What is the treatment for severe pediatric seasonal allergic rhinitis?

From the Guidelines

For severe child seasonal allergies, I strongly recommend starting with intranasal corticosteroids, such as fluticasone propionate (Flonase) or mometasone furoate (Nasonex), as they are the most effective medication class for controlling sneezing, itching, rhinorrhea, and nasal congestion, the 4 major symptoms of allergic rhinitis 1.

Treatment Approach

When treating severe child seasonal allergies, it's essential to consider the most effective treatment options.

• Intranasal corticosteroids are typically the most effective medication class for controlling symptoms of allergic rhinitis, including sneezing, itching, rhinorrhea, and nasal congestion 1.
• Second-generation antihistamines, such as cetirizine (Zyrtec) or loratadine (Claritin), can be used as an adjunct therapy to reduce symptoms of allergic rhinitis, but they have little objective effect on nasal congestion 1.
• Oral anti-LT agents, such as montelukast (Singulair), may be useful in the treatment of allergic rhinitis, but their efficacy is generally less than that of intranasal corticosteroids 1.

Dosage and Administration

• Intranasal corticosteroids should be used at the lowest effective dose in children, and patients should be instructed to direct sprays away from the nasal septum to minimize local side effects 1.
• Second-generation antihistamines can be administered once daily, with dosages varying depending on the child's age and weight.
• Oral anti-LT agents, such as montelukast (Singulair), can be administered daily, with dosages varying depending on the child's age.

Additional Measures

• Environmental measures, such as keeping windows closed during high pollen days, having children shower after outdoor activities, using HEPA air purifiers in bedrooms, and regularly washing bedding in hot water, can also help reduce symptoms of allergic rhinitis.
• In particularly severe cases, consulting an allergist about immunotherapy (allergy shots) may be necessary to provide long-term desensitization to specific allergens.

From the FDA Drug Label

Astelin® Nasal Spray is indicated for the treatment of the symptoms of seasonal allergic rhinitis such as rhinorrhea, sneezing, and nasal pruritus in adults and children 5 years and older The safety and effectiveness of Astelin Nasal Spray at a dose of 1 spray per nostril twice daily has been established for patients 5 through 11 years of age for the treatment of symptoms of seasonal allergic rhinitis

Treatment for severe child seasonal allergies:

• Azelastine (IN) is indicated for the treatment of symptoms of seasonal allergic rhinitis in children 5 years and older.
• The safety and effectiveness of Azelastine (IN) have been established for patients 5 through 11 years of age at a dose of 1 spray per nostril twice daily.
• For children under 5 years, the safety and effectiveness of Azelastine (IN) have not been established.
• Montelukast (PO) is also an option for the treatment of seasonal allergic rhinitis in pediatric patients 2 to 14 years of age. 2 2 3

From the Research

Treatment Options for Severe Child Seasonal Allergies

• The combination of montelukast and loratadine may improve symptoms of seasonal allergic rhinitis (SAR) more than treatment with either drug alone 4.
• Allergen avoidance is the first step in the management of seasonal allergic rhinitis, and symptomatic relief can be achieved with pharmacotherapy, such as oral or intranasal second-generation antihistamines or intranasal corticosteroids 5.
• For more severe cases, treatment with an intranasal corticosteroid in combination with various agents may be necessary, and patients who require medications for more than 6 months per year or have intolerable side effects may be candidates for immunotherapy 5.

Comparison of Treatment Options

• A study comparing the effectiveness of fluticasone nasal spray and the combination of loratadine and montelukast found that both treatments provided clinically meaningful responses, but the overall results favored fluticasone propionate 6.
• Another study found that the combination of azelastine hydrochloride nasal spray and fluticasone propionate nasal spray provided a significant improvement in total nasal symptom scores compared to either agent alone 7.
• A comparison of fluticasone propionate aqueous nasal spray and oral montelukast found that fluticasone propionate provided significantly greater improvement in daytime and nighttime seasonal allergic rhinitis symptoms 8.

Key Findings

• Intranasal corticosteroids, such as fluticasone propionate, may be more effective than leukotriene receptor antagonists, such as montelukast, in relieving symptoms of seasonal allergic rhinitis 8.
• The combination of an intranasal antihistamine and an intranasal corticosteroid may provide a substantial therapeutic benefit for patients with seasonal allergic rhinitis compared to therapy with either agent alone 7.