Treatment for Nasal Allergies: An Updated Review

Nasal allergies, sometimes called allergic rhinitis, are a common problem, affecting as many as four out of every 10 adults in the U.S.[1] Symptoms often include sneezing; itchy, runny or stuffed nose; and post-nasal drip.[2] Sometimes these symptoms are accompanied by clogged sinuses or red, itchy and watery eyes.

One key to treating nasal allergies is identifying and avoiding allergy triggers, which can include pollen, dust, mold and animal dander. Allergy specialists sometimes use a skin test to help patients pinpoint and avoid specific allergens.

If avoiding or significantly reducing exposure to triggers is not enough and symptoms persist, there are a large number of treatments available. Yet these different treatments are not equal in effectiveness, and some carry dangerous risks and should be avoided by some or all allergy patients. Learn the best available treatments to stay safe and relatively symptom-free during allergy season and throughout the year.

Nasal steroids

Steroid-containing nasal sprays have long been available to treat nasal allergies, and an increasing body of evidence shows that they are the most effective choice for relieving nose-related allergy symptoms. Multiple randomized trials have consistently shown that steroid nasal sprays are more effective than antihistamines for nose-related symptoms, regardless of the cause of the allergy.[3]

While effective, nasal steroids carry significant side effects. The most common of these are bad taste, nosebleed, headache and sore throat.[4] Steroids delivered as a pill or through an inhaler are known to cause more serious systemwide side effects, including suppression of the immune system, reduced adrenal gland function, eye disease, osteoporosis, high blood pressure, diabetes, and slowed growth in children.[5],[6],[7],[8]

When nasal steroids are used at low doses for nasal allergy treatment, the amount of drug absorbed into the blood often may be small enough that a patient will avoid some side effects.[9],[10] Nevertheless, there have been studies showing that when nasal steroids are used over a long-term period at twice the allergy dosage recommended for children in the drug labeling, they can slightly impair growth, suggesting that enough of the drug can be absorbed at high doses to cause at least some of the systemwide effects seen with steroid pills and inhalers.[11],[12]

Given these risks, patients should take nasal steroids only for moderate or severe nasal allergies, and should periodically ask their doctors to reduce their dosage once symptoms are controlled, aiming for the lowest possible dose needed.

Antihistamines

Antihistamines are as effective as nasal steroids in reducing itching, sneezing, runny nose and eye symptoms, but have less impact on nasal congestion.[13] These pills are the preferred drug for treating mild or intermittent nasal allergy symptoms, as they work quickly and are affordable and convenient.[14]

Older “first generation” antihistamines (see table, for examples) pass easily into the brain, where they can cause drowsiness and mental impairment.[15] Other side effects include constipation and urinary retention.[16] Public Citizen’s Health Research Group recommends that first-generation antihistamines not be used to treat nasal allergies, because they offer no additional benefits and carry a higher risk of side effects than other antihistamines.

Common Allergy Treatments

* Product is available over the counter

Newer second- and third-generation antihistamines (see table) are just as effective as older antihistamines for nasal allergies and are less sedating.[17] Nevertheless, these drugs still have some sedative effects, particularly cetirizine (ZYRTEC).[18]

Several antihistamines also are sold as eye drops and nasal sprays. Antihistamine eye drops (see table) are approved by the Food and Drug Administration to treat eye-related allergy symptoms.[19],[20],[21],[22] Antihistamine nasal sprays start working faster than nasal steroids to relieve symptoms, but nasal steroids usually produce better symptom relief over the longer term, particularly for nasal congestion.[23],[24],[25] Antihistamine nasal sprays also can be expensive and have a bitter taste.[26],[27] In addition, azelastine (ASTELIN, ASTEPRO, OPTIVAR) produced mild sedative effects during clinical testing, although it is not clear whether the risk of sedative effects is higher or lower with azelastine spray than with second- and third-generation antihistamine pills.[28],[29]

A combination steroid-antihistamine spray, azelastine-fluticasone propionate (DYMISTA), was approved in 2012, but both azelastine and fluticasone are sold as separate, less expensive sprays, meaning there is little need to buy this expensive combination product.

Decongestants: Do not use to treat allergies

Pseudoephedrine and phenylephrine are sometimes sold in combination with an antihistamine (see table). We recommend that these combinations, as well as stand-alone decongestant sprays, not be used to treat allergies.[30],[31] These drugs may provide temporary symptom relief, but if they are used for more than a few days, stopping them may trigger rebound congestion, leading patients to become dependent on them.[32] Oral decongestants also may cause headache, high blood pressure, tremors, urinary retention, dizziness and insomnia.[33]

Other drugs

Cromolyn, sold as an eye drop (CROLOM) or nasal spray (over the counter only), is less effective than nasal steroids in treating allergies but carries very few side effects.[34],[35]

We recommend that patients do not use montelukast (SINGULAIR) for allergy treatment, as it is less effective than steroids or antihistamines and has been linked to psychiatric symptoms and a serious condition related to inflammation of blood vessels.[36],[37],[38]

Finally, allergy shots, which are generally offered by an allergy specialist, work by exposing a patient to low doses of an identified allergen, leading the body to adjust and reduce its allergic response over time. However, these injections require a skin test, work very slowly, are effective for only certain types of allergies and can require years of repeated treatment. Shots are generally reserved for patients who have tried and failed to achieve adequate symptom relief with other treatments.

What You Can Do

If you have mild or intermittent allergy symptoms that cannot be eliminated by avoiding the source of the allergy, consider a second- or third-generation antihistamine. For more severe symptoms, the most effective choice for treatment is a nasal steroid spray.

Cromolyn is less effective than both antihistamines and steroids, but it may be a good option for patients who cannot tolerate the side effects of other allergy drugs.

Avoid first-generation antihistamines, decongestants and montelukast, as these offer no benefits over safer alternatives.

References

[1] Long A, McFadden C, DeVine D, et al. Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. Agency for Healthcare Research and Quality. AHRQ Publication No. 02-E024. May 2002.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] Mayo Clinic. Prednisone and other corticosteroids. http://www.mayoclinic.org/steroids/ART-20045692?pg=2.

[6] Kelly HW, Sternberg AL, Lescher R, Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med. 2012;367(10):904-912.

[7] Benninger MS, Ahmad N, Marple B. The safety of intranasal steroids. Otolaryngol Head Neck Surg. 2003;129:739-750.

[8] MayoClinic. Prednisone and other corticosteroids: What side effects can steroids cause? Nov. 26, 2015. http://www.mayoclinic.org/steroids/ART-20045692?pg=2, accessed February 9, 2016.

[9] Wilson AM, Sims EJ, McFarlane LC, Lipworth BJ. Effects of intranasal corticosteroids on adrenal, bone, and blood markers of systemic activity in allergic rhinitis. J Allergy Clin Immunol. 1998;102(4):598-604.

[10] Benninger MS, Ahmad N, Marple B. The safety of intranasal steroids. Otolaryngol Head Neck Surg. 2003;129:739-750.

[11] Lee LA, Sterline R, Maspero J, et al. Growth velocity reduced with once-daily fluticasone furoate nasal spray in prepubescent children with perennial allergic rhinitis. J Allergy Clin Immunol Pract 2014;2:421-7.

[12] VERAMYST – fluticasone furoate spray, metered. Updated May 2015. http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/022051s011lbl.pdf. Accessed February 9, 2016.

[13] Yanez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: A systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89:479-484.

[14] Seidman MD, Gurgel RK, Lin SY, et al. Clinical Practice Guideline: Allergic Rhinitis. 2015;152(IS):S1-S43.

[15] Simons FE, Simons KJ. Clinical pharmacology of new histamine H1 receptor antagonists. SOClin Pharmacokinet. 1999;36(5):329.

[16] Busse PJ. Allergic respiratory disease in the elderly. Am J Med. 2007;120(6):498.

[17] Long A, McFadden C, DeVine D, et al. Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. Agency for Healthcare Research and Quality. AHRQ Publication No. 02-E024. May 2002.

[18] Carson S, Lee N, Thakurta S. Drug Class Review: Newer Antihistamines: Final Report Update 2. Drug Class Reviews. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0009327/. Accessed January 15, 2016

[19] DailyMed. OPTIVAR — azelastine hydrochloride solution/drops. Updated 04/14. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f4b9597c-5b50-4889-be41-20bd1f13aaa5. Accessed February 9, 2016.

[20] DailyMed. Emadine — emedastine difumarate solution. Updated 07/11. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=98a010d5-4905-4abf-a9d2-c85a07daa23b. Accessed February 9, 2016.

[21] DailyMed. Elestat — epinastine hydrochloride solution/drops. Updated 12/11. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a9628ec7-bbeb-4cfa-932f-645a8aca8987. Accessed February 9, 2016.

[22] DailyMed. Pataday — olopatadine hydrochloride solution/drops. Updated 01/16. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e1eb5130-e59d-4590-8b04-7b1a6adae5bd. Accessed February 9, 2016.

[23] Yanez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89:479-484.

[24] Patel P, D’Andrea C, Sacks HJ. Onset of action of azelastine nasal spray compared with mometasone nasal spray and placebo in subjects with seasonal allergic rhinitis evaluated in an environmental exposure chamber. Am J Rhinol. 2007;21(4):499-503.

[25] Kaliner MA, Storms W, Tilles S, et al. Comparison of olopatadine 0.6% nasal spray versus fluticasone propionate 50 microg in treatment of seasonal allergic rhinitis. Allergy Asthma Proc. 2009; 30(3):255-62.

[26] DailyMed. OLOPATADINE HYDROCHLORIDE NASAL – olopatadine hydrochloride spray. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8839d17f-97e2-4c38-8ea0-a6ba1fdf2ff8. Accessed January 15, 2016.

[27] DailyMed. ASTELIN — azelastine hydrochloride spray, metered. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=46b2ddff-d40a-43ac-b027-4fac9fc2f4b9. Accessed January 15, 2016.

[28] DailyMed. ASTELIN — azelastine hydrochloride spray, metered. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=46b2ddff-d40a-43ac-b027-4fac9fc2f4b9. Accessed January 15, 2016.

[29] Berger W, Hampel F Jr., Bernstein J, et al. Impact of azelastine nasal spray on symptoms and quality of life compared with cetirizine oral tablets in patients with seasonal allergic rhinitis. Ann Allerg Asthma Immunol. 2006;97(3):375-381.

[30] WorstPills.org. Drug profile: fexofenadine and pseudoephedrine (ALLEGRA D); loratadine and pseudoephedrine (CLARITIN D, CLARITIN D 24); promethazine and phenylephrine (PROMETHAZINE VC); triprolidine and pseudoephedrine (ACTIFED). /monographs/view/222. Last reviewed February 28, 2015.

[31] WorstPills.org. Drug profile: pseudoephedrine (SUDAFED). Last reviewed August 31, 2015. /monographs/view/205. Accessed February 9, 2016.

[32] Sur D, Plesa M. Treatment of allergic rhinitis. Am Fam Physician. 2015;92(11):985-992.

[33] Ibid.

[34] Welsh PW, Stricker WE, Chu CP, et al. Efficacy of beclomethasone nasal solution, flunisolide, and cromolyn in relieving symptoms of ragweed allergy. Mayo Clin Proc. 1987;62(2):125.

[35] Long A, McFadden C, DeVine D, et al. Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. Agency for Healthcare Research and Quality. AHRQ Publication No. 02-E024. May 2002.

[36] Nathan RA. Do leukotriene receptor antagonists have a place in pharmacotherapy of allergic rhinitis? Ann Allergy Asthma Immunol. 2003;90(5):466-468.

[37] DailyMed. Label: SINGULAIR — Montelukast sodium granule. Updated March 2015. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8c166755-7711-4df9-d689-8836a1a70885

[38] WorstPills.org. Drug profile: montelukast (SINGULAIR). Last reviewed August 31, 2015. /monographs/view/240. Accessed February 5, 2016.