Treatment Recommendation for Seasonal Allergies in Urgent Care
For a patient presenting with seasonal allergies in urgent care, prescribe an intranasal corticosteroid (such as fluticasone propionate 2 sprays per nostril once daily) as monotherapy for initial treatment. 1, 2
First-Line Treatment: Intranasal Corticosteroids
Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion. 2, 3
The Joint Task Force on Practice Parameters (American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology) provides a strong recommendation for intranasal corticosteroid monotherapy over combination therapy with oral antihistamines for initial treatment in patients aged 12 years or older. 1
High-quality evidence demonstrates that intranasal corticosteroids are superior to oral antihistamines and leukotriene receptor antagonists for comprehensive symptom control. 2, 3
Fluticasone propionate nasal spray is FDA-approved and readily available over-the-counter for patients 6 years and older. 4
When NOT to Add Oral Antihistamines Initially
Do not routinely combine an oral antihistamine with an intranasal corticosteroid for initial treatment, as adding an oral antihistamine has not been proven to provide additional benefit for nasal symptom control. 1, 2
The evidence shows that intranasal corticosteroid alone is often sufficient, and combination therapy should not be assumed to be superior. 2, 3
Alternative Option: Oral Antihistamines Alone
If the patient prefers oral medication or has contraindications to intranasal corticosteroids, second-generation oral antihistamines like cetirizine 10 mg once daily or loratadine 10 mg once daily are appropriate alternatives. 2, 5
Second-generation antihistamines cause significantly less sedation (0.4-3% at recommended doses) compared to first-generation options. 3
Cetirizine has been shown to reduce total symptom scores by 36.7% versus 12.0% with placebo in controlled pollen challenge studies. 6
Escalation for Moderate-to-Severe Symptoms
For patients with moderate-to-severe seasonal allergic rhinitis who fail monotherapy, consider adding an intranasal antihistamine to the intranasal corticosteroid (weak recommendation based on limited evidence). 1, 2
This combination approach is preferred over escalating to systemic corticosteroids. 2
Critical Pitfalls to Avoid
Never use oral corticosteroids for routine management of allergic rhinitis; reserve them only for severe, intractable cases unresponsive to all other treatments. 2, 3
Do not use intramuscular Kenalog for routine management, as intranasal corticosteroid formulations have superior efficacy and safety profiles. 2
Avoid first-generation antihistamines due to sedation and cognitive impairment risks. 3
Do not exceed maximum recommended doses (e.g., fluticasone 200 mcg/day), as higher doses are not more effective. 3
Practical Prescribing Details
Intranasal corticosteroids typically require 12-48 hours for onset of action, so counsel patients on realistic expectations for symptom relief. 2
If immediate symptom relief is needed while waiting for intranasal corticosteroid to take effect, a second-generation oral antihistamine can be used temporarily. 2
Cetirizine demonstrates onset of action within 1 hour versus 3 hours for loratadine in controlled studies. 6, 7