What is the recommended care plan for patients with seasonal allergies?

Recommended Care Plan for Seasonal Allergies

Intranasal corticosteroids are the first-line treatment for seasonal allergies due to their superior effectiveness in controlling symptoms compared to other medication classes. 1

First-Line Treatment Options

For Adults and Adolescents (12+ years):

• Intranasal corticosteroid monotherapy (preferred first-line treatment)
  • Fluticasone propionate: 2 sprays (50 mcg each) in each nostril once daily (200 mcg total) 2
  • Alternative regimen: 1 spray in each nostril twice daily (200 mcg total) 2
  • Once symptoms are controlled, may reduce to 1 spray in each nostril once daily (100 mcg total) for maintenance 1, 2

For Children (4-11 years):

• Intranasal corticosteroid
  • Start with 1 spray in each nostril once daily (100 mcg total) 2
  • May increase to 2 sprays in each nostril once daily (200 mcg total) if inadequate response 2
  • Once controlled, decrease to maintenance dose of 1 spray in each nostril once daily 2

Second-Line and Alternative Options

1. Intranasal antihistamines (e.g., azelastine, olopatadine)

   • More effective than oral antihistamines, particularly for nasal congestion 1
   • Faster onset of action compared to oral antihistamines (15 minutes vs. 60-75 minutes) 3

2. Oral second-generation antihistamines

   • Options include cetirizine, fexofenadine, desloratadine, loratadine 4
   • Useful for mild intermittent symptoms or when predominant symptoms are ocular 1, 4
   • Avoid first-generation antihistamines due to sedating effects 1

3. Leukotriene receptor antagonists (e.g., montelukast)

   • Less effective than intranasal corticosteroids for nasal symptom reduction 5
   • May be considered for patients who cannot tolerate intranasal medications 5
   • May be beneficial in patients with concurrent mild persistent asthma 5

Combination Therapy for Moderate-Severe Symptoms

For patients with inadequate response to monotherapy:

• Intranasal corticosteroid + intranasal antihistamine

  • Most effective combination for moderate-severe symptoms 1
  • Provides >40% relative improvement versus monotherapy 1

• Avoid adding oral antihistamine to intranasal corticosteroid

  • Evidence does not support benefit of this combination 5
  • May increase risk of side effects, particularly sedation with first-generation antihistamines 5

Important Precautions

1. Avoid topical decongestants for >3 days

   • Risk of rhinitis medicamentosa (rebound congestion) 1

2. Avoid intramuscular or parenteral corticosteroid injections

   • Potential for significant side effects 1

3. Regular use is more effective than as-needed use

   • Morning dosing of once-daily intranasal corticosteroids effective for controlling symptoms throughout the day 1
   • As-needed use may be considered for some patients with seasonal allergic rhinitis ≥12 years of age 2

Allergen Avoidance Measures

• Identify and minimize exposure to triggering allergens 4
• Consider environmental controls based on specific allergen sensitivities

Immunotherapy Considerations

• Consider for patients with inadequate response to pharmacologic therapy 1
• Only disease-modifying treatment option available 1
• May reduce development of asthma in patients with allergic rhinitis 1

Monitoring and Follow-up

• Assess symptom control and medication adherence
• Monitor for side effects of intranasal corticosteroids (headache, pharyngitis, epistaxis, nasal irritation) 1
• Identify and manage comorbidities (asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, otitis media) 1

Common Pitfalls to Avoid

• Using oral antihistamines as first-line treatment when intranasal corticosteroids are more effective
• Adding oral antihistamines to intranasal corticosteroids without clear evidence of benefit
• Using topical decongestants for extended periods
• Failing to identify and address comorbid conditions
• Inconsistent or as-needed use of intranasal corticosteroids when regular use is more effective