Can I use fluticasone (fluticasone) plus azelastine nasal spray along with tablet fexofenadine at night for a patient with allergic rhinitis not responding to Montek LC (levocetirizine) and fluticasone nasal spray?

Management of Refractory Allergic Rhinitis

Direct Answer

Yes, you should switch to the combination of fluticasone-azelastine nasal spray for this patient who has failed monotherapy with fluticasone alone, but adding oral fexofenadine provides no additional benefit and should be discontinued. 1

Rationale for Combination Intranasal Therapy

The fluticasone-azelastine combination nasal spray is superior to fluticasone monotherapy and represents the appropriate next step for patients with inadequate response to intranasal corticosteroids alone. 1, 2

• The combination provides symptom score reductions of -5.31 to -5.7 compared to -3.84 to -5.1 for fluticasone alone, representing a greater than 40% relative improvement over either agent used as monotherapy. 1, 2

• Four high-quality studies consistently demonstrated that fluticasone-azelastine combination showed the greatest symptom reduction, followed by fluticasone alone, then azelastine alone, then placebo. 1

• The 2017 Joint Task Force on Practice Parameters specifically addresses adding intranasal antihistamines to intranasal corticosteroids for patients with inadequate response, finding this combination provides additional benefit. 1

Why NOT to Add Oral Fexofenadine

Adding oral antihistamines like fexofenadine to intranasal corticosteroids provides no clinically meaningful benefit and should not be used. 1

• The 2015 AAO-HNS guidelines explicitly state that "oral antihistamines should not be routinely used as additive therapy" when patients have incomplete control with intranasal steroids. 1

• The largest trials showed no benefit of intranasal corticosteroid plus oral antihistamine compared with intranasal corticosteroid plus placebo in adults. 1

• The 2017 Joint Task Force concluded there is no benefit to adding an oral antihistamine to an intranasal corticosteroid for initial or ongoing treatment. 1

Addressing the Leukotriene Receptor Antagonist

Discontinue the Montek LC (montelukast-levocetirizine combination) as it contains both an oral antihistamine and a leukotriene receptor antagonist, neither of which adds benefit to intranasal corticosteroids. 1

• Leukotriene receptor antagonists should not be offered as primary therapy for allergic rhinitis and should not routinely be used as additive therapy for patients on intranasal steroids. 1

• Three studies comparing intranasal corticosteroids to intranasal corticosteroids plus leukotriene receptor antagonists showed no significant benefit for the combination. 1

Specific Treatment Recommendation

Switch to fluticasone-azelastine combination nasal spray (2 sprays per nostril twice daily) as monotherapy. 1, 2, 3

• This addresses moderate-to-severe allergic rhinitis more effectively than your current regimen. 2, 3

• The combination has superior efficacy for nasal congestion, which is often the most bothersome symptom and poorly controlled by oral antihistamines. 4, 5

• For patients with prominent ocular symptoms, the azelastine-fluticasone combination provides better relief than fluticasone alone. 2

Safety Profile

The combination therapy has a favorable safety profile with low rates of adverse events. 1, 2

• Dysgeusia (bitter taste) is the most common side effect, occurring in 2.1% to 13.5% of patients, and can be minimized with correct dosing technique (avoid tilting head back, point spray away from nasal septum). 1, 2, 4

• Epistaxis rates are similar to or lower than placebo. 1, 2

• Somnolence occurs in only 0.4% to 1.1% of patients using azelastine-containing treatments. 1, 2

Alternative if Combination Unavailable

If the fixed-dose combination product is unavailable, you can use separate azelastine and fluticasone nasal sprays administered sequentially, which has been shown to provide the same benefit. 1, 5

Next Steps if This Fails

If the patient remains symptomatic after 2-4 weeks on fluticasone-azelastine combination therapy, refer for allergen-specific IgE testing and consider immunotherapy (sublingual or subcutaneous). 1

• Immunotherapy should be offered to patients with inadequate response to pharmacologic therapy and is supported by high-quality evidence showing altered natural history and long-term cost-effectiveness. 1