What medication is recommended for a patient with a known allergy to hay?

Medication for Hay Fever (Allergic Rhinitis)

For patients with hay fever (allergic rhinitis), intranasal corticosteroids are the first-line medication recommended, as they are the most effective treatment for all nasal symptoms including congestion, sneezing, itching, and runny nose. 1, 2

Primary Treatment Approach

Intranasal corticosteroids should be prescribed first for any patient with hay fever whose symptoms affect their quality of life, as this represents a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery. 1 These medications are superior to all other pharmacologic options and control the full spectrum of allergic rhinitis symptoms. 2

• Intranasal steroids should be used continuously throughout allergen exposure periods rather than intermittently for optimal prevention of symptom recurrence. 3
• This medication class is more effective than leukotriene receptor antagonists (like montelukast) for patients 15 years or older. 2

Second-Line Options for Specific Symptoms

If sneezing and itching are the primary complaints, oral second-generation antihistamines should be recommended as first-line therapy. 1, 2

Recommended Second-Generation Antihistamines:

• Loratadine 10 mg once daily - FDA-approved for temporary relief of hay fever symptoms including runny nose, sneezing, itchy/watery eyes, and itching of nose or throat. 4
• Cetirizine 10 mg once daily - FDA-approved for the same indications. 5 Note that cetirizine may cause sedation in approximately 10% of patients at recommended doses. 6, 7
• Fexofenadine 180 mg once daily - offers the best overall balance of effectiveness and safety among second-generation antihistamines, with essentially no sedation. 7

Intranasal antihistamines may be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis. 1, 2

Escalation for Inadequate Response

For moderate to severe hay fever not responding to monotherapy, combine an intranasal corticosteroid with an intranasal antihistamine, as this combination provides greater symptom reduction than either agent alone. 3, 2

• Do NOT add an oral antihistamine to an intranasal corticosteroid, as this provides no additional benefit. 2
• Combination pharmacologic therapy should be offered when monotherapy fails. 1

Medications to Avoid as Primary Therapy

Oral leukotriene receptor antagonists (like montelukast) should NOT be offered as primary therapy for hay fever, as they are less effective than intranasal corticosteroids. 1, 3

Disease-Modifying Treatment for Refractory Cases

Allergen immunotherapy (subcutaneous or sublingual) should be offered or referred for patients with inadequate response to pharmacologic therapy with or without environmental controls. 1, 3, 2

• Immunotherapy is the only treatment that can alter the natural history of allergic rhinitis and prevent long-term recurrence. 3
• It can prevent development of new allergen sensitivities and reduce future asthma risk, particularly in children. 3

Critical Pitfalls to Avoid

• Never use intranasal decongestants beyond 10 days, as this causes rhinitis medicamentosa (rebound congestion) that worsens the underlying condition. 3
• Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine, brompheniramine) as they produce sedation, impairment, and worsen sleep architecture. 6
• Do not use oral corticosteroids for routine treatment due to significant long-term adverse effects; reserve only for rare patients with severe intractable symptoms. 3
• Sedative antihistamines should not be prescribed for elderly patients with pruritus or hay fever due to safety concerns. 1

Adjunctive Measures

Environmental controls should be advised for patients with identified allergens correlating with symptoms, including keeping windows closed during high pollen seasons, avoiding outdoor activities when pollen counts are elevated, and using air conditioning. 1, 3