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

Dosage and Administration

• Recommended dosage: 1 spray per nostril twice daily for adults and adolescents ≥12 years 1
• For optimal efficacy:
  • Gently blow nose before administration
  • Shake bottle well before use
  • Tilt head slightly forward
  • Insert spray tip into nostril
  • Breathe in gently while spraying 1

Efficacy

The combination of azelastine and fluticasone in Ryaltris provides superior efficacy compared to either component alone:

• 37-40% relative improvement with combination therapy versus 24-29% for individual components 1
• Greater reduction in Total Nasal Symptom Score (TNSS) compared to monotherapy 1, 2
• Studies show that the combination therapy reduced TNSS by -5.31 to -5.7 points compared to -3.84 to -5.1 for fluticasone alone and -3.25 to -4.54 for azelastine alone 3
• Improvement in both nasal and ocular symptoms 3, 1

Treatment Algorithm

1. First-line for mild symptoms: Intranasal corticosteroid alone (e.g., fluticasone)
2. For moderate to severe symptoms: Combination therapy with azelastine/fluticasone (Ryaltris) 1
3. For patients who cannot tolerate intranasal corticosteroids: Consider oral antihistamines or leukotriene receptor antagonists (e.g., montelukast), though these are less effective 3
4. For patients with concurrent asthma: Consider adding a leukotriene receptor antagonist 3, 1

Side Effects and Safety

• Most common side effect: Bitter taste (dysgeusia) in 2.1-13.5% of patients 3, 1
• Other potential side effects:
  • Epistaxis (nosebleed)
  • Headache
  • Somnolence (0.4-1.1% of patients) 1
• Recent studies show somnolence rates with intranasal antihistamines are similar to placebo (0.4-3%) 1
• Overall excellent safety profile 4

Clinical Considerations

• Combination therapy is particularly beneficial for patients with moderate to severe symptoms not adequately controlled with monotherapy 3, 2
• The 2017 Joint Task Force on Practice Parameters provides a weak recommendation for combination therapy as initial treatment for moderate to severe seasonal allergic rhinitis 3
• Patient satisfaction studies suggest that sensory attributes (taste, smell, irritation) are important factors in treatment adherence 5

Pitfalls and Caveats

• Exceeding the recommended dose does not provide additional efficacy 6
• Individual response to treatment may vary, with onset of action occurring as soon as 12 hours but maximum effect taking several days 6
• Quality of life improvements with combination therapy do not consistently exceed the minimal clinically important difference compared to monotherapies 3
• For pediatric patients (4-11 years), treatment should be initiated with lower doses and increased only if inadequate response is observed 6