Can levocetirizine (antihistamine) and montelukast (leukotriene receptor antagonist) be used to treat a blocked nose?

Treatment of Nasal Obstruction with Levocetirizine and Montelukast

Combination therapy with levocetirizine and montelukast can be effective for treating nasal obstruction, particularly in patients with allergic rhinitis, though intranasal corticosteroids remain the first-line therapy for nasal congestion.

First-Line Treatment Options

• Intranasal corticosteroids are recommended as first-line therapy for nasal congestion, providing superior relief for nasal congestion, rhinorrhea, sneezing, and reduced sense of smell 1
• For persistent or moderate-to-severe symptoms, intranasal corticosteroids are more effective than either antihistamines or leukotriene receptor antagonists (LTRAs) alone 2, 1

Role of Levocetirizine (Antihistamine)

• Levocetirizine is effective for symptoms of allergic rhinitis, particularly:
  • Sneezing
  • Rhinorrhea (runny nose)
  • Itching
• Less effective for nasal congestion/obstruction compared to intranasal corticosteroids 1
• Works by blocking histamine H1 receptors, reducing allergic inflammatory response

Role of Montelukast (LTRA)

• Montelukast is effective in treating both seasonal and perennial allergic rhinitis 2
• Similar efficacy to antihistamines when used as monotherapy 2
• May be particularly useful in patients with coexisting asthma and allergic rhinitis 2
• Has an excellent safety profile and is approved for use in children as young as 6 months 2

Combination Therapy Effectiveness

• The combination of montelukast and levocetirizine has shown greater efficacy than either agent alone in persistent allergic rhinitis 3

• In a randomized, double-blind study, the combination therapy resulted in:

  • Greater improvement in nasal symptoms (mean score 2.14 ± 0.39) compared to levocetirizine alone (3.02 ± 0.64) or montelukast alone (3.44 ± 0.55) 3
  • Greater decreases in inflammatory markers (eosinophil cationic protein) 3

• However, another study found that montelukast, levocetirizine, and their combination were equally effective in controlling symptoms of allergic rhinitis 4

Treatment Algorithm for Nasal Obstruction

1. First-line therapy: Intranasal corticosteroids

2. For patients with inadequate response after 2-4 weeks:

   • Add levocetirizine for predominant symptoms of sneezing, itching, or rhinorrhea
   • Add montelukast if patient has coexisting asthma or if antihistamines alone are insufficient
   • Consider combination therapy with levocetirizine and montelukast for persistent symptoms

3. For severe symptoms or inadequate response:

   • Consider a short course (5-10 days) of oral corticosteroids to break the inflammatory cycle 1
   • Consider referral to specialist if symptoms remain uncontrolled after 4-6 weeks of optimal therapy 1

Special Considerations

• Stability concerns: When combining montelukast (alkaline stable) with levocetirizine (acid stable), a bilayer tablet formulation is recommended for improved stability compared to a matrix tablet 5

• Patients with asthma: Montelukast has been approved for both rhinitis and asthma, making it a good choice for patients with both conditions 2

• Long-term management: Combination therapy shows gradual increase in symptom improvement over 6 weeks of treatment 6

Caveats and Limitations

• The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) does not recommend adding montelukast to nasal corticosteroids for chronic rhinosinusitis with nasal polyps 2

• Combination therapy may increase cost and potential for side effects compared to monotherapy

• For chronic rhinosinusitis, evidence for montelukast is limited, with most studies focused on allergic rhinitis 2

• Consider saline nasal irrigations as an adjunctive therapy to help reduce inflammation and improve muco-ciliary clearance 1