Allergic rhinitis is sometimes called “hay fever” or “seasonal allergies,” although it can be caused by nonseasonal things as well. Allergic rhinitis refers to inflammation in the nose (rhinitis) that occurs when you are exposed to a substance you are allergic to. It is an extremely common condition, affecting 10% to 30% of adults in the United States. The most common symptoms of allergic rhinitis are sneezing, runny nose, and nasal congestion. Additional symptoms include watery or itchy eyes, itchy throat, an uncomfortable sensation in the nose, difficulty breathing through the nose, cough, headache, and fatigue.

To understand what causes allergic rhinitis, it helps to understand what an allergy is. Allergies occur when your immune system reacts to something that is usually harmless to most people. When a person has an allergy to something, the immune system mistakenly believes the substance is harmful to the body and mounts a reaction against it.

Substances that cause allergic reactions are called allergens. There are many different kinds of allergens including foods, plants, animals, metals, chemicals, and medications. Allergic rhinitis, in particular, is caused by allergens that are airborne and that enter the body through the nose. Common airborne allergens found outdoors include tree pollens, grass pollens, and weed pollens. Common airborne allergens found indoors include animal dander, dust mites, and mold.

Outdoor allergens are usually seasonal because plants release pollen at certain times of the year. Spring allergies are commonly due to tree pollens. Late spring and summer allergies are commonly due to grass pollens. Late summer and autumn allergies are commonly due to weed pollens, such as ragweed pollen. In fact, ragweed pollen is one of the primary causes of allergic rhinitis and 75% of people with pollen allergies are allergic to ragweed.

Indoor allergens may be present throughout the year. However, certain situations can make indoor allergies worse. For example, animal dander allergies may be worse in the winter because pets may spend more time indoors and there is less circulating fresh air. And mold allergies may be worse if there is a very rainy spring season.

When you experience an allergic reaction, the following steps occur:

The first time the body is exposed to an allergen, it responds by creating antibodies known as immunoglobulin E (IgE). IgE antibodies attach to the surface of immune cells called mast cells and basophils. The next time the body is exposed to the same allergen, the allergen links up with the IgE antibodies. This prompts the mast cells and basophils to release inflammatory chemicals, including histamine and leukotrienes. The release of histamine and leukotrienes causes the symptoms that are typically associated with allergies. Histamine is responsible for watery eyes, runny nose, sneezing, and itchy skin. Leukotrienes are responsible for inflammation and the production of a large amount of mucus. Of note, IgE antibodies are normally helpful in the body because they help protect against parasites. Similarly, the release of histamine and leukotrienes is a natural response that helps the body protect itself against invaders. However, in the case of an allergy, the production of IgE antibodies and the release of histamine and leukotrienes occur when they shouldn’t. Because of this, allergies are considered a type of hypersensitivity reaction. A hypersensitivity reaction is when the immune system acts in a way that would normally be helpful but, instead, is exaggerated, unnecessary, and harmful.

It is unclear why some people develop allergies and others do not. What healthcare professionals do know, is that the tendency to develop allergies is genetic. This means if your family members have allergies, you are more likely to have them as well. Additionally, certain allergic conditions commonly occur together. Known as the “atopic triad,” these conditions are allergic rhinitis, eczema (also called atopic dermatitis), and allergic asthma.

You can learn more about allergies here.

Azelastine

Azelastine is a type of medication known as a second-generation antihistamine. Antihistamine medications block the action of histamine, an inflammatory chemical the body releases during an allergic reaction. The release of histamine leads to a number of symptoms including watery eyes, runny nose, sneezing, and itchy skin. Azelastine helps stop these symptoms from happening.

Fluticasone propionate

Fluticasone propionate is a type of medication known as a second-generation glucocorticoid. Glucocorticoids are corticosteroid hormones that are effective at reducing inflammation. Corticosteroid hormones are not the same thing as anabolic steroids, which are the steroids commonly associated with athletic enhancement. By reducing inflammation, fluticasone propionate decreases nasal congestion.

Levocetirizine

Levocetirizine is a type of medication known as a third-generation antihistamine. Antihistamine medications block the action of histamine, an inflammatory chemical the body releases during an allergic reaction. The release of histamine leads to a number of symptoms including watery eyes, runny nose, sneezing, and itchy skin. Levocetirizine helps stop these symptoms from happening.

Montelukast

Montelukast is a type of medication known as a leukotriene receptor antagonist. Leukotriene receptor antagonists block the action of leukotrienes, inflammatory chemicals the body releases during an allergic reaction. The release of leukotrienes leads to a number of symptoms including nasal congestion. Montelukast helps stop these symptoms from happening.

Azelastine

Azelastine comes as a nasal spray that delivers the medication directly to the inside of the nose. It is used two times per day, once in the morning and once in the evening. If possible, try to take the medication at the same time each day. To properly use the nasal spray, follow these steps:

1. Before first use, pump the bottle about 5 times until a mist appears. Also do this if the product hasn’t been used in 3+ days.

2. Shake the bottle gently.

3. Blow your nose to clear it before each use.

4. Slightly tilt your head forward and insert the applicator tip into your nostril.

5. Hold the applicator tip inside your nose and point the tip towards the outer corner of your eye. It’s helpful to use the opposite hand with each nostril to ensure that the tip is facing the outer corner of your eye. The goal is NOT to spray the medication straight back. You also do not want to point the tip towards the midline of the nose (where the septum is) because that can cause nosebleeds.

6. Close off the other nostril with a finger. Breathe in, and press the pump to release the spray while inhaling.

7. Hold your breath for a few seconds, and breathe out slowly through your mouth after each spray.

8. Alternate nostrils after each pump (e.g. right-left-right-left)

9. After using the spray, gently sniff.

10. Wipe the tip of the applicator with a clean tissue after each use.

Watch how to use nasal sprays here.

If you are using more than one kind of nasal spray for treatment, it is okay to use the medications at the same time of the day (one after the other) or to stagger them throughout the day.

Fluticasone propionate

Fluticasone propionate comes as a nasal spray that delivers the medication directly to the inside of the nose. To use it, pump two sprays in each nostril one time per day. If possible, try to take the medication at the same time each day. To properly use the nasal spray, follow these steps:

1. Before first use, pump the bottle about 5 times until a mist appears. Also do this if the product hasn’t been used in 3+ days.

2. Shake the bottle gently.

3. Blow your nose to clear it before each use.

4. Slightly tilt your head forward and insert the applicator tip into your nostril.

5. Hold the applicator tip inside your nose and point the tip towards the outer corner of your eye. It’s helpful to use the opposite hand with each nostril to ensure that the tip is facing the outer corner of your eye. The goal is NOT to spray the medication straight back. You also do not want to point the tip towards the midline of the nose (where the septum is) because that can cause nosebleeds.

6. Close off the other nostril with a finger. Breathe in, and press the pump to release the spray while inhaling.

7. Hold your breath for a few seconds, and breathe out slowly through your mouth after each spray.

8. Alternate nostrils after each pump (e.g. right-left-right-left)

9. After using the spray, gently sniff.

10. Wipe the tip of the applicator with a clean tissue after each use.

Watch how to use nasal sprays here.

If you are using more than one kind of nasal spray for treatment, it is okay to use the medications at the same time of the day (one after the other) or to stagger them throughout the day.

Levocetirizine

Levocetirizine is an oral medication that should be taken by mouth once daily in the evening. If possible, try to take the medication at the same time each day. Generally, it is okay to take levocetirizine with other medications but you should check with your Ro-affiliated provider or your other healthcare provider.

Montelukast

Montelukast is an oral medication that should be taken by mouth once daily in the evening. If possible, try to take the medication at the same time each day. Generally, it is okay to take montelukast with other medications but you should check with your Ro-affiliated provider or your other healthcare provider.

In addition to your prescribed treatment, there are many other steps you should be taking to treat your allergic rhinitis. They include:

Allergen avoidance

Perhaps the easiest alternative treatment to do on your own for allergic rhinitis is allergen avoidance. Successful allergen avoidance requires two things: Awareness of what you are allergic to and the ability to avoid those things.

If you have undergone allergy testing, you may already know the specific things you are allergic to. This makes the first step easy. However, if you have not undergone allergy testing, you can still figure out what you are allergic to by paying close attention to your allergy triggers. Think about when your symptoms are worst. Do you sneeze a lot when you go outside in the spring? You may have a tree pollen allergy. Do you get congested when you visit your friend who has a dog? You may have an allergy to dog dander. Once you have identified the things that trigger your symptoms, you can do your best to stay away from them.

Since airborne allergens are the cause of allergic rhinitis, it may be difficult to control allergic rhinitis with allergen avoidance alone. Nonetheless, there are steps you can take that might be helpful. Consider trying the following:

• If you have pollen allergies, you may benefit from staying indoors during certain times of the year or avoiding freshly cut grass. You can also keep your windows closed at home and in your car to avoid airborne exposure.

• If you have animal dander allergies, you may not want to own a pet or visit the homes of friends who have pets.

• If you have dust mite allergies, you may want to purchase a hypoallergenic mattress cover and pillow covers for your bed. Weekly washing of your bed linens will also help decrease the level of dust mite exposure.

• If you have mold allergies, you may benefit from staying out of places where mold commonly grows, such as basements. Molds thrive in warm, damp areas, which also includes showers and bathrooms. Keeping your bathroom well ventilated or dry (with a dehumidifier) can help keep mold levels to a minimum.

High Efficiency Particulate Air (HEPA) filter To help with any airborne allergies, you may benefit from purchasing a HEPA filter. HEPA filters are devices that can help remove allergens like pollen, pet dander, dust mites, and smoke from the air. This can improve the quality of the air you are breathing and reduce the symptoms you experience indoors. HEPA filters are beneficial wherever you spend a lot of time so consider a filter for home and work.

Nasal saline irrigation Another way to improve nasal symptoms is to perform nasal saline irrigation. Nasal saline irrigation is a practice that involves flushing the nasal passages with a large volume of a saline solution. It is highly recommended that everybody with airborne allergies irrigates their nose at least once a day (but ideally twice) per day. If you have airborne allergies, irrigating once before going outside and once when you come home is extremely helpful to clear the nose of the allergen particles that are causing your symptoms. Numerous companies sell devices that can be used for nasal saline irrigation, such as the neti pot or the Neil Med irrigation bottle. Make sure you carefully follow the instructions of each product you buy, as they may be different from one another.

Nasal saline irrigation provides several benefits. First, it functions as a form of allergen avoidance, since it washes out the nasal cavities and any allergens that may be lingering there. Second, irrigation keeps the sinuses moisturized and studies have shown that it can actually improve the function of cells that are responsible for moving mucus. And third, performing nasal saline irrigation prior to using a nasal spray medication can help clean the area first, which may maximize the medication’s effectiveness. Many people like to take a hot shower and then irrigate their nose either in the shower or shortly after the shower while the bathroom is still steamy. If you irrigate before using your nasal sprays, it is important to wait 20–30 minutes after irrigating to spray the medication to make sure the medication is not washed away by the draining irrigation fluid.

Nasal saline irrigation can cause an unusual sensation that might be uncomfortable at first. It should always be performed with a warmed solution that is intended for nasal irrigation and not with fresh water.

If you are mixing your own solution, it is extremely important that you do NOT use tap water, as this could be contaminated with organisms. Make sure you are following all manufacturer instructions and always only use water that has been distilled, sterilized, or boiled. Very rarely, a fatal infection called primary amebic meningoencephalitis (PAM) can occur due to irrigation that is performed with tap water. If you use boiled water, do not mix the solution or use the water until it has cooled down to room temperature. Most people find it easy to buy bottles of distilled water and use that for their irrigations. It is also important to clean the irrigation device regularly.

Nasal saline spray Using a nasal saline spray is a way to keep the nose moist and can gently rinse the nose throughout the day without needing to do a full irrigation. Other benefits of using a nasal saline spray include that it is easy to carry a bottle in your pocket or purse and that you can’t overdose on it (since it is not a medication). However, nasal saline sprays may not be as effective as full irrigation. Like with nasal saline irrigation, if you are making your own solution, always only use water that has been distilled, sterilized, or boiled.

Azelastine

If you accidentally miss a dose, take it when you remember. However, if your next dose is supposed to be within a couple of hours, skip the missed dose and resume your normal schedule. Do not take a double dose.

Fluticasone propionate

If you accidentally miss a dose, take it when you remember. However, if your next dose is supposed to be within a couple of hours, skip the missed dose and resume your normal schedule. Do not take a double dose.

Levocetirizine

If you accidentally miss a dose and remember later at night, take it when you remember. However, if you remember the next day, keep in mind that this medication may cause drowsiness. If it is more than a few hours before when your next dose is supposed to be, you may take the missed dose but should be prepared for the possibility that you may not be able to drive or operate heavy machinery. If you remember within a few hours of when your next dose is supposed to be, skip the missed dose and resume your normal schedule. Do not take a double dose.

Montelukast

If you accidentally miss a dose, skip the missed dose and resume your normal schedule the following day when your next dose is due. Do not take more than one dose in 24 hours.

Azelastine

Using too much azelastine is generally not considered dangerous. However, it may cause drowsiness and frequent spraying of the medication into your nose could cause trauma to the lining inside of your nose, which could lead to nosebleeds. If you have sprayed too much azelastine and are experiencing symptoms, contact a healthcare provider immediately.

Fluticasone propionate

Using too much fluticasone propionate at one time is generally not considered dangerous. However, chronic overuse may cause specific signs and symptoms. Using greater than what is recommended by your physician can lead to trauma and irritation of the lining of the inside of the nose, which can lead to nosebleeds. Also, fluticasone is a corticosteroid which can affect other parts of your body aside from your nose. Long-term use of high levels of corticosteroid hormones can cause symptoms such as thinning skin, changes in body fat distribution, and increased acne or facial hair. If you are experiencing worrisome symptoms, contact a healthcare provider.

Levocetirizine

Taking extra doses of levocetirizine in a 24-hour period may result in drowsiness, agitation, or restlessness. There is no specific treatment for a levocetirizine overdose. If you are experiencing symptoms, contact poison control and a healthcare provider immediately.

While overdose is possible, death is unlikely to occur from taking an extra daily dose by accident. In tests done on mice, the maximum non-lethal dose of levocetirizine was approximately 200 times the daily dose in humans. In tests done on rats, the maximum non-lethal dose of levocetirizine was approximately 390 times the daily dose in humans.

Montelukast

Taking extra doses of montelukast in a 24-hour period may result in abdominal pain, vomiting, difficulty sleeping, headache, thirst, and restlessness. There is no specific treatment for a montelukast overdose. If you are experiencing symptoms, contact poison control and a healthcare provider immediately.

While overdose is possible, death is unlikely to occur from taking an extra daily dose by accident. In tests done on mice, the maximum non-lethal dose of montelukast was approximately 335 times the daily dose in humans. In tests done on rats, the maximum non-lethal dose of montelukast was approximately 230 times the daily dose in humans.

A list of side effects, contraindications, precautions, and drug interactions is at the bottom of this page. However, it is important to mention two things here:

1. You have been prescribed medication for the treatment of allergic rhinitis. This medication is NOT intended to treat other types of allergies, such as food allergies or insect venom (e.g. bee sting) allergies. If you are suffering from other types of allergies, speak to a healthcare provider. Alternative treatment may be warranted.

2. Your prescribed medication is also NOT a treatment for anaphylaxis. Anaphylaxis is a sudden and severe allergic reaction that may cause itching of the mouth and lips, swelling of the airway, tongue, and lips, flushing, hives, decreased blood pressure, difficulty breathing, confusion, and loss of consciousness. The symptoms of anaphylaxis occur rapidly and are life-threatening, requiring emergent treatment with a medication called epinephrine and a visit to the emergency room.

It is rare for airborne allergies to cause anaphylaxis. However, it is possible for a person to have cross-reactivity between pollens and foods. This means if you have allergies to certain pollens, you are at an increased risk of having allergies to certain foods. An example of this is birch pollen. If you are allergic to birch pollen, you may also be allergic to apples, carrots, celery, hazelnuts, potatoes, and certain other foods.

If you have a history of severe allergic reactions or anaphylaxis, it is important that your healthcare provider is made aware. You may also benefit from keeping an epinephrine auto-injector with you, such as an EpiPen.

It is possible to have tests performed that determine the specific allergens you are sensitive to. One of these tests is called a skin prick test or a scratch test and it is done by a type of doctor known as an allergist/immunologist. During the skin prick test, a drop of purified liquid allergen is placed on the skin and then the skin is scratched, introducing the allergen into the body. Alternatively, a small amount of the allergen can be injected under the skin. This is repeated multiple times on different areas of the skin to test multiple allergens at once. After about 15 minutes, the skin is examined to see if there are red lumps, which indicate reactivity to the allergens. As an alternative to the skin prick test, blood tests can be done that check for IgE antibodies to common allergens.

Testing alone cannot diagnose allergies and results must be interpreted in the context of a patient’s medical history and physical exam. For example, the test result for a specific allergen may come back positive. However, if you do not experience clinically significant symptoms when you are exposed to that allergen, you would not be diagnosed with an allergy.

For many people, undergoing allergy testing is unnecessary. If your symptoms are consistent with allergic rhinitis, especially if they occur seasonally, it is reasonable to begin treatment without further testing.

It is important to remember that your online visit does not replace routine in-person care with your healthcare provider, such as for an annual physical. While telemedicine has its benefits, there are some components of a health check-up that can’t be fully completed via telemedicine, including the physical exam and laboratory testing. There may also be recommended screening tests for you depending on your age, sex, and family history that require in-person evaluation.

You should still plan on seeing your in-person provider as you normally would, especially if treatment is not working for you. In this case, your healthcare provider may be able to perform additional tests to evaluate any potential underlying causes of your condition.

Azelastine

Azelastine is rapid-acting and typically starts working within 15 minutes. If it is working, you will see improvement in your sneezing and your itchy and runny nose. After a few days of use, you may also notice an improvement in your overall congestion.

Fluticasone propionate

Fluticasone starts working after 12 hours. However, it may take several days of continued usage to experience the full benefits and most people do not see the full benefits until 10 to 14 days of continuous, daily usage. If it is working, you will experience an improvement in your nasal congestion.

Levocetirizine

Levocetirizine is fast-acting and typically starts working after 1 hour. If it is working, you will see an improvement in your sneezing, runny nose, and itchy eyes and this improvement should last approximately 24 hours per dose. It is important that you take the medication daily as the effects will wear off after approximately 24 hours.

Montelukast

Montelukast may start working after the first dose in some users. However, to experience maximum benefits, montelukast should be continued for several days. If it is working, you will notice an improvement in your nasal congestion.

If your treatment is not working, double-check that you are taking all of your medications correctly. For example, nasal sprays need to be administered in a specific way to be maximally effective and it is common for patients to require additional assistance when first learning how to use them. If you have questions about how to use a nasal spray, please reach out to us.

If you are sure that you are taking all of your medications correctly, consider the following:

If the treatment has worked a little, you may require additional medication.

The severity of allergic rhinitis varies greatly from person to person. While some people may be able to control their symptoms without any medication at all, others may require three or more medications to experience relief. Based on your answers during the online visit, your physician has determined that treatment with your prescribed medications is appropriate for you. However, if you have only experienced mild improvement and still have bothersome symptoms, it may be appropriate to start an additional medication. Please let your physician know what symptoms you are still experiencing.

It is important to keep in mind that it may not be possible to make your symptoms go away completely. The goal of treating allergic rhinitis is to improve the condition to a point where it is tolerable and you are able to function better in your daily life. However, you may still experience occasional symptoms, especially on days when the pollen count is high or if you have prolonged exposure to an allergen that you are sensitive to.

If the treatment has not worked at all, you may have a different condition

If your treatment has not worked at all, it is possible you have a different condition. Other medical conditions, such as infections, can sometimes cause the same symptoms as allergic rhinitis but will not improve with treatment. If this is the case, you should see a healthcare provider in person who is able to perform a physical examination and/or testing.

Immunotherapy

Some people who cannot control their symptoms with medications or other alternative means may choose to undergo immunotherapy. Immunotherapy is also known as allergy shots. It is often seen as a more laborious way of treating allergies but, for the right type of person, immunotherapy can offer sustained relief from allergies.

Prior to beginning immunotherapy, an individual is tested to determine his or her specific allergens. The individual is then injected with small and increasing amounts of those allergens on a schedule. By injecting the individual with allergens, his or her immune system is slowly retrained, becoming desensitized to those allergens. This means that when the individual is exposed to the allergens in the real world, he or she mounts less of a reaction to them.

Allergy shots are given on a weekly basis for several months. It may take up to a year to see any improvement in symptoms. The injections can then be given every few weeks for approximately 3 to 5 years. Allergy shots can potentially trigger anaphylaxis, so they must always be given in a healthcare provider’s office under supervision.

Another form of immunotherapy is now available called sublingual immunotherapy or allergy drops. The idea behind allergy drops is the same as allergy shots and involves gradual desensitization to certain allergens. Allergy drops are placed under the tongue daily and do not require administration in a healthcare provider’s office. However, there are not many allergens that are currently FDA-approved for allergy drops. Additionally, since allergy drops are newer, their long-term efficacy is unknown.

Other medications

There are many other oral and nasal medications that can be taken for allergic rhinitis. There are also eye drops that can be used to treat itchy eyes. Some of these medications are available over-the-counter while others require a prescription. If one medication does not work well for you, it is possible that a different medication or a combination of medications might be better. Every patient is different.

In addition to antihistamines, glucocorticoids, and montelukast, other types of medications that may be beneficial for treating allergy symptoms include:

1. Decongestants: These medications can be taken orally, like pseudoephedrine, or via nasal spray, like oxymetazoline. However, oral decongestants have a number of side effects including high blood pressure and headache and they should not be taken by anybody who has high blood pressure, closed-angle glaucoma, cardiovascular disease, hyperthyroidism, bladder obstruction, or who is taking MAOI medication. Additionally, nasal spray decongestants should NOT be used alone or on a routine basis, as continued usage will cause rebound nasal congestion, a condition called rhinitis medicamentosa. Signs of rebound nasal congestion include feeling congested minutes or hours after using the nasal spray, using the nasal spray multiple times per day, and feeling the urge to use the nasal spray much more than what was prescribed or written on the instructions. If you are experiencing these symptoms, it is important that you see your in-person healthcare provider.

2. Cromolyn sodium: This medication is a nasal spray. It can help by stabilizing mast cells, blocking the release of histamine and other inflammatory compounds. While cromolyn sodium is effective at reducing symptoms, it is not as effective as antihistamines or glucocorticoids and it also needs to be taken more frequently.

3. Ipratropium bromide: This medication is a nasal spray that can help treat allergic and non-allergic runny nose. However, it is not as effective at treating other symptoms of allergic rhinitis such as nasal congestion, itchy nose, and sneezing. While it is safe to combine some allergy medications, certain combinations may be dangerous. Therefore, it is always important to talk to your healthcare provider about what you are taking, including over-the-counter medications. Do not start any new medications in addition to the treatment you have been prescribed here without first talking to a healthcare provider.

Alternative medicine and herbal remedies

In addition to prescription and over-the-counter medications, some people suffering from allergic rhinitis may benefit from complementary and alternative medicine.

Remedies that have shown some efficacy in treating allergic rhinitis include the following:

• Acupuncture and acupressure

• Ayurvedic medicine, including a mixture of seven Indian herbs (Albizia lebbeck, Terminalia chebula, T. bellerica, Phyllanthus emblica, Piper nigrum, P. longum, and Zingiber officinale)

• Herbal therapies, including butterbur, Tinospora cordifolia, a mixture of cinnamon bark, Spanish needle, and acerola, Benifuuki green tea, Yupingfeng granules, ginseng, and Tonggyu-tang

• Topical treatments, including capsaicin, cellulose powder, and a petrolatum-based allergen-absorbing ointment

Remedies with less strong evidence include the following:

• Herbal therapies, including quercetin, stinging nettle, Perilla frutescens, steamed eucalyptus, menthol, Ginkgo biloba, milk thistle, and grape seed extract

• Laser therapy

Azelastine

The information below is taken from the Prescriber’s Digital Reference (PDR), which can be found here.

Side effects:

• Azelastine commonly causes a bitter taste in the mouth which can be unpleasant for some users.

• Azelastine may be mildly sedating. Users should exercise caution when taking azelastine and should be aware that mental alertness may be decreased. This can impact the ability to drive or operate machinery.

• Azelastine may cause nosebleeds. If this is occurring, please stop using the medication and see your in-person healthcare provider. In the meantime, you can use nasal saline spray (not irrigation) followed by vaseline to help minimize the nosebleeds and heal the traumatized nasal lining.

• Additional side effects listed in the PDR include bronchospasm, atrial fibrillation, anaphylactoid reactions, dyspnea, blurred vision, conjunctivitis, depression, sinus tachycardia, hypertension, furunculosis, stomatitis, elevated hepatic enzymes, constipation, glossitis, hematuria, contact dermatitis, confusion, tolerance, chest pain, palpitations, urinary retention, ocular irritation, rhinitis, headache, drowsiness, pharyngitis, fatigue, ocular pain, pruritus, dysesthesia, nasal irritation, xerostomia, nausea, laryngitis, nasal dryness, nasal congestion, throat irritation, hyperkinesis, vertigo, dizziness, anxiety, hypoesthesia, flushing, diarrhea, weight gain, appetite stimulation, abdominal pain, increased urinary frequency, amenorrhea, malaise, back pain, myalgia, sneezing, rhinalgia, epistaxis, sinusitis, cough, vomiting, dysgeusia, fever, infection, paresthesias, insomnia, xerophthalmia, and rash.

Contraindications & precautions:

• Azelastine should not be used by anybody who has an allergy or sensitivity to azelastine.

• Azelastine should not be used by anybody who is pregnant or nursing.

Drug interactions:

• Azelastine should not be used with alcohol or with other medications that depress the central nervous system.

• The full list of medication interactions is listed in the PDR.

Fluticasone propionate

The information below is taken from the Prescriber’s Digital Reference (PDR), which can be found here.

Side effects:

• Fluticasone propionate may cause nosebleeds. If this is occurring, please stop using the medication and see your in-person healthcare provider. In the meantime, you can use nasal saline spray (not irrigation) followed by vaseline to help minimize the nosebleeds and heal the traumatized nasal lining.

• Additional side effects listed in the PDR include ocular hypertension, nasal septum perforation, increased intracranial pressure, keratitis, visual impairment, skin atrophy, anaphylactoid reactions, angioedema, Churg-Strauss syndrome, vasculitis, muscle paralysis, bronchospasm, cholecystitis, dysphonia, conjunctivitis, contact dermatitis, migraine, cataracts, withdrawal, hypothalamic-pituitary-adrenal (HPA) suppression, adrenocortical insufficiency, Cushing’s syndrome, growth inhibition, elevated hepatic enzymes, blurred vision, hematoma, erythema, skin ulcer, impaired wound healing, hypotension, eosinophilia, osteopenia, osteoporosis, depression, wheezing, dyspnea, palpitations, glycosuria, oral ulceration, hyperglycemia, leukopenia, thrombocytopenia, bleeding, tolerance, headache, sinusitis, fatigue, malaise, pharyngitis, nasal congestion, throat irritation, arthralgia, insomnia, rhinitis, musculoskeletal pain, hoarseness, cough, rash, xerosis, fever, epistaxis, pruritus, skin irritation, back pain, nasal irritation, ocular irritation, dizziness, laryngitis, rhinorrhea, sneezing, dysmenorrhea, otalgia, dental pain, menstrual irregularity, folliculitis, xerophthalmia, urticaria, striae, acneiform rash, telangiectasia, skin hypopigmentation, vesicular rash, miliaria, purpura, acne vulgaris, hypertrichosis, ecchymosis, flushing, restlessness, irritability, agitation, anxiety, muscle cramps, rhinalgia, anosmia, nasal dryness, and weight gain.

Contraindications & precautions:

• Fluticasone propionate should not be used by anybody who has an allergy or sensitivity to fluticasone propionate.

• Fluticasone propionate should not be used by anybody who is pregnant or nursing.

• Fluticasone propionate is contraindicated in patients with corticosteroid hypersensitivity, milk protein hypersensitivity, acute bronchospasm, or status asthmaticus.

• Fluticasone propionate should be used with caution in geriatric patients, tobacco smokers, and patients with Cushing’s syndrome, hypothalamic-pituitary-adrenal (HPA) suppression, occlusive dressing, skin abrasion, surgery, diabetes mellitus, recent nasal septal perforation, recent nasal surgery, recent nasal trauma, fungal infection, herpes infection, measles, tuberculosis, varicella, viral infection, malnutrition, osteoporosis, hepatic disease, acne rosacea, acne vulgaris, perioral dermatitis, peripheral vascular disease, skin atrophy, cataracts, glaucoma, increased intraocular pressure, ocular exposure, or formaldehyde hypersensitivity.

Drug interactions:

• Fluticasone propionate should not be used with drugs that inhibit CYP3A4, including ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, ketoconazole, telithromycin, conivaptan, lopinavir, nefazodone, and voriconazole.

• The full list of medication interactions is listed in the PDR.

Levocetirizine

The information below is taken from the Prescriber’s Digital Reference (PDR), which can be found here.

Side effects:

• Levocetirizine may cause nasal irritation, dry mouth, and sore throat.

• Levocetirizine may be mildly sedating. Users should exercise caution when taking levocetirizine and should be aware that mental alertness may be decreased. This can impact the ability to drive or operate machinery.

• Additional side effects listed in the PDR include seizures, angioedema, anaphylactoid reactions, hemolytic anemia, suicidal ideation, acute generalized exanthematous pustulosis (AGEP), glomerulonephritis, visual impairment, constipation, elevated hepatic enzymes, dyspnea, dyskinesia, thrombocytopenia, sinus tachycardia, palpitations, hypotension, hepatitis, cholestasis, hallucinations, dystonic reaction, depression, myoclonia, dysuria, urinary retention, blurred vision, diarrhea, drowsiness, nasal congestion, fatigue, fever, cough, xerostomia, infection, pharyngitis, epistaxis, insomnia, pruritus, urticaria, rash, weight gain, agitation, syncope, dizziness, arthralgia, tremor, asthenia, myalgia, vertigo, vomiting, dysgeusia, nausea, and paresthesias.

Contraindications & precautions:

• Fluticasone propionate should not be used by anybody who has an allergy or sensitivity to fluticasone propionate.

• Levocetirizine should not be used by anybody who has an allergy or sensitivity to levocetirizine, cetirizine, or hydroxyzine.

• Levocetirizine should not be used by anybody who is pregnant or nursing.

• Levocetirizine is contraindicated in patients on dialysis or patients with kidney failure or kidney impairment.

• Levocetirizine should be used with caution in geriatric patients and patients with bladder obstruction, prostatic hypertrophy, or urinary retention.

Drug interactions:

• Levocetirizine should not be used with alcohol or with other medications that depress the central nervous system.

• Levocetirizine interacts with the medications theophylline and ritonavir.

• The full list of medication interactions is listed in the PDR.

Montelukast

The information below is taken from the Prescriber’s Digital Reference (PDR), which can be found here.

Side effects:

• Montelukast is generally well tolerated but may cause headaches.

• Additional side effects listed in the PDR include Churg-Strauss syndrome, vasculitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, pancreatitis, erythema nodosum, anaphylactoid reactions, angioedema, seizures, suicidal ideation, pyuria, atopic dermatitis, myopia, wheezing, gastritis, conjunctivitis, elevated hepatic enzymes, eosinophilia, hepatitis, edema, thrombocytopenia, palpitations, bleeding, depression, confusion, memory impairment, impulse control symptoms, hostility, dysphemia, hallucinations, urinary incontinence, dizziness, fatigue, asthenia, nasal congestion, nausea, dyspepsia, rash, vomiting, sinusitis, fever, laryngitis, pharyngitis, abdominal pain, headache, cough, urticaria, infection, diarrhea, rhinitis, rhinorrhea, epistaxis, influenza, myalgia, weight loss, pruritus, arthralgia, hypoesthesia, muscle cramps, drowsiness, paresthesias, ecchymosis, somnambulism, nightmares, abnormal dreams, tremor, anxiety, agitation, irritability, restlessness, and insomnia.

Contraindications & precautions:

• Fluticasone propionate should not be used by anybody who has an allergy or sensitivity to fluticasone propionate.

• Montelukast should not be used by anybody who has an allergy or sensitivity to montelukast.

• Montelukast should not be used by anybody who is pregnant or nursing.

• Montelukast is not an effective treatment for patients with acute bronchospasm or status asthmaticus.

• Montelukast should be used with caution in geriatric patients and patients with phenylketonuria, behavioral changes, depression, psychiatric event, suicidal ideation, alcoholism, hepatic disease, hepatitis, jaundice, or corticosteroid withdrawal.

Drug interactions:

• Montelukast has minor interactions with the medications atropine, hyoscyamine, phenobarbital, scopolamine, belladonna alkaloids, ergotamine, carbamazepine, enzalutamide, gemfibrozil, hydantoins, lumacaftor, ivacaftor, mitotane, primidone, rifamycins, St. John’s Wort, and warfarin.

• The full list of medication interactions is listed in the PDR.