What are the recommended medications for seasonal allergic rhinitis (hay fever)?

Recommended Medications for Seasonal Allergic Rhinitis (Hay Fever)

Intranasal corticosteroids are the most effective first-line medication for treating seasonal allergic rhinitis. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective monotherapy for seasonal allergic rhinitis, providing superior control of all nasal symptoms including congestion, rhinorrhea, sneezing, and itching 1
• Onset of therapeutic effect occurs between 3-12 hours after administration 1
• Can be used as needed (PRN) but more effective when used regularly 2
• Examples include fluticasone propionate, mometasone furoate, and budesonide 1
• Dosing for adults: typically 1-2 sprays in each nostril once daily (200 mcg total daily dose for fluticasone) 2
• When given in recommended doses, not generally associated with clinically significant systemic side effects 1
• Local side effects may include epistaxis, nasal irritation, and headache 1

Second-Generation Oral Antihistamines

• Effective for symptoms of rhinorrhea, sneezing, and itching, but less effective for nasal congestion 1
• Preferred over first-generation antihistamines due to less sedation and fewer anticholinergic effects 1
• Options include cetirizine, loratadine, desloratadine, and fexofenadine 1, 3
• Fexofenadine, loratadine, and desloratadine cause minimal or no sedation at recommended doses 1
• Rapid onset of action makes them suitable for as-needed (PRN) use in episodic allergic rhinitis 1
• Side effects may include headache and, rarely, sedation at higher doses 1

Second-Line Treatment Options

Intranasal Antihistamines

• Effective for seasonal allergic rhinitis with more rapid onset than intranasal corticosteroids 1
• More effective for nasal congestion than oral antihistamines 1
• Examples include azelastine and olopatadine 1
• Side effects include bitter taste, epistaxis, and potential somnolence 1
• May be appropriate first-line therapy for specific patients despite generally being considered second-line 1

Leukotriene Receptor Antagonists

• Less effective than intranasal corticosteroids for nasal symptom reduction 1
• Montelukast is approved for seasonal allergic rhinitis 1, 4
• May be preferred by patients who cannot tolerate intranasal medications 1
• May be particularly useful in patients with concurrent asthma 1
• Works by blocking leukotriene-mediated effects associated with allergic rhinitis symptoms 4

Combination Therapies

• For moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment 1
• Adding an oral antihistamine to an intranasal corticosteroid has not been proven to provide additional benefit for most patients 1
• May consider adding an oral antihistamine for patients with residual symptoms despite appropriately dosed intranasal corticosteroids 1

Special Considerations

Decongestants

• Oral decongestants like pseudoephedrine reduce nasal congestion 1
• Side effects include insomnia, irritability, palpitations, and hypertension 1
• Topical decongestants should not be used continuously due to risk of rhinitis medicamentosa 1

Short-term Oral Corticosteroids

• A short course (5-7 days) may be appropriate for very severe nasal symptoms 1
• Preferred to single or recurrent administration of intramuscular corticosteroids 1

Other Options

• Intranasal cromolyn: Less effective than nasal corticosteroids 1
• Intranasal anticholinergics (ipratropium): Reduces rhinorrhea but not other symptoms 1

Treatment Algorithm

1. First-line: Intranasal corticosteroid monotherapy 1
2. Alternative first-line: Second-generation oral antihistamine (if patient refuses intranasal medication or has predominantly mild symptoms) 1, 3
3. Second-line/Add-on:
   • Intranasal antihistamine 1
   • Leukotriene receptor antagonist (especially with concurrent asthma) 1, 4
4. For severe symptoms: Consider combination therapy with intranasal corticosteroid plus intranasal antihistamine 1
5. For very severe symptoms: Short course of oral corticosteroids (5-7 days) 1

Common Pitfalls to Avoid

• Using first-generation antihistamines, which cause sedation and performance impairment 1
• Continuous use of topical decongestants leading to rhinitis medicamentosa 1
• Undertreatment with as-needed rather than regular use of intranasal corticosteroids 2
• Overuse of oral corticosteroids or use of intramuscular corticosteroids 1
• Delaying treatment until symptoms are severe rather than starting at the beginning of allergy season 1