Managing Seasonal Allergies

Nasal corticosteroids

See a comparison of nasal sprays for allergic rhinitis later in the document.

First-line for moderate to severe, persistent symptoms.^3,5

Nasal congestion.^3,5

Itchy, irritated, or watery eyes.³

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 at the end of this document.

First-line for mild or intermittent symptoms (second generation).^3,5

Itching, sneezing, rhinorrhea (second generation).⁵

Under two years (most second generation).^9,22

• Under 12 years (fexofenadine [Canada only]).²³

Elderly, risk of excessive sedation (first generation, cetirizine).⁹

Risk for decreased cognition or motor skills (first generation).⁹

Glaucoma (first generation).⁹

Severe liver impairment.⁹

Severe kidney impairment (cetirizine, desloratadine, rupatadine [Canada]).^9,24

With moderate or strong CYP3A4 inhibitors, grapefruit juice (rupatadine [Canada]).²⁴

With orange, grapefruit, or apple juice; other OATP inhibitors (fexofenadine).⁷

Prolonged QT interval (Canada: bilastine, rupatadine).^24,25

Nasal antihistamines

See a comparison of nasal sprays for allergic rhinitis later in the document.

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

Under two years (Astepro [US]) or under five years (Astelin [US]).⁹

Under six years (olopatadine).⁹

Neither 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 in combination with an oral antihistamine (intranasal).³

Intermittent nasal congestion.²

Hypertension, arrhythmia, coronary heart disease, hyperthyroidism, glaucoma, diabetes, and benign prostatic hypertrophy (oral).²

Prolonged use (more than three to five days) (intranasal).^2,3

With monoamine oxidase inhibitors.⁶

Monotherapy (intranasal).⁶

Cromolyn (intranasal [US])

See a comparison of nasal sprays for allergic rhinitis later in the document.

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

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

Azelastine 0.1%
(US only)^c,f
(previously brand Astelin)
(AH)
Rx

1 to 2 sprays
in each nostril BID

5 to 11 years:
1 spray in each nostril BID

Yes

(200 sprays)
US: ~$20

Azelastine 0.15%
(US only)
(Astepro Allergy)^f
(AH)
OTC

1 to 2 sprays in each nostril BID
OR
2 sprays in each nostril once daily
(max 4 sprays in each nostril
per day)

6 to 11 years:
1 spray in each nostril BID
(max 2 sprays in each nostril
per day)

No

(120 sprays)
US: ~$20
(200 sprays)
US: ~$40

Azelastine 0.15%
(US only)
(Astepro)^f
(AH)
Rx

Seasonal allergies:
1 to 2 sprays in each nostril BID
OR
2 sprays in each nostril once daily

Perennial allergies:
2 sprays in each nostril BID

6 to 11 years:
1 spray in each nostril BID

Yes

(200 sprays)
US: ~$45

Azelastine/Fluticasone
(Dymista)^c,f
(AH/S)
Rx

(fluticasone: 50 mcg/spray)
1 spray
in each nostril BID

(fluticasone: 50 mcg/spray)
6 years and older:
1 spray in each nostril BID

Yes

(120 sprays)
US: ~$170
Canada: ~$114

Beclomethasone
(Canada only)^f
(S)
Rx

(50 mcg/spray)
2 sprays in each nostril BID

(50 mcg/spray)
6 years and older
2 sprays in each nostril BID

Yes

(200 sprays)
Canada: ~$13

Beclomethasone
(US only)
(Beconase AQ)^f
(S)
Rx

(42 mcg/spray)
1 to 2 sprays
in each nostril BID

(42 mcg/spray)
6 to 12 years:
1 to 2 sprays in each nostril BID

No

(180 sprays)
US: ~$290

Beclomethasone
(US only)
(Qnasl)^g
(S)
Rx

(80 mcg/spray):
2 sprays in each nostril once daily

(40 mcg/spray):
4 to 11 years:
1 spray in each nostril
once daily

No

(80 mcg; 120 sprays)
US: ~$295
(40 mcg; 60 sprays)
US: ~$295

Budesonide
(Rhinocort Aqua)^f
(S)
Rx

US (32 mcg/spray):
1 to 4 sprays
in each nostril once daily

US (32 mcg/spray)
6 to 11 years:
1 to 2 sprays in each nostril
once daily

No

(120 sprays)
US: ~$150

Canada (64 mcg/spray):
1 spray in each nostril BID
OR
2 sprays in each nostril once daily

Canada (64 mcg/spray):
6 to 11 years:
1 to 2 sprays in each nostril once daily

Yes

(64 mcg; 165 sprays)
Canada: ~$11

Budesonide
(US only)
(Rhinocort Allergy)^f
(S)
OTC

(32 mcg/spray)
1 or 2 sprays
in each nostril once daily

(32 mcg/spray)
6 to 11 years:
1 to 2 sprays in each nostril
once daily

Yes

(120 sprays)
US: ~$16

Ciclesonide
(Omnaris)^f
(S)
Rx

(50 mcg/spray)
2 sprays
in each nostril once daily

(50 mcg/spray)
6 to 11 years (US):
(for seasonal allergic rhinitis indication only):
2 sprays in each nostril
once daily
Not indicated for patients under 12 years (Canada)

No

(120 sprays)
US: ~$300
Canada: ~$29

Ciclesonide
(US only)
(Zetonna)^g
(S)
Rx

(37 mcg/spray)
1 spray
in each nostril once daily

Not indicated for patients under 12 years.

No

(60 sprays)
US: ~$220

Cromolyn
(US only)
(NasalCrom)^f
(MCS)
OTC

1 spray in each nostril
three to six times each day

2 to 11 years:
1 spray in each nostril
three to six times each day

Yes

(200 sprays)
US: ~$14

Flunisolide
(US only)^f
(S)
Rx

(50 mcg/spray)
2 sprays
in each nostril BID to TID
(max 8 sprays in each nostril
per day)

(50 mcg/spray)
6 to 14 years:
2 sprays in each nostril BID
OR
1 spray in each nostril TID
(max 4 sprays in each nostril
per day)

Yes

(200 sprays)
US: ~$56

Fluticasone furoate
(US only)
(Flonase Sensimist)^f
(S)
OTC

(27.5 mcg/spray)
Week 1: 2 sprays in each nostril once daily
Week 2 to 6 months: 1 to 2 sprays in each nostril once daily, as needed

(27.5 mcg/spray)
2 to 11 years:
1 spray in each nostril
once daily

No

(60 sprays)
US: ~$13 (120 sprays)
US: ~$20

Fluticasone furoate
(Canada only)
(Avamys)^f
(S)
OTC

(27.5 mcg/spray)
2 sprays in each nostril
once daily

(27.5 mcg/spray)
1 to 2 sprays in each nostril once daily

No

(120 sprays)
Canada: ~$31

Fluticasone propionate
(US only)
(Flonase Allergy Relief)^e,f
(S)
OTC

(50 mcg/spray)
Week 1: 2 sprays in each nostril once daily
Week 2 to 6 months: 1 to 2 sprays in each nostril once daily, as needed

(50 mcg/spray)
4 to 11 years:
1 spray in each nostril
once daily

Yes

(144 sprays)
US: ~$14

Fluticasone propionate
(Canada only)
(Flonase)
(S)
Rx

Not indicated for patients over the age of 18 years.

(50 mcg/spray)
4 to 11 years:
1 to 2 sprays in each nostril once daily
12 to 17 years:
2 sprays in each nostril once or twice daily

Yes

(60 sprays)
Canada: ~$14
(120 sprays)
Canada: ~$22

Ipratropium
0.03%^d,f
(Ipravent [Canada];
Previously brand Atrovent  [US])
(ACH)
Rx

(21 mcg/spray)
2 sprays in each nostril BID to TID

(21 mcg/spray)
6 to 12 years (US) or
12 years and older (Canada):
2 sprays in each nostril
BID to TID

Yes

(345 sprays)
US: ~$36
Canada: ~$31

Ipratropium
0.06%(US only)^c,f,h
(Previously brand Atrovent)
(ACH)
Rx

2 sprays in each nostril four times daily

5 to 12 years:
2 sprays in each nostril four times daily

Yes

(165 sprays)
US: ~$36

Mometasone
(US only)
(Nasonex 24HR Allergy)^c,f
(S)
OTC

(50 mcg/spray)
2 sprays
in each nostril once daily

(50 mcg/spray)
2 to 11 years:
1 spray in each nostril
once daily

No

(60 sprays)
US: ~$13
(120 sprays)
US: ~$20

Mometasone^f
(Previously available as brand Nasonex [US]; 
Nasonex [Canada])
(S)
Rx

(50 mcg/spray)
2 sprays in each nostril once daily (US)
Not indicated in patients older than 11 years old for seasonal or perennial allergic rhinitis (Canada)

(50 mcg/spray)
2 to 11 years (US) or 3 to 11 years (Canada):
1 spray in each nostril
once daily

Yes

(120 sprays)
US: ~$120
(140 sprays)
Canada: ~$11

Olopatadine
(US only)
(Patanase)^c,f
(AH)
Rx

2 sprays in each nostril BID

6 to 11 years:
1 spray in each nostril BID

Yes

(240 sprays)
US: ~$83

Olopatadine/Mometasone
(Ryaltris)^c,f
(AH/S)
Rx

(mometasone: 25 mcg/spray)
2 sprays in each nostril BID

(mometasone:  25 mcg/spray)
Not indicated for patients under 12 years (US)

6 to 11 years (Canada):
1 spray in each nostril
twice daily

No

(240 sprays)
US: ~$250
Canada: ~$59

Triamcinolone
(Canada only)
(Nasacort AQ)
Rx

Not indicated for patients older than 12 years

(55 mcg/spray)
4 to 12 years
1 spray in each nostril once daily; may increase to 2 sprays in each nostril if needed

Yes

(120 sprays)
Canada: ~$19

Triamcinolone
(US only)
(Nasacort Allergy 24HR)^f
(S)
OTC

(55 mcg/spray)
1 to 2 sprays in each nostril once daily

(55 mcg/spray)
2 to 5 years:
1 spray in each nostril
once daily
6 to 12 years:
1 to 2 sprays in each nostril
once daily

Yes

(60 sprays)
US: ~$12
(120 sprays)
US: ~$15

First-Generation Antihistamines^11-13,19

Second-Generation Antihistamines^11-13,19

Some examples of first-generation antihistamines include:

• brompheniramine
• chlorpheniramine
• diphenhydramine
• dimenhydrinate
• hydroxyzine
• meclizine

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 others).

Can be more expensive than first-generation antihistamines.