Can Azelastine Nasal Spray and Allegra Be Prescribed Together?
Yes, azelastine nasal spray and Allegra (fexofenadine) can be prescribed simultaneously for allergic rhinitis, and this combination is both safe and clinically rational, though azelastine monotherapy may provide equivalent symptom control in most patients. 1
Evidence Supporting Combination Therapy
A randomized controlled trial directly evaluated this combination in patients with seasonal allergic rhinitis who remained symptomatic despite fexofenadine treatment, demonstrating that both azelastine monotherapy and the combination of azelastine plus fexofenadine significantly improved Total Nasal Symptom Scores compared to placebo (P = .007 and P = .003, respectively). 1
Importantly, azelastine nasal spray monotherapy was as effective as the combination of azelastine plus fexofenadine for all measured outcomes, including individual symptoms of runny nose, sneezing, itchy nose, and nasal congestion. 1
There are no pharmacological contraindications or drug interactions between intranasal azelastine and oral fexofenadine, as they work through complementary mechanisms—azelastine provides rapid topical antihistamine action with onset within 15 minutes, while fexofenadine offers systemic H1-receptor blockade. 2, 3
Clinical Decision Algorithm
When to Prescribe the Combination
Consider adding azelastine to fexofenadine when patients remain symptomatic after 1 week of oral antihistamine therapy alone, particularly if they have moderate-to-severe nasal symptoms requiring rapid relief. 1
The combination may be appropriate for patients who need both systemic symptom control (ocular symptoms, throat itching) from fexofenadine and rapid nasal symptom relief from azelastine. 1
When Azelastine Monotherapy Is Preferred
For most patients with inadequate response to oral antihistamines, switching to azelastine monotherapy rather than adding it to fexofenadine is equally effective and simplifies the regimen. 1
Azelastine demonstrates superior efficacy to oral antihistamines including fexofenadine for nasal symptoms, making monotherapy a rational first step before combination therapy. 4
Important Clinical Considerations
Sedation Profile
Fexofenadine is truly non-sedating even at higher-than-recommended doses, making it the safest oral antihistamine choice when sedation must be avoided. 5
Azelastine nasal spray has low somnolence rates (0.4% to 3%) comparable to placebo in recent studies, though older data reported rates up to 11.5%. 6
When prescribing both agents together, counsel patients about the theoretical additive sedation risk, though clinically significant sedation is unlikely given the low rates with each agent individually. 6
Symptom Coverage
Oral antihistamines like fexofenadine effectively reduce rhinorrhea, sneezing, and itching but have limited effect on nasal congestion. 5
Azelastine nasal spray is effective for all four cardinal nasal symptoms including nasal congestion, providing broader symptom control than oral antihistamines alone. 6, 2
This complementary symptom coverage provides the rationale for combination therapy in patients with persistent congestion despite oral antihistamine use. 1
Common Pitfalls to Avoid
Do not assume combination therapy is always superior—the evidence shows azelastine monotherapy provides equivalent benefit to the combination in most patients who fail oral antihistamines. 1
If combination therapy is prescribed, consider whether intranasal corticosteroids might be more appropriate than adding azelastine to fexofenadine, as intranasal corticosteroids remain the most effective medication class for controlling all symptoms of allergic rhinitis. 5
For patients requiring combination therapy, consider azelastine plus fluticasone propionate nasal spray instead, as this combination provides 40% greater symptom reduction than either agent alone and superior efficacy to azelastine plus oral antihistamine combinations. 6, 7, 8
Practical Prescribing Guidance
Fexofenadine dosing: 60 mg twice daily or 180 mg once daily for adults. 9
Azelastine nasal spray dosing: 2 sprays per nostril twice daily (0.1% or 0.15% formulation) for patients ≥6 years. 6
Warn patients about bitter taste with azelastine (occurs in 8-20% of patients), which is the most common adverse effect. 2
Continuous daily dosing is more effective than as-needed use for seasonal or perennial allergic rhinitis, though azelastine's rapid onset makes it suitable for episodic use if symptoms are truly intermittent. 5, 2