How to manage a case of allergic rhinitis not responding to montelukast (Singulair) at night and fluticasone (Flonase) nasal spray at night?

Management of Allergic Rhinitis Refractory to Montelukast and Fluticasone Nasal Spray

Add an intranasal antihistamine (azelastine) to your current fluticasone nasal spray regimen, as combination therapy with intranasal corticosteroid plus intranasal antihistamine provides superior symptom control compared to intranasal corticosteroid monotherapy and is significantly more effective than montelukast-based regimens.

Discontinue Montelukast

• Montelukast should not be used as primary therapy for allergic rhinitis and is significantly less effective than intranasal corticosteroids for controlling nasal symptoms 1.
• Direct comparative studies demonstrate that fluticasone propionate is more effective than montelukast alone for daytime symptoms, and particularly superior for nighttime symptoms and nasal congestion 2.
• Montelukast is reserved for patients who cannot tolerate intranasal corticosteroids or those with concurrent mild persistent asthma, but even in these cases it is not the preferred agent 1.
• Recent FDA warnings regarding neuropsychiatric adverse effects further support limiting montelukast use to selected patients only 3.

Optimize Intranasal Corticosteroid Therapy

Before adding medications, ensure proper fluticasone administration:

• Verify correct dosing: Adults should use 200 mcg daily (2 sprays per nostril once daily), which can be given as 100 mcg twice daily if needed 4.
• Confirm adequate duration: Maximum effect may take several days to weeks; ensure the patient has used fluticasone regularly for at least 4-7 days 4.
• Check administration technique: Sprays should be directed away from the nasal septum to minimize local side effects and maximize efficacy 1.
• Consider timing: While evening dosing was used in your case, fluticasone can be administered morning or evening with similar efficacy 4, 5.

Add Intranasal Antihistamine (First-Line Escalation)

The combination of intranasal corticosteroid plus intranasal antihistamine is the most effective pharmacologic therapy for moderate to severe allergic rhinitis:

• Studies demonstrate that fluticasone propionate (200 mcg) plus azelastine (548 mcg) as combination therapy reduces total nasal symptom scores by 5.31-5.7 points compared to 3.84-5.1 for fluticasone alone and only 2.2-3.03 for placebo 1.
• This represents a greater than 40% relative improvement over either agent alone, with clinically meaningful differences in symptom control 1.
• Specific regimen: Add azelastine nasal spray (137 mcg per spray, 1-2 sprays per nostril twice daily) to your current fluticasone regimen 1.
• The combination is particularly effective for nasal congestion, which is often the most refractory symptom 1.

Common Pitfall to Avoid

• The most common adverse effect of azelastine is dysgeusia (bitter taste), occurring in 2.1-13.5% of patients 1. Counsel patients about this expected side effect to improve adherence.

Alternative: Add Oral Antihistamine (Second-Line Option)

If intranasal antihistamine is not tolerated or available:

• Add a second-generation oral antihistamine (cetirizine, loratadine, desloratadine, or fexofenadine) to fluticasone 1, 6.
• While generally less effective than adding intranasal antihistamine, the combination of fluticasone plus cetirizine has shown benefit for pruritus and some patient-rated symptoms 1.
• One study found at least 50% of patients with seasonal allergic rhinitis require both intranasal corticosteroids and oral antihistamines for adequate symptom control 1.
• However, comparative studies show fluticasone plus cetirizine is less effective than fluticasone plus azelastine for total symptom scores and nasal itching 7.

What NOT to Do

• Do not add montelukast to fluticasone: Studies in patients with asthma and allergic rhinitis show that adding montelukast to fluticasone propionate provides no additional benefit compared to fluticasone alone 1.
• Do not combine oral antihistamine with montelukast without intranasal corticosteroid: While combination antihistamine-antileukotriene therapy may be as effective as corticosteroids in some studies, it is inferior to intranasal corticosteroid-based regimens for nighttime symptoms and nasal eosinophilia 2, 7.
• Do not use short-term oral corticosteroids routinely: Reserve 5-7 day courses only for very severe or intractable symptoms 1.

Additional Considerations

• Verify the diagnosis: Ensure this is truly allergic rhinitis with specific IgE testing if not already performed, as nonallergic rhinitis responds differently to therapy 1.
• Address environmental controls: Counsel on allergen avoidance measures appropriate to the patient's specific sensitizations 1.
• Consider immunotherapy: If combination pharmacotherapy fails, refer for sublingual or subcutaneous immunotherapy, which is recommended for patients with inadequate response to medications 1.
• Evaluate for comorbidities: Assess for asthma, chronic rhinosinusitis, or nasal polyps, which may require additional management 1.

Monitoring Response

• Reassess symptoms after 2-4 weeks of combination therapy 1.
• If inadequate response persists despite optimized combination therapy, refer to an allergist/immunologist for further evaluation and consideration of immunotherapy 1.