How long should nasal corticosteroids (NS) spray with azelastine be used to manage allergic rhinitis?

Duration of Nasal Corticosteroid Spray with Azelastine for Allergic Rhinitis

Nasal corticosteroid spray with azelastine should be used for up to 6 months for allergic rhinitis before reassessment, with follow-up recommended within 2-4 weeks of initiating treatment to evaluate response and side effects. 1

Dosing and Administration

For combination therapy with azelastine plus fluticasone (Dymista):

• Approved for ages ≥12 years
• Dosing: 1 spray per nostril twice daily 2

For azelastine alone:

• Ages 6-11 years: 1 spray twice a day
• Ages ≥12 years: 1-2 sprays twice a day or 2 sprays daily 2

Efficacy and Onset of Action

• Combination therapy with intranasal corticosteroid and intranasal antihistamine (azelastine) provides greater symptom reduction than either agent alone 1
• Azelastine has a rapid onset of action (within 15 minutes) 3
• Duration of effect lasts 12-24 hours, allowing for once or twice daily dosing 4
• Studies show azelastine nasal spray monotherapy is as effective as combination therapy with oral loratadine plus intranasal beclomethasone for moderate-to-severe symptoms 5

Side Effects and Monitoring

Common side effects include:

• Bitter taste (most common, reported in 8-19.7% of patients) 2
• Epistaxis (nosebleed)
• Somnolence (reported in 0.9-11.5% of patients) 2
• Headache

Important monitoring considerations:

• Follow-up within 2-4 weeks to assess response and side effects 1
• Monitor for signs of somnolence, especially at initiation of therapy 2
• If taste aversion occurs, a trial of a second formulation may be beneficial 2

Clinical Pearls and Pitfalls

1. Sedation potential: While newer studies show lower somnolence rates (0.4-3%) compared to earlier studies (11%), caution patients about this potential side effect, especially when driving or operating machinery 2

2. Treatment failure: If symptoms persist despite 2-4 weeks of appropriate therapy, consider:

   • Allergen testing
   • Immunotherapy
   • Consultation with an allergist/immunologist 1

3. Special populations: Use with caution in:

   • Older adults
   • Patients with glaucoma
   • Patients on anticoagulants (increased risk of epistaxis) 1

4. Advantage over oral antihistamines: Intranasal antihistamines like azelastine are more effective for nasal congestion than oral preparations 2

5. Flexibility of use: Azelastine can be used as first- or second-line therapy and is especially useful for patients with episodic nasal symptoms or as pretreatment prior to allergen exposure 2