What is the most effective medication for seasonal allergic rhinitis?

From the Guidelines

For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, intranasal corticosteroids are the preferred medication, as they are the most effective class in controlling symptoms, including sneezing, itching, rhinorrhea, and nasal congestion, as stated in the 2017 joint task force on practice parameters 1. Some key points to consider when treating seasonal allergic rhinitis include:

• Intranasal corticosteroids, such as fluticasone (Flonase) or triamcinolone (Nasacort), are the most effective medication class for controlling symptoms of allergic rhinitis, and should be used as monotherapy for initial treatment 1.
• For moderate to severe seasonal allergic rhinitis, the combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment, although this is a weak recommendation 1.
• Oral antihistamines, such as cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra), can be used in addition to intranasal corticosteroids for relief of symptoms such as sneezing, itching, and runny nose, but are not as effective for nasal congestion 1.
• Environmental measures, such as keeping windows closed during high pollen days, showering after outdoor activities, and using air purifiers with HEPA filters, can also help reduce allergen exposure and alleviate symptoms [@Example@].

From the FDA Drug Label

Patients with seasonal allergic rhinitis may find as-needed use of Fluticasone Propionate Nasal Spray, USP (not to exceed 200 mcg daily) effective for symptom control The studies demonstrated significantly greater reduction in TNSS (sum of nasal congestion, rhinorrhea, sneezing, and nasal itching) with Fluticasone Propionate Nasal Spray, USP, 200 mcg compared to placebo.

• Fluticasone Propionate Nasal Spray, USP is effective for symptom control in patients with seasonal allergic rhinitis.
• The medication can be used as-needed (not to exceed 200 mcg daily) or with regular use for greater symptom control.
• The recommended dosage for adult patients is 200 mcg once daily (two 50-mcg sprays in each nostril once daily) or 100 mcg twice daily (one 50-mcg spray in each nostril twice daily) 2.

From the Research

Seasonal Allergy Medication Options

• Second-generation antihistamines, such as cetirizine, fexofenadine, desloratadine, and loratadine, are effective for mild to moderate cases of seasonal allergic rhinitis 3, 4.
• Intranasal corticosteroids, such as fluticasone, triamcinolone, budesonide, and mometasone, are recommended for more severe cases or for patients who do not respond to antihistamines 3, 4.
• Combination therapy with an intranasal corticosteroid and an antihistamine may be necessary for some patients 3, 4.

Treatment Considerations

• The choice of medication should be based on the severity and frequency of symptoms, as well as patient preference 4.
• Patients with mild intermittent or mild persistent allergic rhinitis may be treated with a second-generation H1 antihistamine or an intranasal antihistamine 4.
• Patients with persistent moderate to severe allergic rhinitis should be treated initially with an intranasal corticosteroid, either alone or in combination with an intranasal antihistamine 4.

Specific Medications

• Cetirizine has been shown to be effective in reducing symptoms of seasonal allergic rhinitis, with significant antihistaminic activity delivered over a full 24 hours 5.
• Levocetirizine, when added to fluticasone, did not provide any clinically significant benefits in a study of 27 patients with seasonal allergic rhinitis 6.