Is Xyzal (levocetirizine) and Astepro (azélastine) nasal spray a good combination for a 15-year-old with an upper respiratory infection?

This is NOT a good combination for a 15-year-old with an upper respiratory infection

This combination of Xyzal (levocetirizine) and Astepro (azelastine) nasal spray is inappropriate for treating an upper respiratory infection (URI) because these medications are specifically indicated for allergic rhinitis, not viral or bacterial infections. 1

Why This Combination is Inappropriate

Wrong Indication

• Antihistamines are not effective for upper respiratory tract infections. Controlled trials have demonstrated that antihistamine-decongestant combination products do not work for URI symptoms in children. 1
• Both levocetirizine and azelastine are FDA-approved exclusively for allergic rhinitis (seasonal and perennial), not for infectious rhinitis. 1, 2
• The efficacy of cold and cough medications for symptomatic treatment of upper respiratory tract infections has not been established, and these antihistamines fall into this category when used for URIs. 1

Key Distinction: Allergic vs. Infectious Rhinitis

• Differentiating infectious from noninfectious rhinitis can be very difficult for both physicians and parents, but this distinction is critical for appropriate treatment. 1
• If the 15-year-old truly has a URI (viral or bacterial infection), antihistamines provide no therapeutic benefit. 1
• If symptoms are actually due to allergic rhinitis being mistaken for a URI, then this combination could be considered, but even then it's not optimal (see below). 1

If This Were Actually Allergic Rhinitis

Even if the diagnosis were allergic rhinitis rather than URI, this specific combination has issues:

Redundancy and Lack of Evidence

• Using two antihistamines together (oral levocetirizine + intranasal azelastine) lacks evidence-based support. The guidelines do not recommend combining an oral antihistamine with an intranasal antihistamine. 1
• This represents therapeutic duplication of the same drug class without proven additive benefit. 1

Better Alternatives for Allergic Rhinitis

• Intranasal corticosteroids are the most effective medication class for controlling allergic rhinitis symptoms and should be first-line therapy. 1, 3
• If combination therapy is needed for moderate-to-severe allergic rhinitis, the evidence-based approach is azelastine plus fluticasone (intranasal corticosteroid), not azelastine plus an oral antihistamine. 3
• The azelastine-fluticasone combination provides 40% relative improvement in symptom reduction compared to either agent as monotherapy. 3

Age-Appropriate Considerations

• Both medications are FDA-approved for age 15: levocetirizine is approved for ages ≥6 years, and azelastine 0.15% is approved for ages ≥6 years. 1, 2
• However, age-appropriateness doesn't make the combination appropriate for the wrong indication. 1

What Should Be Done Instead

For a True URI

• Supportive care is the mainstay of treatment for viral URIs. 1
• Avoid antihistamines as they provide no benefit and may cause unnecessary side effects (somnolence, bitter taste). 1

If Allergic Rhinitis is the Actual Diagnosis

• Start with an intranasal corticosteroid as monotherapy (most effective single agent). 1, 3
• If inadequate response, consider adding azelastine to the intranasal corticosteroid (not to an oral antihistamine). 3
• Alternatively, use azelastine-fluticasone combination spray as first-line therapy for moderate-to-severe symptoms. 3

Common Pitfall to Avoid

The most critical error here is treating a presumed URI with medications designed for allergic conditions. This leads to unnecessary medication exposure, cost, potential side effects (somnolence rates of 0.4-3% with azelastine, plus bitter taste), and no clinical benefit. 1