizine may be more effective than loratadine in reducing symptom scores 3, 4

2. Intranasal Antihistamines

   • Rapid onset of action (15-30 minutes)
   • Options include azelastine and olopatadine
   • Potential drawbacks include bitter taste and somnolence 2

3. Combination Therapy for Moderate-to-Severe Symptoms

   • For moderate to severe seasonal allergic rhinitis, the combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment 1
   • This combination has shown greater symptom reduction than either agent alone

Third-Line Options

1. Leukotriene Receptor Antagonists (e.g., Montelukast)
   • Less effective than intranasal corticosteroids 1
   • Not recommended as primary therapy for allergic rhinitis 2
   • May be considered when patients have coexisting asthma 5

Important Considerations

Efficacy Comparisons

• In controlled studies, intranasal corticosteroids like fluticasone have demonstrated superior efficacy compared to oral antihistamines and leukotriene receptor antagonists 1
• Among antihistamines, cetirizine has shown greater improvement in symptoms compared to terfenadine and placebo 3, and also demonstrated superior efficacy to loratadine in field studies 4

Safety Considerations

• Intranasal corticosteroids have a well-established safety profile 6
• Second-generation antihistamines have minimal sedation compared to first-generation options 2
• Avoid oral decongestants in children under 6 years due to safety concerns 2
• Prolonged use of topical decongestants can lead to rebound congestion (rhinitis medicamentosa) 2

Common Pitfalls to Avoid

1. Inadequate dosing or improper administration technique of intranasal corticosteroids, which can reduce efficacy
2. Using first-generation antihistamines due to significant sedation and anticholinergic effects
3. Relying solely on oral antihistamines for patients with significant nasal congestion
4. Prolonged use of topical decongestants leading to rebound congestion
5. Failure to consider combination therapy in patients with moderate-to-severe symptoms not responding to monotherapy

For patients with persistent symptoms despite optimal pharmacotherapy, referral for consideration of allergen immunotherapy may be appropriate, as it is the only disease-modifying treatment option available for seasonal allergic rhinitis 1, 2.