Nasal Antihistamine Options for Allergic Rhinitis
Intranasal antihistamines are effective treatment options for seasonal, perennial, or episodic allergic rhinitis and can be used as first-line or second-line therapy depending on patient characteristics and symptom patterns. 1
Available Intranasal Antihistamine Options
FDA-Approved Products
Azelastine (Astelin) 0.1% solution (137 μg per spray)
- Indications: Seasonal allergic rhinitis, vasomotor rhinitis
- Ages: ≥6 years
- Dosing: Ages 6-11: 1 spray twice daily; Ages ≥12: 1-2 sprays twice daily or 2 sprays daily
- Prescription only 1
Azelastine (Astepro) 0.15% solution (205.5 μg per spray)
- Indications: Seasonal and perennial allergic rhinitis
- Ages: ≥6 years
- Dosing: Ages 6-11: 1 spray twice daily; Ages ≥12: 1-2 sprays twice daily or 2 sprays daily
- Prescription only 1
Olopatadine (Patanase) 0.6% (665 μg per spray)
- Indications: Seasonal allergic rhinitis
- Ages: ≥6 years
- Dosing: Ages 6-11: 1 spray twice daily; Ages ≥12: 2 sprays twice daily
- Prescription only 1
Azelastine plus fluticasone (Dymista) (137 μg azelastine, 50 μg fluticasone per spray)
- Indications: Seasonal allergic rhinitis
- Ages: ≥12 years
- Dosing: 1 spray per nostril twice daily
- Prescription only 1
Efficacy and Clinical Use
Advantages of Intranasal Antihistamines
- Rapid onset of action (within 15-30 minutes), making them ideal for episodic symptoms or pre-treatment before allergen exposure 1, 2
- Targeted delivery to nasal tissues while limiting systemic effects 1
- Superior efficacy for nasal congestion compared to oral antihistamines 1, 3
- Effective even in patients who fail oral antihistamine treatment 4
Comparative Efficacy
- Intranasal antihistamines show equality or superiority to oral antihistamines for nasal symptoms 1, 3
- Azelastine has shown comparable efficacy to fluticasone propionate (a potent intranasal corticosteroid) and superior efficacy to mometasone furoate 4, 5
- The combination of azelastine and fluticasone provides greater efficacy than either agent used alone for difficult-to-treat seasonal allergic rhinitis 6, 5
Safety and Adverse Effects
Common Side Effects
- Bitter taste (most common, can be minimized with correct dosing technique) 1, 2
- Epistaxis (nosebleed) 1
- Somnolence (reported rates 0.4-3%, similar to placebo in recent studies) 1, 2
- Headache 1
Safety Considerations
- Caution with concurrent use of alcohol or CNS depressants due to potential for additional reductions in alertness 7
- Monitor for somnolence at initiation of therapy 1
- Follow-up advised to assess response and side effects 1
Clinical Decision Making
When to Consider as First-Line Therapy
- Patients with episodic nasal symptoms requiring rapid relief 1
- Patients needing pre-treatment before allergen exposure 1
- Patients with predominant nasal congestion who prefer not to use intranasal corticosteroids 1, 3
When to Consider as Second-Line Therapy
- After failure of intranasal corticosteroids or oral antihistamines 6
- For patients with moderate to severe symptoms requiring combination therapy 6
Dosing Considerations
- Lower doses (1 spray per nostril twice daily) are effective with improved tolerability compared to higher doses 4
- Can be used on an as-needed basis without compromising clinical efficacy 4
Important Clinical Pearls
- Correct dosing technique is essential to minimize bitter taste and optimize efficacy 4
- Prime the delivery system before initial use and after storage for 3 or more days 7
- Keep head tilted downward when spraying to avoid medication flowing into the throat 7
- Alternate sprays between nostrils and breathe gently to avoid drawing medication into the throat 7
Conclusion
Intranasal antihistamines represent an effective option for allergic rhinitis treatment with advantages of rapid onset and targeted delivery. While the American Academy of Otolaryngology-Head and Neck Surgery guidelines suggest they may generally represent second-line therapy after intranasal corticosteroids or oral antihistamines due to taste, cost, and need for twice-daily dosing, they may be appropriate first-line therapy for specific patients, particularly those with episodic symptoms requiring rapid relief.