Management of Refractory Allergic Rhinitis

Treatment Recommendations

The American Academy of Otolaryngology-Head and Neck Surgery recommends switching to a combination of fluticasone-azelastine nasal spray for patients who have failed monotherapy with fluticasone alone, as it provides superior symptom reduction 1, 2
The Joint Task Force on Practice Parameters suggests that adding intranasal antihistamines to intranasal corticosteroids provides additional benefit for patients with inadequate response 1
The combination of fluticasone and azelastine provides symptom score reductions of -5.31 to -5.7, representing a greater than 40% relative improvement over either agent used as monotherapy 1, 3

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that oral antihistamines should not be routinely used as additive therapy for patients with incomplete control with intranasal steroids 2
The 2017 Joint Task Force concluded that there is no benefit to adding an oral antihistamine to an intranasal corticosteroid for initial or ongoing treatment 1
Leukotriene receptor antagonists should not be offered as primary therapy for allergic rhinitis and should not routinely be used as additive therapy for patients on intranasal steroids 2, 4

The combination therapy has a favorable safety profile with low rates of adverse events, including dysgeusia (bitter taste) in 2.1% to 13.5% of patients, and epistaxis rates similar to or lower than placebo 1, 3
Somnolence occurs in only 0.4% to 1.1% of patients using azelastine-containing treatments 1, 3

If the fixed-dose combination product is unavailable, separate azelastine and fluticasone nasal sprays administered sequentially can provide the same benefit 1
Immunotherapy should be offered to patients with inadequate response to pharmacologic therapy, as it is supported by high-quality evidence showing altered natural history and long-term cost-effectiveness 2