Management of Allergic Rhinitis Refractory to Montelukast and Fluticasone Nasal Spray

Discontinue Montelukast

The American Academy of Otolaryngology-Head and Neck Surgery recommends that montelukast should not be used as primary therapy for allergic rhinitis, as it is significantly less effective than intranasal corticosteroids for controlling nasal symptoms 1, 2.
Montelukast is reserved for patients who cannot tolerate intranasal corticosteroids or those with concurrent mild persistent asthma, but even in these cases, it is not the preferred agent 1.

The Journal of Allergy and Clinical Immunology suggests that proper administration technique is crucial for maximizing efficacy, and sprays should be directed away from the nasal septum to minimize local side effects 3.

The American College of Physicians recommends that the combination of intranasal corticosteroid plus intranasal antihistamine is the most effective pharmacologic therapy for moderate to severe allergic rhinitis, with a greater than 40% relative improvement over either agent alone 1, 4.
The combination of fluticasone propionate (200 mcg) plus azelastine (548 mcg) reduces total nasal symptom scores by 5.31-5.7 points compared to 3.84-5.1 for fluticasone alone and only 2.2-3.03 for placebo 1, 4.
Azelastine nasal spray (137 mcg per spray, 1-2 sprays per nostril twice daily) can be added to the current fluticasone regimen, with the most common adverse effect being dysgeusia (bitter taste), occurring in 2.1-13.5% of patients 1.

The Journal of Allergy and Clinical Immunology recommends that a second-generation oral antihistamine (cetirizine, loratadine, desloratadine, or fexofenadine) can be added to fluticasone if intranasal antihistamine is not tolerated or available 5.

The Rhinology society recommends that montelukast should not be added to fluticasone, as studies show no additional benefit compared to fluticasone alone 6.

The American Academy of Otolaryngology-Head and Neck Surgery suggests that diagnosis should be verified with specific IgE testing if not already performed, and environmental controls should be addressed through allergen avoidance measures 2.
The Journal of Allergy and Clinical Immunology recommends that immunotherapy should be considered if combination pharmacotherapy fails, and patients should be evaluated for comorbidities such as asthma, chronic rhinosinusitis, or nasal polyps 2, 7.

The Journal of Allergy and Clinical Immunology recommends that symptoms should be reassessed after 2-4 weeks of combination therapy, and if inadequate response persists, patients should be referred to an allergist/immunologist for further evaluation and consideration of immunotherapy 3, 7, 2.