A 10-year-old patient with seasonal allergies and persistent respiratory symptoms, including nasal congestion and cough, despite taking Xyzal (levocetirizine) and using an inhaler, what is the cause of his symptoms?

From the Guidelines

This 10-year-old patient with seasonal allergies should continue taking Xyzal and add a daily intranasal corticosteroid spray, such as fluticasone, to better control nasal congestion and postnasal drip, which are likely causing the cough, as recommended by the 2017 Joint Task Force on Practice Parameters 1. The patient's symptoms, including nasal congestion, postnasal drainage, and cough, suggest allergic rhinitis with a possible reactive airway component, as evidenced by the response to the inhaler.

• The use of intranasal corticosteroids is supported by the 2017 guideline, which recommends monotherapy with an intranasal corticosteroid for initial treatment of seasonal allergic rhinitis in persons aged 12 years or older 1.
• The patient should continue using the rescue inhaler (likely albuterol) as needed for acute breathing difficulties.
• Increased fluid intake and saline nasal rinses can help thin secretions and alleviate symptoms.
• The patient should be evaluated by their primary care provider within 1-2 weeks to assess if a daily controller medication like a low-dose inhaled corticosteroid is needed. The patient's response to the inhaler and the presence of nasal congestion and postnasal drip suggest a possible reactive airway component, which should be monitored and addressed to prevent progression to more serious conditions like asthma exacerbation or respiratory infection.
• If symptoms worsen, particularly with increased work of breathing, fever, or if the rescue inhaler becomes ineffective, the patient should return for immediate evaluation 1.

From the Research

Patient's Symptoms and Current Treatment

• The patient is a 10-year-old with a significant past medical history of seasonal allergies, currently taking Xyzal as prescribed.
• The patient's father reports concerns of shortness of breath related to seasonal allergies, despite the patient taking Xyzal and using an inhaler.
• The patient's symptoms include nasal congestion, postnasal drainage, and a dry, sporadic cough.
• The patient denies any shortness of breath, chest pain, or fever, but the father reported labored breathing that resolved after using the inhaler.

Effectiveness of Current Treatment

• According to 2, levocetirizine (Xyzal) is a selective, potent, oral histamine H(1) receptor antagonist that is effective in the treatment of allergic rhinitis.
• However, 3 suggests that adding an antihistamine like levocetirizine to an intranasal corticosteroid may not provide significant benefits for most patients.
• The patient's continued symptoms despite taking Xyzal as prescribed may indicate the need for additional or alternative treatment.

Alternative Treatment Options

• 4 found that combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray was more effective than either agent alone in treating seasonal allergic rhinitis.
• 5 found that intranasal ciclesonide coadministration with inhaled fluticasone propionate-salmeterol did not suppress cortisol in allergic rhinitis patients, suggesting that combination therapy may be safe and effective.
• 6 reviews the pharmacologic properties, safety, tolerability, and effectiveness of levocetirizine in allergic rhinitis and chronic idiopathic urticaria, and may provide additional guidance on treatment options.

Considerations for Future Treatment

• The patient's symptoms and response to current treatment should be closely monitored to determine the best course of action.
• Additional treatment options, such as combination therapy with an intranasal corticosteroid and an antihistamine, may be considered if the patient's symptoms persist.
• Consultation with a healthcare professional is necessary to determine the best treatment plan for the patient's specific needs.