Allergic rhinitis affects about 1 in 6 people in the US and is a source of much discomfort, as well as loss of sleep and productivity. Often, antihistamines are the first line of treatment used by both patients and physicians. These guidelines provide much needed, straightforward guidance. Based on both efficacy and side effect profile, intranasal corticosteroids are the first line of approach. When studied alone and in combination with oral antihistamines, there is no improvement in symptoms when oral antihistamines are added to intranasal corticosteroids and first line treatment. It is important to note that adding an oral antihistamine to an intranasal corticosteroid is still a reasonable choice for patients who have persistent symptoms while on an intranasal corticosteroid. For patients with severe allergic rhinitis, initial treatment with both an intranasal corticosteroid and an intranasal antihistamine (azelastine) has greater efficacy than either agent alone. In one study, there was a 40% relative improvement with fluticasone propionate plus azelastine than with either agent alone.¹ For patients with severe allergic rhinitis, the combination is worth considering. —Neil Skolnik, MD

1. Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2008;100:74-81. doi:10.1016/S1081-1206(10)60408-5.