Azelastine Nasal Spray Dosing
For allergic rhinitis, use azelastine nasal spray 1-2 sprays per nostril twice daily in adults and children ≥12 years, or 1 spray per nostril twice daily in children 6-11 years; no dose adjustment is needed for renal impairment as azelastine is metabolized hepatically with minimal renal excretion. 1
Standard Dosing by Age
Adults and Children ≥12 Years
- Azelastine 0.1% (Astelin): 1-2 sprays per nostril twice daily 1, 2
- Azelastine 0.15% (Astepro): 1-2 sprays per nostril twice daily OR 2 sprays per nostril once daily 2, 3
- The once-daily 0.15% formulation may improve adherence while maintaining efficacy 2, 4
Children 6-11 Years
- Both 0.1% and 0.15% formulations: 1 spray per nostril twice daily 2, 3, 1
- Not approved for children <6 years 3
Renal Impairment Considerations
No dosage adjustment is required for patients with renal impairment. Azelastine undergoes primarily hepatic metabolism via cytochrome P450 enzymes, with minimal renal elimination of the parent drug. The standard dosing regimens above apply regardless of renal function status.
Dosing Optimization
Lower Dose Option
- 1 spray per nostril twice daily is effective for seasonal allergic rhinitis and significantly reduces side effects 5
- Bitter taste decreases from 19.7% (with 2 sprays) to 8.3% (with 1 spray) 5
- Somnolence decreases from 11.5% (with 2 sprays) to 0.4% (with 1 spray) 5
- This lower dose provides comparable efficacy with improved tolerability 5
Once-Daily Option
- Azelastine 0.15%: 2 sprays per nostril once daily is effective for moderate-to-severe symptoms 4
- Provides 24-hour symptom control with improved convenience 4
- May enhance adherence in patients who struggle with twice-daily dosing 2
Clinical Pharmacology
Onset and Duration
- Onset of action: 15-30 minutes after administration 2, 6, 7
- Duration of action: Up to 12 hours 3, 8
- Rapid onset makes it useful for episodic symptoms or pre-allergen exposure prophylaxis 2
Administration Technique
- Prime with 4 sprays before initial use 1
- Re-prime with 2 sprays if ≥3 days have elapsed since last use 1
- Avoid spraying in eyes 1
- Proper technique minimizes bitter taste, the most common side effect 9
Common Side Effects
- Bitter taste: 4.5-19.7% (dose-dependent) 3, 5
- Somnolence: 0.4-3% (comparable to placebo in recent studies) 2, 6
- Epistaxis and headache: Reported but generally mild 3
- Counsel patients about potential somnolence at therapy initiation, though rates are low 6
Treatment Positioning
First-Line or Second-Line Use
- Can be used as first-line therapy for allergic rhinitis 2
- Particularly effective for nasal congestion, where it outperforms oral antihistamines 2, 6
- Effective even in patients who failed oral antihistamine therapy 2, 9
Combination Therapy
- Azelastine + fluticasone propionate (Dymista): 1 spray per nostril twice daily for ages ≥12 years 3
- Combination provides 40% greater symptom reduction than either agent alone 6
- Consider for patients with moderate-to-severe symptoms or those who failed monotherapy 6
Key Clinical Pearls
- No renal dose adjustment needed - this is a hepatically metabolized drug
- Start with 1 spray per nostril twice daily to minimize side effects, then titrate up if needed 5
- Consider 0.15% once-daily formulation for adherence issues 4
- Emphasize proper administration technique to reduce bitter taste 9
- Onset within 15-30 minutes allows for as-needed use before allergen exposure 2, 8