What is the best course of treatment for a 16-year-old male presenting with a 3-week history of intermittent cough and congestion, nasal stuffiness, and nasal discharge, who has been taking Flonase (fluticasone) and has a history of seasonal allergies?

Treatment Recommendation for 16-Year-Old with Prolonged Allergic Rhinitis Symptoms

Continue the intranasal fluticasone (Flonase) that is already helping, optimize the dosing to 200 mcg once daily (2 sprays per nostril), and add an oral second-generation antihistamine (cetirizine, loratadine, or fexofenadine) to address the persistent cough and sneezing symptoms. 1

Clinical Assessment

This presentation is consistent with allergic rhinitis rather than acute bacterial sinusitis or viral upper respiratory infection based on:

• Duration of 3 weeks with waxing/waning pattern suggests allergic rather than infectious etiology 2
• History of seasonal allergies and symptoms worse in the morning when going outside (allergen exposure) 2
• Partial response to intranasal corticosteroid (Flonase) confirms allergic component 1
• Absence of severe criteria for bacterial sinusitis: no fever ≥39°C for 3+ consecutive days, no worsening after initial improvement, and symptoms present >10 days but without the severe pattern 2

The productive cough with clear sputum and sore throat are likely from postnasal drainage, a common manifestation of allergic rhinitis 2

Specific Treatment Algorithm

Step 1: Optimize Intranasal Corticosteroid Dosing

Increase fluticasone to 200 mcg once daily (2 sprays per nostril in the morning):

• The patient is already experiencing benefit, indicating appropriate diagnosis 1
• For adolescents ≥12 years with inadequate response to lower doses, 200 mcg daily is the recommended dose 3
• Maximum effect may take several days, so continue for at least 2-4 weeks 3, 4
• Critical technique: Direct sprays away from the nasal septum to minimize bleeding and irritation 2, 1

Step 2: Add Oral Second-Generation Antihistamine

Start cetirizine 10 mg, loratadine 10 mg, or fexofenadine 180 mg once daily:

• Second-generation antihistamines are specifically recommended for patients whose primary complaints include sneezing and nasal symptoms 1
• These agents are preferred over first-generation antihistamines because they avoid sedation and performance impairment 2
• Continuous daily use is more effective than intermittent use for ongoing allergen exposure 2
• Antihistamines effectively reduce cough associated with postnasal drainage from allergic rhinitis 2

Step 3: Environmental Control Measures

Implement specific allergen avoidance:

• Since symptoms worsen in the morning when going outside, focus on outdoor allergen exposure 2
• Keep windows closed during high pollen days 2
• Shower and change clothes after outdoor exposure 2
• Use HEPA filters indoors 2

What NOT to Do

Do not add montelukast (leukotriene receptor antagonist): Despite being marketed for allergic rhinitis, montelukast is significantly less effective than intranasal corticosteroids and should not be used as primary therapy 2, 5

Do not prescribe antibiotics: This 3-week presentation does not meet criteria for acute bacterial sinusitis (no fever ≥39°C for 3+ days, no severe worsening pattern) 2

Do not use topical decongestants beyond 3-5 days: Risk of rhinitis medicamentosa with prolonged use 2, 1

Do not prescribe oral or parenteral corticosteroids: Reserved only for very severe or intractable rhinitis, not indicated here 2

Alternative Escalation if Inadequate Response

If symptoms persist after 2-4 weeks of optimized intranasal corticosteroid plus oral antihistamine:

Add intranasal antihistamine (azelastine) to the fluticasone:

• Combination intranasal corticosteroid + intranasal antihistamine provides >40% relative improvement over monotherapy 1, 5
• Azelastine 137 mcg per spray, 1-2 sprays per nostril twice daily 5
• Most effective pharmacologic therapy for moderate-to-severe allergic rhinitis 1, 5
• Main side effect is bitter taste (dysgeusia) in 2-13% of patients 5

When to Refer to Allergist

Consider referral if 2:

• Prolonged manifestations despite optimal medical therapy
• Symptoms significantly interfere with school performance or quality of life
• Need for specific allergen identification for targeted avoidance or immunotherapy consideration
• Symptoms present for >3 weeks despite combination therapy warrants specialist evaluation 2, 5

Monitoring

Reassess in 2-4 weeks 5:

• Expect improvement in nasal congestion, rhinorrhea, sneezing, and cough within 3-7 days 3, 4
• Maximum benefit may take up to 2 weeks 3
• If adequate control achieved, can attempt to decrease to fluticasone 100 mcg daily (1 spray per nostril) for maintenance 3