What is the best treatment option for an adult or child aged 5 and older with allergic rhinitis, considering azelastine?

Azelastine for Allergic Rhinitis: Treatment Recommendations

Primary Recommendation

For adults and children ≥5 years with moderate-to-severe allergic rhinitis, initiate combination therapy with azelastine plus fluticasone nasal spray rather than monotherapy, as this provides 40% greater symptom reduction than either agent alone. 1, 2, 3

Treatment Algorithm by Severity

Moderate-to-Severe Symptoms

• Start with azelastine-fluticasone combination spray as first-line therapy, delivering superior symptom control with Total Nasal Symptom Score reductions of -5.31 to -5.7 points compared to -3.84 to -5.1 for fluticasone alone and -3.25 to -4.54 for azelastine alone 1, 3
• This combination is particularly effective for patients who have failed previous oral antihistamine therapy 1
• The combination provides better relief for ocular symptoms than fluticasone alone 3

Mild-to-Moderate Symptoms (Monotherapy Options)

If combination therapy is unavailable or cost-prohibitive:

• Azelastine 0.15% (Astepro): 1-2 sprays per nostril twice daily for ages ≥6 years 1
• Azelastine 0.1% (Astelin): 1-2 sprays per nostril twice daily for ages ≥6 years 1
• For children 5-11 years: one spray per nostril twice daily 4
• For adults and children ≥12 years: one or two sprays per nostril twice daily 4

Key Clinical Advantages

Rapid Onset

• Azelastine works within 15 minutes compared to hours for oral antihistamines 1, 5
• The 0.15% formulation demonstrates onset of action within 30 minutes 6

Comprehensive Symptom Control

• Effective for rhinorrhea, sneezing, nasal pruritus, and nasal congestion - a key advantage over oral antihistamines 1, 4, 7
• Addresses both early and late phase allergic symptoms through antihistaminic, antiallergic, and anti-inflammatory mechanisms 8

Administration Technique (Critical for Safety)

Use contralateral spray technique - aim the spray away from the nasal septum:

• This reduces epistaxis risk by four-fold 2
• Reduces treatment discontinuation by three-fold 2
• Prime with 4 sprays before initial use; reprime with 2 sprays if ≥3 days have elapsed since last use 4

Safety Profile and Monitoring

Common Adverse Events

• Dysgeusia (bitter taste): Most common side effect, occurring in 8.3% with 1 spray/nostril twice daily versus 19.7% with 2 sprays/nostril twice daily 1, 9
• Somnolence: Modern studies show rates of 0.4-3%, comparable to placebo 1, 9, 6
• Epistaxis: Rates similar to or lower than placebo with combination therapy 3

Long-Term Safety

• Nasal tissue remains healthy with prolonged use, as demonstrated by biopsies after 1-5 years of continuous therapy 2
• Examine the nasal septum periodically (every 6-12 months) to check for mucosal erosions that may precede septal perforation 2
• Systemic absorption of fluticasone is negligible, making the combination safe for long-term use 2

Special Populations

• Patients with glaucoma, cataracts, or osteoporosis: The azelastine-fluticasone combination offers distinct safety advantages due to azelastine's lack of systemic corticosteroid effects 2
• Children: Growth effects are minimal at recommended fluticasone doses 2

Important Clinical Caveats

Comparative Efficacy

• While intranasal corticosteroids alone are generally more effective than intranasal antihistamines for controlling nasal symptoms, the combination surpasses both 3
• The 2017 Joint Task Force provides only a weak recommendation for combination therapy as initial treatment, reflecting concerns about potential study bias, lack of add-on therapy studies, and consideration of cost 3

Dosing Considerations

• Regular daily use is required to maintain symptom control with the corticosteroid component, which has delayed onset (12 hours) and reaches maximal efficacy in days to weeks 2
• The lower dose regimen (1 spray/nostril twice daily) provides effective symptom control with improved tolerability compared to 2 sprays/nostril twice daily 9

What to Avoid

• Never use oral or parenteral corticosteroids for chronic rhinitis except rare cases of severe intractable symptoms unresponsive to all other treatments, and only as short courses (5-7 days) 2
• Parenteral corticosteroids are contraindicated due to greater potential for adrenal suppression, muscle atrophy, and fat necrosis 2