What are the treatment options for seasonal allergies?

Treatment Options for Seasonal Allergies

For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, intranasal corticosteroids are recommended as first-line monotherapy rather than combination therapy with oral antihistamines. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective medication class for controlling all symptoms of allergic rhinitis 2
• Works primarily through anti-inflammatory effects
• Examples: fluticasone, triamcinolone, budesonide, mometasone 3
• Common side effects: nasal irritation, epistaxis (6.9%), headache (16.1%) 4
• Should be used regularly for optimal effect

Second-Generation Oral Antihistamines

• Effective for sneezing, itching, and rhinorrhea, but less effective for nasal congestion 2
• Better safety profile than first-generation antihistamines
• Examples: cetirizine, fexofenadine, desloratadine, loratadine 3
• Appropriate for mild intermittent or mild persistent allergic rhinitis 3

Intranasal Antihistamines

• Examples: azelastine, olopatadine 3
• Can be used as monotherapy for mild symptoms
• May be combined with intranasal corticosteroids for enhanced efficacy

Second-Line Treatment Options

Leukotriene Receptor Antagonists

• For patients aged 15 years or older, intranasal corticosteroids are recommended over leukotriene receptor antagonists 1
• Montelukast has demonstrated efficacy for seasonal allergic rhinitis 5
• Particularly useful in patients with comorbid asthma 2

Combination Therapy

• For moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment 1
• This combination provides superior symptom relief compared to either medication alone 2

Treatment Algorithm Based on Symptom Severity

1. Mild Intermittent Symptoms:

   • Second-generation oral antihistamine OR
   • Intranasal antihistamine

2. Mild Persistent Symptoms:

   • Intranasal corticosteroid monotherapy

3. Moderate to Severe Symptoms:

   • Intranasal corticosteroid monotherapy OR
   • Combination of intranasal corticosteroid plus intranasal antihistamine

Special Considerations

Inadequate Response to Standard Therapy

• Studies show that even with optimal pharmacotherapy, up to 62% of patients experience troublesome residual symptoms 6
• For patients with severe symptoms not responding to conventional treatments, consider:
  • Short course (5-7 days) of oral corticosteroids 2
  • Allergen immunotherapy for long-term management 2

Comorbid Conditions

• Allergic rhinitis is associated with asthma, eczema, chronic sinusitis, and headaches 3
• Coordinate treatment approach for patients with comorbidities 2
• Consider leukotriene receptor antagonists for patients with both allergic rhinitis and asthma 2

Age-Specific Considerations

• Avoid first-generation antihistamines in older adults due to risk of psychomotor impairment and falls 2
• OTC cough and cold medications should be avoided in young children due to safety concerns 2

Common Pitfalls to Avoid

1. Undertreatment: Many patients use medications inappropriately or inconsistently, leading to poor symptom control 6

2. Overreliance on oral antihistamines: While convenient, they are less effective for nasal congestion than intranasal corticosteroids 3

3. Inadequate duration of treatment: Intranasal corticosteroids may take several days to reach full effectiveness

4. Neglecting allergen avoidance: Reduction of exposure to triggering allergens should accompany pharmacotherapy 3

5. Failure to recognize mixed forms: Studies show that up to 80% of allergic rhinitis patients have mixed seasonal and perennial forms 7, requiring year-round management strategies

By following this evidence-based approach to treating seasonal allergies, clinicians can help patients achieve better symptom control and improved quality of life.