What is the recommended dosage and treatment plan for Azelastine (nasal spray) for allergic rhinitis?

Azelastine Nasal Spray Dosage and Treatment Plan for Allergic Rhinitis

For allergic rhinitis, azelastine nasal spray is recommended at a dose of 1-2 sprays per nostril twice daily for adults and children 12 years and older, and 1 spray per nostril twice daily for children 6-11 years. 1, 2

Formulations and Dosing Recommendations

Azelastine 0.1% (Astelin)

• FDA Indications: Seasonal allergic rhinitis, vasomotor rhinitis 1
• Approved Ages: 6 years and older 1
• Dosing:
  • Children 6-11 years: 1 spray per nostril twice daily 1, 2
  • Adults and children ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays once daily 1, 2

Azelastine 0.15% (Astepro)

• FDA Indications: Seasonal allergic rhinitis, perennial allergic rhinitis 1
• Approved Ages: 6 years and older 1
• Dosing:
  • Children 6-11 years: 1 spray per nostril twice daily 1
  • Adults and children ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays once daily 1, 3

Azelastine plus fluticasone (Dymista)

• FDA Indications: Seasonal allergic rhinitis 1
• Approved Ages: 12 years and older 1
• Dosing: 1 spray per nostril twice daily 1

Administration Instructions

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

Efficacy and Onset of Action

• Intranasal azelastine has shown equality or superiority to oral antihistamines for nasal symptoms 1
• Onset of action occurs within 15-30 minutes after administration 1, 4
• Duration of action is up to 12 hours 5
• Particularly effective for nasal congestion compared to oral antihistamines 1
• Shows benefit even in patients who fail oral antihistamine treatment 1

Side Effects and Safety Considerations

• Common side effects: Bitter taste, epistaxis, somnolence, headache 1
• Bitter taste reported in 8.3-9.4% of patients at recommended doses 4, 6
• Somnolence rates in recent studies range from 0.4-3%, which is only slightly higher than placebo 1, 4
• Lower doses (1 spray per nostril twice daily) show improved tolerability with reduced bitter taste (8.3% vs 19.7%) and somnolence (0.4% vs 11.5%) compared to higher doses 6
• Caution should be taken at initiation of therapy for signs of somnolence 1
• Follow-up with a clinician is advised to assess response and side effects 1

Treatment Considerations

• Intranasal antihistamines can be used as first- or second-line therapy for allergic rhinitis 1
• Especially useful for episodic nasal symptoms or as pretreatment prior to allergen exposure due to rapid onset of action 1
• If taste aversion occurs, a trial of a second formulation may be preferred in patients who have had symptomatic benefit 1
• The need for twice-daily dosing and side effects may lead some patients to prefer other medication classes 1
• Once-daily dosing with azelastine 0.15% (2 sprays/nostril once daily) has shown efficacy and may improve adherence 3

Special Populations

• For children 6-11 years, the recommended dose is 1 spray per nostril twice daily for all formulations 1, 2
• No contraindications are listed for any azelastine formulations 1

Remember that intranasal antihistamines like azelastine provide targeted delivery to nasal tissues while limiting systemic effects, making them particularly effective for nasal symptoms of allergic rhinitis 1.