Treatment for Seasonal Allergies
For initial treatment of seasonal allergic rhinitis in patients aged 12 years and older, prescribe monotherapy with an intranasal corticosteroid rather than combination therapy or oral antihistamines alone. 1
First-Line Therapy: Intranasal Corticosteroids
Intranasal corticosteroids (such as fluticasone, triamcinolone, budesonide, or mometasone) are the most effective medication class for controlling all four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion. 2, 3
These agents should be used as monotherapy for initial treatment, as adding an oral antihistamine to an intranasal corticosteroid has not been proven to provide additional benefit for nasal symptom control. 3
The Joint Task Force on Practice Parameters issued a strong recommendation against routinely prescribing combination therapy with an intranasal corticosteroid plus an oral antihistamine for initial treatment, based on high-quality evidence showing no additional clinical benefit. 1
Typical dosing for adults: fluticasone propionate 100 mcg once daily (maximum 200 mcg/day), with assessment of response after 4-7 days. 2
Second-Line Options: Oral Antihistamines
Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) are appropriate for patients with mild-to-moderate symptoms or those who prefer oral medication. 4, 5
These agents are less effective than intranasal corticosteroids, particularly for nasal congestion, but provide relief for sneezing, itching, and rhinorrhea. 4, 5
Cetirizine 10 mg once daily is effective for adults and children ≥6 years of age (5 mg once daily for ages 2-5 years), though it may cause more sedation (0.4-3% at recommended doses) compared to fexofenadine or loratadine. 6, 7, 8
Cetirizine demonstrates onset of action within 1 hour, compared to 3 hours for loratadine, based on controlled pollen challenge studies. 7
Alternative Agents: Leukotriene Receptor Antagonists
Intranasal corticosteroids are strongly recommended over leukotriene receptor antagonists (such as montelukast) for initial treatment in patients aged 15 years and older. 1
Montelukast 10 mg once daily is FDA-approved for seasonal allergic rhinitis but is less effective than intranasal corticosteroids for comprehensive symptom control. 9
Combination Therapy for Moderate-to-Severe Disease
For patients with moderate-to-severe seasonal allergic rhinitis aged 12 years and older who fail monotherapy, combination therapy with an intranasal corticosteroid plus an intranasal antihistamine (such as azelastine) may be considered. 1, 3
This is a weak recommendation based on limited evidence, but combination therapy provides greater symptom reduction than either agent alone in patients ≥12 years. 3, 6
The combination product azelastine-fluticasone (137 mcg/50 mcg per spray) is FDA-approved only for patients ≥12 years of age. 6
Critical Pitfalls to Avoid
Never use oral corticosteroids for routine management of seasonal allergic rhinitis; reserve them only for severe, intractable cases unresponsive to other treatments. 2, 3
Do not assume combination therapy is always superior to monotherapy; intranasal corticosteroid alone is often sufficient and should be tried first. 2, 3
Avoid first-generation antihistamines (such as diphenhydramine) due to sedation and cognitive impairment. 2
Do not exceed maximum recommended doses of intranasal corticosteroids (e.g., fluticasone 200 mcg/day), as higher doses are not more effective. 2
Avoid intramuscular corticosteroids (such as Kenalog) for routine management; intranasal formulations have superior efficacy and safety profiles. 3
Treatment Algorithm by Severity
For mild intermittent symptoms (<4 consecutive days/week or <4 consecutive weeks/year):
- Start with a second-generation oral antihistamine (cetirizine, loratadine, fexofenadine) or intranasal antihistamine (azelastine, olopatadine). 4
For persistent moderate-to-severe symptoms (>4 consecutive days/week and >4 consecutive weeks/year):