Treatment Escalation for Refractory Allergic Rhinitis
Add intranasal azelastine to the current Flonase regimen—this combination provides superior symptom control compared to either agent alone and represents the most effective pharmacologic therapy for moderate-to-severe allergic rhinitis. 1, 2
Optimize Current Intranasal Corticosteroid Therapy
Before adding medications, ensure the patient is using Flonase correctly:
- Verify proper administration technique: The spray should be directed away from the nasal septum (using the contralateral hand for each nostril) to maximize efficacy and minimize epistaxis risk 1, 2, 3
- Confirm adequate dosing: Adults can use up to 200 mcg daily (2 sprays per nostril once daily), and the current twice-daily regimen may not be providing the full recommended dose 4
- Consider increasing to maximum dose: If currently using less than 200 mcg daily, increase to 2 sprays per nostril once daily in the morning 4
First-Line Escalation: Add Intranasal Antihistamine
The combination of intranasal corticosteroid plus intranasal antihistamine provides >40% relative improvement over either agent alone and is specifically recommended for moderate-to-severe allergic rhinitis with inadequate response to monotherapy 1, 2:
- Azelastine nasal spray: 137 mcg per spray, 1-2 sprays per nostril twice daily 2
- Clinical evidence: Reduces total nasal symptom scores by 5.31-5.7 points compared to 3.84-5.1 for fluticasone alone 2
- Common side effect: Dysgeusia (bitter taste) occurs in 2.1-13.5% of patients but is generally tolerable 2
- Proven efficacy in treatment failures: Azelastine is specifically effective in patients who do not respond to oral antihistamines 5
What NOT to Do
Do not add or continue oral antihistamines as the next step—while second-generation oral antihistamines can be added if intranasal antihistamine is not tolerated, studies show no additional benefit when added to intranasal corticosteroids in patients already failing therapy 1, 2
Do not use montelukast—leukotriene receptor antagonists should not be offered as primary or adjunctive therapy for allergic rhinitis, as they are significantly less effective than intranasal corticosteroids and provide no additional benefit when combined with them 1, 2
Verify Diagnosis and Address Underlying Issues
Before escalating therapy further, consider:
- Confirm allergic rhinitis diagnosis: If not already done, perform specific IgE testing (skin or blood) to verify the diagnosis and identify causative allergens 1, 2
- Assess for comorbidities: Evaluate for asthma, chronic rhinosinusitis, nasal polyps, sleep-disordered breathing, or other conditions that may be contributing to symptoms 1, 2
- Review environmental controls: Ensure the patient is avoiding identified allergens and implementing appropriate environmental measures 1, 2
If Combination Therapy Fails
Consider immunotherapy (sublingual or subcutaneous) for patients with inadequate response to combination pharmacologic therapy—this is the definitive next step for refractory allergic rhinitis 1, 2:
- Indications: Patients with demonstrable specific IgE antibodies to clinically relevant allergens who fail optimal pharmacotherapy 1, 2
- Benefits: May prevent development of new allergen sensitizations and reduce risk of future asthma development 1
- Timing: Refer to allergist/immunologist if symptoms remain inadequate after 2-4 weeks of combination intranasal corticosteroid plus intranasal antihistamine therapy 2
Alternative Second-Line Option
If intranasal antihistamine is not tolerated or unavailable:
- Add oral second-generation antihistamine: Cetirizine, loratadine, desloratadine, or fexofenadine can be added to fluticasone, though this is less effective than adding intranasal antihistamine 1, 2
- Caveat: This combination has not been adequately studied in patients specifically failing intranasal corticosteroid monotherapy 1