What is the dosage and treatment plan for Azelastine (antihistamine) for allergic rhinitis?

Azelastine Dosage and Treatment Plan for Allergic Rhinitis

For allergic rhinitis treatment, azelastine nasal spray is dosed at 1-2 sprays per nostril twice daily depending on age and formulation, with specific FDA-approved regimens for different concentrations. 1, 2

Dosage Recommendations by Age and Formulation

Azelastine 0.1% (Astelin)

• Adults and children ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays per nostril once daily 1, 2
• Children 6-11 years: 1 spray per nostril twice daily 1, 2
• FDA-approved for seasonal allergic rhinitis and vasomotor rhinitis 1

Azelastine 0.15% (Astepro)

• Adults and children ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays per nostril once daily 1
• Children 6-11 years: 1 spray per nostril twice daily 1
• FDA-approved for both seasonal and perennial allergic rhinitis 1

Azelastine plus fluticasone (Dymista)

• Adults and children ≥12 years: 1 spray per nostril twice daily 1
• Contains 137 μg of azelastine and 50 μg of fluticasone per spray 1
• FDA-approved for seasonal allergic rhinitis 1

Administration Instructions

• Before initial use, prime the delivery system with 4 sprays or until a fine mist appears 2
• When 3 or more days have elapsed since last use, re-prime with 2 sprays 2
• Avoid spraying in the eyes 2

Clinical Efficacy and Advantages

• Rapid onset of action (within 15-30 minutes) 3, 4
• Effective for up to 12 hours in patients with seasonal allergic rhinitis 5
• Intranasal antihistamines show equality or superiority to oral antihistamines for nasal symptoms 1
• Particularly effective for nasal congestion compared to oral preparations 1
• Shows benefit even in patients who fail oral antihistamine treatment 1

Treatment Algorithm

1. First-line therapy options:

   • Intranasal antihistamines like azelastine can be used as first-line therapy for allergic rhinitis 1
   • Intranasal corticosteroids are generally considered most effective for controlling symptoms 1

2. For moderate-to-severe symptoms:

   • Consider combination therapy with intranasal corticosteroid plus intranasal antihistamine 1
   • Combination therapy shows greater symptom reduction than either agent alone 1

3. For episodic symptoms:

   • Intranasal antihistamines are especially useful due to rapid onset of action 1
   • Can be used as pretreatment prior to nasal allergen exposure 1

Common Side Effects and Precautions

• Bitter taste: Most common adverse effect (8.4-13.5% of patients) 1, 4
• Somnolence: Recent studies show rates of 0.4-3%, which are only slightly greater than placebo 1, 4
• Other side effects: Epistaxis and headache 1
• If taste aversion occurs, consider trying a different formulation 1
• Caution should be taken at initiation for signs of somnolence 1
• Follow-up with a clinician is advised to assess response and side effects 1

Clinical Pearls

• Targeted delivery to nasal tissues limits systemic effects compared to oral antihistamines 1
• If one formulation causes taste aversion, a trial of a second formulation may be beneficial 1
• The need for twice-daily dosing may affect patient adherence 1
• For patients with both seasonal allergic rhinitis and asthma, consider that leukotriene receptor antagonists are not recommended as primary therapy for allergic rhinitis 1