Managing Seasonal Allergies

Nasal corticosteroids

See our chart, Nasal Sprays for Allergic Rhinitis.

• first-line for moderate to severe, persistent symptoms.^3,5
• nasal congestion.^3,5
• itchy, irritated, or watery eyes.³

• in children:^9,14
  • under six years (budesonide).
  • under four years (fluticasone propionate).
  • under two years (triamcinolone, mometasone [three years in Canada], fluticasone furoate).

Oral antihistamines

See our comparison of first- and second-generation antihistamines later in this document.

• first-line for mild or intermittent symptoms (second generation).^3,5
• itching, sneezing, rhinorrhea (second generation).⁵

• under two years (most secondgeneration).^9,22
  • under 12 years (fexofenadine [Canada only]).¹²
• in older adults, risk of excessive sedation (first generation, cetirizine).⁹
• due to risk for decreased cognition or motor skills (first generation).⁹
• with glaucoma (first generation).⁹
• if severe liver impairment.⁹
• if moderate to severe kidney impairment.^9,13
• with moderate or strong CYP3A4 inhibitors, grapefruit juice.^9,13
• with orange or apple juice; other OATP inhibitors (fexofenadine).⁹
• if prolonged QT interval (Canada:bilastine, rupatadine).^7,13

Nasal antihistamines

See our chart, Nasal Sprays for Allergic Rhinitis.

• add-on therapy with nasal steroids, if needed (especially for nasal congestion, rhinorrhea).^1,3,8

• in children:
  • under two years (azelastine 0.1% by prescription only [US]).⁹
  • under six years (azelastine 0.15% [US], olopatadine [US]).⁹
  • under five years (azelastine 0.1% [US]).⁹

• (note: not available as single-ingredient nasal sprays in Canada).

Ophthalmic antihistamines

• add-on therapy for eye symptoms with nasal steroids, if needed.¹

• under three years (ketotifen, olopatadine [Canada]).^9,15,16
• under two years (olopatadine [US]).⁹

Decongestants (intranasal, oral)

• inadequate response from a nasal steroid for nasal congestion.²
• use intranasal in combination with an oral antihistamine.³
• intermittent nasal congestion.²

• if hypertension, arrhythmia, coronary heart disease, hyperthyroidism, glaucoma, diabetes, and benign prostatic hypertrophy (oral).²
• prolonged use of intranasal (more than three to five days).^2,3
• with monoamine oxidase inhibitors.⁶
• as monotherapy (intranasal).⁶
• oral phenylephrine due to lack of efficacy.²³

Cromolyn (intranasal [US])

See our chart, Nasal Sprays for Allergic Rhinitis.

• prevention.
• inadequate response with other treatments.
• children when parents have safety concerns with other therapy.⁶

• under two years.⁹

Leukotriene receptor antagonists (montelukast)

• use as a last resort.^6,10
• use if coexisting asthma.¹

• for seasonal allergic rhinitis:under two years (US),
  under 15 years (Canada).^17,18
• if anxiety, depression, and psychiatric disorders.⁶

Oral corticosteroids

• use as a last resort for severe symptoms.^6,20,21

• prolonged use (more than a few days).^6,20,21

Comparison of First- and Second-Generation Antihistamines. Second-generation antihistamines are often recommended over first-generation antihistamines as they are as effective for seasonal allergies and have less sedation or other adverse effects.^11,19

First-Generation Antihistamines^11,19

Second-Generation Antihistamines^11,19

• Some examples of first-generation antihistamines include: brompheniramine, chlorpheniramine, diphenhydramine, doxylamine, hydroxyzine

• Non-selective (target histamine-1 receptors, but also cholinergic, alpha-adrenergic, and serotonergic receptors).
• Can have substantial adverse effects, especially in older patients (not recommended in patients >65 years old).
• Most common adverse effect is sedation.May decrease cognitive and motor skills, use with caution.
• Some (especially children) may have stimulating effects
  (e.g., insomnia, anxiety, hallucinations).
• Can cause anticholinergic effects (e.g., dry mouth, dry eyes, constipation, tachycardia).

• Some examples of second-generation antihistamines include:
  • bilastine (Canada only)
  • cetirizine
  • desloratadine
  • fexofenadine
  • loratadine
  • rupatadine (Canada only)
• Selective (more specific to peripheral histamine-1 receptors; don’t cross the blood-brain barrier).
• Generally well tolerated.
• Generally not sedating (note that cetirizine may be slightly more sedating than other second generation antihistamines).
• Can be more expensive than first-generation antihistamines.