What medications can help a 46-year-old female (F) with worsening symptoms of seasonal allergic rhinitis?

From the Guidelines

For a 46-year-old female with worsening seasonal allergies, the most effective treatment option is to use an intranasal corticosteroid, such as fluticasone (Flonase) or triamcinolone (Nasacort), as the first-line treatment, as recommended by the 2017 Joint Task Force on Practice Parameters 1.

Treatment Options

• Over-the-counter antihistamines like cetirizine (Zyrtec) 10mg daily, loratadine (Claritin) 10mg daily, or fexofenadine (Allegra) 180mg daily can be used as additional treatment options.
• Nasal corticosteroid sprays, such as fluticasone (Flonase) or triamcinolone (Nasacort), used as 1-2 sprays per nostril daily, are particularly effective for nasal congestion and can be used alongside antihistamines.
• For eye symptoms, ketotifen (Zaditor) or olopatadine (Pataday) eye drops can help.
• If these measures aren't sufficient, adding a leukotriene modifier like montelukast (Singulair) 10mg daily might help, though this requires a prescription.

Key Considerations

• Start medications before allergy season begins for best results, and continue throughout the season.
• These medications work by blocking histamine receptors or reducing inflammation, addressing the underlying immune response to allergens.
• Environmental measures like keeping windows closed during high pollen days, showering after outdoor activities, and using air purifiers can complement medication therapy.

Evidence-Based Recommendation

The 2017 Joint Task Force on Practice Parameters recommends using an intranasal corticosteroid as the first-line treatment for seasonal allergic rhinitis, due to its effectiveness in reducing nasal symptoms and improving quality of life 1.

From the FDA Drug Label

PRINCIPAL DISPLAY PANEL-500'S COUNT Rising® 16571-402-50 Original Prescription Strength Cetirizine Hydrochloride Tablets USP 10 mg 6 yrs & older Antihistamine ALLERGY Indoor & Outdoor Allergies 24 Hour Relief of: •Sneezing •Runny Nose •Itchy, Watery Eyes •Itchy Throat or Nose The patient can be treated with cetirizine (PO) for relief of symptoms associated with seasonal allergies, including sneezing, runny nose, itchy, watery eyes, and itchy throat or nose 2.

• Key benefits: 24-hour relief, antihistamine
• Dosage: 10 mg, for individuals 6 years and older

From the Research

Medication Options for Seasonal Allergies

• Oral and intranasal antihistamines, such as cetirizine, loratadine, and levocetirizine, can help alleviate symptoms of seasonal allergies 3, 4, 5, 6
• Intranasal corticosteroids, like fluticasone propionate, are considered first-line treatment for moderate to severe allergic rhinitis and can be used alone or in combination with oral antihistamines 3, 4
• Combination therapy of fluticasone propionate and an oral antihistamine, such as loratadine, may have comparable efficacy to intranasal corticosteroid alone 4
• Leukotriene receptor antagonists, oral and intranasal decongestants, and oral and intranasal anticholinergics are also available options for managing seasonal allergies 3

Specific Medications and Their Efficacy

• Fluticasone propionate was found to have equal or greater efficacy in reducing nasal symptom scores compared to cetirizine and loratadine 3, 4
• Levocetirizine as add-on therapy to fluticasone propionate did not demonstrate significant additional benefits 5
• Cetirizine plus pseudoephedrine and loratadine plus pseudoephedrine were both efficacious for perennial allergic rhinitis, with cetirizine providing marginally better relief of sneezing and nasal congestion 6