What is the best practice treatment for seasonal hay fever (allergic rhinitis) in Australia?

Best Practice Treatment for Seasonal Hay Fever in Australia

For initial treatment of seasonal allergic rhinitis (hay fever), intranasal corticosteroids are strongly recommended as monotherapy over other treatment options due to their superior effectiveness in controlling all major symptoms. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion 1
• Monotherapy with an intranasal corticosteroid is strongly recommended over combination therapy with an oral antihistamine for initial treatment 2
• Examples include fluticasone, triamcinolone, budesonide, and mometasone 3
• Most effective for persistent moderate to severe symptoms 3

Oral Antihistamines

• Second-generation (non-sedating) antihistamines like cetirizine, fexofenadine, desloratadine, and loratadine are effective for symptom relief with less sedation than first-generation options 1, 3
• Suitable for mild to moderate symptoms, particularly when patients prefer oral medication 4
• Less effective than intranasal corticosteroids for nasal congestion 1

Intranasal Antihistamines

• Examples include azelastine and olopatadine 3
• Can be used as first-line treatment for mild intermittent or mild persistent allergic rhinitis 3
• Faster onset of action compared to intranasal corticosteroids 1

Treatment Algorithm Based on Symptom Severity

For Mild Intermittent Symptoms

• Second-generation oral antihistamine OR intranasal antihistamine 3
• Sodium cromoglycate eye drops for predominant eye symptoms 4, 5

For Moderate to Severe or Persistent Symptoms

• Intranasal corticosteroid as monotherapy 2, 1
• For patients aged 15 years or older, intranasal corticosteroids are strongly recommended over leukotriene receptor antagonists 2

For Severe Symptoms with Inadequate Response

• Combination of intranasal corticosteroid and intranasal antihistamine may be considered (weak recommendation) 2
• Adding an oral antihistamine to an intranasal corticosteroid has NOT been proven to provide additional benefit for nasal symptom control 1

Common Pitfalls and Caveats

• Avoid assuming that combination therapy is always superior to monotherapy; evidence shows intranasal corticosteroid alone is often sufficient 1
• Avoid using oral corticosteroids for routine management of allergic rhinitis; they should be reserved for severe, intractable cases unresponsive to other treatments 1
• Poor adherence to treatment is common - approximately 73% of patients do not use their medications regularly, contributing to suboptimal symptom control 6
• Even with optimal pharmacotherapy, about 62% of patients may experience troublesome residual symptoms, indicating a potential need for specialist assessment 6

Additional Considerations

• Allergen avoidance, while effective for indoor allergens, is usually inadequate for outdoor allergens that cause seasonal allergic rhinitis 2
• For patients with moderate-to-severe seasonal allergic rhinitis who don't respond adequately to pharmacotherapy, specific allergen immunotherapy (subcutaneous or sublingual) may be beneficial as it is the only disease-modifying therapeutic method 2
• Emerging evidence suggests probiotics may help reduce hay fever symptoms and improve quality of life, though more research is needed 7

Remember that treatment effectiveness should be reassessed regularly, and patients with inadequate symptom control despite optimal therapy should be referred for specialist evaluation.