Can azelastine (antihistamine) eye drops and nasal spray be used together?

Can Azelastine Eye Drops and Nasal Spray Be Used Together?

Yes, azelastine eye drops and nasal spray can be safely used together for patients with severe allergic rhinoconjunctivitis, and this combination has been specifically studied and proven effective.

Evidence for Combined Use

The combination of azelastine nasal spray and eye drops has been directly evaluated in clinical trials and demonstrates:

• Superior efficacy compared to placebo in patients with severe seasonal rhinoconjunctivitis, with 49% of patients achieving at least 50% reduction in total ocular and nasal symptom scores versus 28% with placebo (p = 0.04) 1
• Reduced need for rescue medication, with patients using the combination requiring significantly less cetirizine rescue therapy (2.7 ± 4.1 tablets vs. 4.9 ± 5.0 tablets, p = 0.02) 1
• High patient and physician satisfaction, with global efficacy rated significantly higher by both investigators (26% vs. 10%, p = 0.05) and patients (28% vs. 7%, p = 0.01) 1

Safety Profile of Combined Therapy

The combination is well-tolerated with no serious adverse events reported 1:

• Common side effects include burning sensation, red eyes, nasal irritation, and bitter taste 1
• Somnolence rates with intranasal azelastine range from 0.9% to 11.5%, though more recent studies show rates of 0.4% to 3%, comparable to placebo 2
• Tolerance was rated as "very good/good" or "satisfactory" in 62%/82% by investigators and 55%/79% by patients 1

Clinical Considerations

When to Use This Combination

Use azelastine eye drops plus nasal spray when:

• Patients have both nasal and ocular symptoms requiring treatment 1
• Symptoms are moderate to severe and affect quality of life 1
• Rapid onset of action is desired (azelastine nasal spray acts within 15 minutes) 2, 3

Dosing Recommendations

Nasal spray formulations 2:

• Azelastine 0.1% (Astelin): 1-2 sprays per nostril twice daily for ages ≥6 years
• Azelastine 0.15% (Astepro): 1-2 sprays per nostril twice daily for ages ≥6 years

Eye drops: Follow FDA-approved dosing for ophthalmic azelastine formulation 1

Important Caveats

Counsel patients about:

• Bitter taste (reported in 19.7% of nasal spray users), which can be minimized with correct dosing technique 2, 3
• Potential somnolence, particularly when initiating therapy, though rates are generally low and comparable to placebo 2
• Proper administration technique to reduce taste-related side effects 3

Contraindications and precautions:

• No specific contraindications listed for azelastine formulations 2
• Monitor for signs of somnolence at initiation, especially in patients operating machinery or driving 2

Alternative Considerations

If the combination is not tolerated or unavailable:

• Intranasal corticosteroids remain the most effective single medication class for allergic rhinitis 4
• Combination azelastine-fluticasone nasal spray (Dymista) provides superior symptom control for nasal symptoms compared to either agent alone 4
• For patients with primarily ocular symptoms, consider topical antihistamine eye drops alone