Azelastine for Allergic Rhinitis, Urticaria, and Conjunctivitis
Azelastine intranasal spray is highly effective for allergic rhinitis at 1-2 sprays per nostril twice daily (ages ≥12 years) or 1 spray per nostril twice daily (ages 5-11 years), and azelastine ophthalmic solution works well for allergic conjunctivitis, but azelastine has no role in treating urticaria. 1
Dosing for Allergic Rhinitis
For seasonal allergic rhinitis:
- Adults and children ≥12 years: 1-2 sprays per nostril twice daily 1
- Children 5-11 years: 1 spray per nostril twice daily 1
For vasomotor (nonallergic) rhinitis:
- Adults and children ≥12 years only: 2 sprays per nostril twice daily 1
Administration Technique
- Prime the pump with 4 sprays before initial use, or 2 sprays if ≥3 days have elapsed since last use 1
- Keep head tilted downward toward toes when spraying to avoid medication draining into throat 1
- Alternate sprays between nostrils 1
- Breathe gently after administration 1
Treatment Strategy: Continuous vs. On-Demand
Continuous daily treatment is superior to on-demand use for both symptom control and reducing allergic inflammation. 2 While on-demand dosing provides acceptable clinical control, it fails to significantly reduce the underlying allergic inflammation that drives symptoms 2. The standard dose (0.56 mg/day) requires fewer rescue puffs during peak allergen exposure compared to half-dose (0.28 mg/day), though both are equally effective at reducing overall symptoms 2.
Efficacy Profile
Azelastine demonstrates rapid onset of action within 15-30 minutes and maintains efficacy for 12 hours. 3, 4 This rapid onset makes it particularly useful for episodic allergic rhinitis when immediate relief is needed 5.
Comparative Effectiveness for Rhinitis:
- Superior to oral antihistamines (desloratadine, cetirizine) for nasal symptom control 4
- Equal or superior to other intranasal antihistamines (levocabastine) 3, 4
- Comparable to fluticasone propionate for overall symptom relief 4
- Less effective than intranasal corticosteroids for comprehensive symptom control, particularly nasal congestion 5, 3
Combination Therapy for Inadequate Response
If azelastine monotherapy provides inadequate control after 2-4 weeks, add intranasal fluticasone to achieve >40% relative improvement in symptoms. 6, 7 The American College of Physicians specifically recommends this combination over adding oral antihistamines, which provide no additional benefit 7.
What NOT to Add:
- Do not add oral antihistamines to azelastine—no proven benefit 7
- Do not add leukotriene receptor antagonists—not effective as add-on therapy 7
Treatment for Allergic Conjunctivitis
Azelastine ophthalmic solution (Optivar) is a dual-action agent effective for allergic conjunctivitis with onset within 30 minutes. 5 It combines antihistamine and mast cell stabilizer properties, making it suitable for both acute relief and longer-term treatment 5.
Ophthalmic Dosing:
- Approved for adults and children ≥3 years 8
- Typically dosed twice daily 8
- Provides maximal effect with minimal exposure to preservatives 8
Important Caveat:
Topical ophthalmic dual-action agents are more effective than oral antihistamines for ocular symptoms, with faster onset of action. 5 Oral antihistamines are generally less effective for eye symptoms and may cause excessive tear film drying 5.
Urticaria Treatment
Azelastine has no established role in treating urticaria. The evidence provided focuses exclusively on rhinitis and conjunctivitis applications. For urticaria, oral antihistamines (not intranasal formulations) are the standard treatment.
Safety Profile
Azelastine is well-tolerated with minimal systemic side effects. 3, 4, 9
Common Side Effects:
- Bitter taste: Most frequent complaint (2.1-13.5% with intranasal use) 7, 3
- Nasal irritation or epistaxis: Minimal rates 7
- Somnolence: Only 0.4-1.1% (no significant difference from placebo) 7, 3
- Brief stinging upon administration with ophthalmic formulation 8
Key Safety Points:
- No significant cardiovascular effects 3
- Sedation rates comparable to placebo 3, 9
- Excellent safety profile in both adults and children 4
Common Pitfalls to Avoid
Do not spray azelastine with head tilted back—this causes medication to drain into the throat where it will be tasted, leading to the bitter taste complaint 1. Proper head-down positioning minimizes this issue.
Do not use azelastine as monotherapy if symptoms remain uncontrolled after 2-4 weeks—escalate to combination therapy with intranasal corticosteroid rather than continuing inadequate treatment 7.
Do not attempt to clear a clogged nozzle with a pointed object—soak the spray pump unit in warm water and squirt several times while submerged 1.