Management of Moderate‑to‑Severe Allergic Rhinitis (Cited Evidence)

Intranasal Corticosteroids (INCS)

For moderate‑to‑severe allergic rhinitis, intranasal corticosteroids such as mometasone furoate, fluticasone propionate, budesonide, and triamcinolone acetonide are equally effective first‑line alternatives to fluticasone furoate. 1
All INCS inhibit multiple inflammatory mediators (histamine, prostaglandins, cytokines) and require several days of continuous daily dosing to achieve maximal therapeutic effect. 2

Intranasal antihistamines (azelastine, olopatadine) provide rapid symptom relief and are effective alternatives for patients who need quick control or who prefer non‑steroidal therapy, although they are generally less effective than INCS for moderate‑to‑severe disease. 3
Azelastine nasal spray has an onset of action within ~30 minutes and is especially useful for episodic or intermittent allergic rhinitis when used on an as‑needed basis. 2
For truly episodic allergic rhinitis, INAH are preferred over INCS because of their rapid relief. 2

Combining an INCS with an INAH yields superior symptom control compared with either agent alone in patients with moderate‑to‑severe allergic rhinitis. (Weak recommendation by the 2017 Joint Task Force) 4
The azelastine‑fluticasone propionate fixed‑dose combination (MP‑AzeFlu) produced the greatest reduction in total nasal symptom scores (‑5.3 to ‑5.7 points) versus fluticasone alone (‑3.8 to ‑5.1) or azelastine alone (‑3.3 to ‑4.5).
Treatment Reduction in Total Nasal Symptom Score (points)
Azelastine + Fluticasone (MP‑AzeFlu) –5.3 to –5.7
Fluticasone alone –3.8 to –5.1
Azelastine alone –3.3 to –4.5
3
Real‑world data from the MASK study show that patients using the INCS + INAH combination required additional medication on only 30–35 % of days, compared with 45–60 % of days for those using an INCS alone. 5
The 2017 Joint Task Force issued a weak recommendation to consider the INCS + INAH combination as initial therapy for moderate‑to‑severe seasonal allergic rhinitis in individuals aged ≥ 12 years. 1

Treatment	Reduction in Total Nasal Symptom Score (points)
Azelastine + Fluticasone (MP‑AzeFlu)	–5.3 to –5.7
Fluticasone alone	–3.8 to –5.1
Azelastine alone	–3.3 to –4.5

Real‑world evidence from MASK indicates that oral antihistamines provide the least effective symptom control among the treatment options evaluated, performing worse than both INCS and INAH. 5
In the MASK 2016 analysis, days treated with loratadine alone or in any combination regimen were associated with the poorest symptom control. 5

The Joint Task Force (2017) gave a strong recommendation to prefer INCS over leukotriene receptor antagonists (e.g., montelukast) for initial treatment of patients aged ≥ 15 years. 1
Five randomized trials demonstrated that INCS achieve greater nasal symptom reduction than montelukast. 4
Montelukast may offer dual benefit for patients who also have mild persistent asthma, but it remains a suboptimal choice for allergic rhinitis when INCS are tolerated. 4

The Joint Task Force (2017) issued a strong recommendation to prescribe INCS monotherapy rather than combining an INCS with an oral antihistamine for initial treatment, as the combination does not add clinically meaningful benefit. 1
Combination of INCS with oral antihistamines does not provide a meaningful additional benefit over INCS alone. 1