Can Xyzal (levocetirizine) and Astepro (azélastine) nasal spray be used together?

Can Xyzal and Astepro Nasal Spray Be Used Together?

Yes, combining levocetirizine (Xyzal) with azelastine nasal spray (Astepro) is appropriate and may be considered for allergic rhinitis treatment, though evidence for additive benefit is limited and the combination should be monitored for cumulative sedation.

Evidence for Combination Therapy

The American Academy of Allergy, Asthma & Immunology guidelines explicitly list "oral antihistamine with intranasal antihistamine" as a recognized combination therapy option for allergic rhinitis, though they note that "controlled studies of additive benefit are lacking" 1. This means the combination is acknowledged as reasonable clinical practice despite limited formal evidence.

Key Considerations for Combined Use

Efficacy Profile:

• Intranasal antihistamines like azelastine show benefit even in patients who fail oral antihistamine treatment, suggesting they work through complementary mechanisms 1
• Intranasal antihistamines are more efficacious than oral preparations specifically for nasal congestion 1
• The combination may be more effective than monotherapy with either agent alone, though supporting studies are limited 1

Safety Concerns - Monitor for Sedation:

• Both medications can cause somnolence: azelastine nasal spray causes sedation in 0.9-11.5% of patients 1, while levocetirizine may cause sedation at recommended doses 1
• The FDA label for azelastine specifically warns: "Concurrent use of Astelin Nasal Spray with alcohol or other CNS depressants should be avoided because additional reductions in alertness and additional impairment of CNS performance may occur" 2
• Patients should be assessed for their individual response before engaging in activities requiring mental alertness such as driving 2

Clinical Algorithm for Use

When to Consider This Combination:

1. Patient has inadequate response to oral antihistamine monotherapy (levocetirizine alone)
2. Nasal congestion is a prominent symptom requiring targeted intranasal therapy 1
3. Rapid onset of action is needed (azelastine works within 15-30 minutes) 3
4. Patient has mixed rhinitis (allergic plus vasomotor components) where azelastine has specific indication 1

Monitoring Requirements:

• Assess for somnolence at treatment initiation and follow-up 1
• Instruct patients to avoid alcohol and other CNS depressants 2
• Evaluate response after 1-2 weeks to determine if combination provides benefit over monotherapy 1

Dosing When Used Together

Levocetirizine (Xyzal):

• Adults and children ≥12 years: 5 mg once daily 1
• Children 6-11 years: 2.5 mg once daily 1

Azelastine 0.15% (Astepro):

• Adults and children ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays once daily 1, 3
• Children 6-11 years: 1 spray per nostril twice daily 1, 3

Common Pitfalls to Avoid

• Do not assume additive benefit is guaranteed - while the combination is safe, many studies have not shown consistent additive benefit when adding an oral antihistamine to intranasal therapy 1
• Do not overlook intranasal corticosteroids - these remain more effective than either antihistamine alone or in combination for most patients with moderate to severe allergic rhinitis 1
• Do not ignore bitter taste complaints - azelastine causes bitter taste in 4.5-19.7% of patients, which may affect compliance 3
• Do not use in children <6 years - azelastine is not approved for this age group 1, 3

Alternative Consideration

If combination therapy is needed, azelastine combined with an intranasal corticosteroid (fluticasone) has stronger evidence for additive benefit than combining oral and intranasal antihistamines 4. The fixed-dose combination product Dymista (azelastine + fluticasone) improved total nasal symptom scores by 37.9% versus 24.8% with azelastine alone in a randomized controlled trial 4.