Azelastine Nasal Spray is Safe in Glaucoma
Azelastine nasal spray is safe to use in patients with glaucoma for treating cold symptoms, as it lacks the anticholinergic and decongestant properties that increase intraocular pressure. 1
Why Azelastine is Safe in Glaucoma
Azelastine is a second-generation antihistamine that works through H1-receptor antagonism without significant anticholinergic effects, distinguishing it from first-generation antihistamines that can worsen glaucoma 2, 1
The medication that poses risk in glaucoma is the decongestant component (pseudoephedrine) found in combination cold preparations, not antihistamines like azelastine 3
First-generation antihistamines with anticholinergic properties can increase intraocular pressure, but azelastine does not have this mechanism of action 3
Evidence Supporting Safety
A 2022 comparative study explicitly states that azelastine can be safely used in patients with glaucoma and cataract due to its lesser side effects, making it a safer alternative to intranasal corticosteroids for long-term use 1
Guidelines recommend ipratropium bromide nasal spray as an alternative when first-generation antihistamine/decongestant combinations are contraindicated in glaucoma patients, but azelastine nasal spray does not carry this same contraindication 3
No specific contraindications are listed for azelastine formulations in glaucoma patients according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Dosing for Cold Symptoms
Azelastine 0.15% (Astepro): 1-2 sprays per nostril twice daily for adults and children ≥12 years 2, 4
Azelastine 0.1% (Astelin): 1-2 sprays per nostril twice daily as an alternative formulation 2, 4
Onset of action occurs within 15 minutes, providing rapid relief of nasal symptoms 2, 4
Common Side Effects (Not Related to Glaucoma)
Bitter taste (4.5-8.3%) is the most common side effect, which can be minimized with correct dosing technique 5, 6
Somnolence rates are low (0.4-3%), comparable to placebo in recent studies 2, 4, 6
Nasal discomfort (4.5%) and epistaxis may occur but are generally mild 4, 5
What to Avoid in Glaucoma Patients
Avoid oral or nasal decongestants (pseudoephedrine, oxymetazoline) as these can increase intraocular pressure through sympathomimetic effects 3
Avoid first-generation antihistamines with strong anticholinergic properties (diphenhydramine, brompheniramine) as these can worsen glaucoma 3, 7
Do not combine azelastine with anticholinergic medications unnecessarily, though azelastine itself lacks significant anticholinergic activity 7