Corticosteroids (steroids) help reduce the inflammatory response associated with allergic reactions. They can help improve both nasal and eye symptoms. Nasal-spray corticosteroids are considered the most effective drugs for controlling the symptoms of moderate-to-severe allergic rhinitis.
Nasal spray steroids may be used alone or in combination with a nasal antihistamine or nasal decongestant. (A nasal spray decongestant should be used only for 3 days or less.)
Corticosteroids available in nasal spray form include:
- Triamcinolone (Nasacort) and fluticasone (Flonase, generic) are available without a prescription
- Mometasone furoate (Nasonex)
- Fluticasone and azelastine (Dymista)
- Beclomethasone (Beconase, Vancenase, generic)
- Flunisolide (Nasarel, generic)
- Budesonide (Rhinocort, generic)
- Ciclesonide (Alvesco, Omnaris)
These nasal sprays are approved for children. Ages vary depending on brand.
Side effects of nasal steroids may include:
- Dryness, burning, stinging in the nasal passage
- Blood-tinged nasal secretions
- Nosebleed (inform your health care provider)
Oral steroids can have many systemic side effects, including stunting growth in children and increasing risk for glaucoma. Nasal spray steroids do not appear to carry these risks. Still, discuss with your health care provider any possible risks and whether these drugs are appropriate for you.
Histamine is one of the chemicals released when antibodies overreact to allergens. It is the cause of many symptoms of allergic rhinitis. Antihistamine drugs block the effects of histamine. These drugs can help prevent and relieve nasal, eye, and itching symptoms associated with allergic rhinitis.
Antihistamine drugs are available in oral tablet and nasal spray forms, and also as a eyedrops and a liquid preparation. Some antihistamines need a prescription while others are available over the counter. Some oral antihistamines come in combination with a decongestant.
Antihistamines are generally categorized as first- or second-generation.
First-generation antihistamines, which include diphenhydramine (Benadryl, generic) and clemastine (Tavist, generic) cause more side effects (such as drowsiness) than most newer second-generation antihistamines. For this reason, second-generation antihistamines are generally preferred and recommended, especially for people whose main symptoms are sneezing and itching.
Second-generation antihistamines are sometimes referred to collectively as nonsedating antihistamines. However, cetirizine (Zyrtec, generic) and the nasal spray antihistamines (Astelin, Patanase) may cause drowsiness when taken at recommended doses. Loratadine (Claritin, generic) and desloratadine (Clarinex) can cause drowsiness when taken at doses exceeding the recommended dose.
Brand Names. Second-generation antihistamines in pill form include:
- Loratadine (Claritin, generic). Loratadine is available over the counter and is approved for children age 2 and older. Loratadine-D (Claritin-D) combines the antihistamine with the decongestant pseudoephedrine. Desloratadine (Clarinex) is similar to Claritin, but is stronger and longer-lasting. It is available only by prescription.
- Cetirizine (Zyrtec, generic). Cetirizine is approved for both indoor and outdoor allergies. It is the only antihistamine to date approved for infants as young as 6 months. It is available over the counter. Cetirizine-D (Zyrtec-D) is a pill that combines the antihistamine with the decongestant pseudoephedrine.
- Fexofenadine (Allegra, generic) is also available over the counter.
- Levocetirizine (Xyzal) is a prescription medication approved to treat seasonal allergic rhinitis in patients age 2 and older. It is available in both pill and liquid form.
- Acrivastine and pseudoephedrine (Semprex-D) is a pill that combines an antihistamine and decongestant.
- Carbinoxamine maleate (Karbinal ER) is available as a liquid for people age 2 and older.
Second-generation antihistamines in nasal form are as good as, or better than the oral forms for treating seasonal allergic rhinitis. However, they can cause drowsiness, and they are not as effective for allergic rhinitis as nasal corticosteroids. Nasal spray antihistamines are available by prescription and include:
- Azelastine (Astelin, Astepro, Dymista)
- Olopatadine (Patanase)
Side effects of antihistamines may include:
- Headache, dry mouth, and dry nose. These are often only temporary and go away during treatment.
- Drowsiness. The nasal spray forms may cause more drowsiness than the pill forms.
- Extended-release forms of loratadine and cetirizine have additional ingredients that can cause other symptoms, including nervousness, restlessness, and insomnia.
- Antihistamines may thicken mucus secretions and can worsen bacterial rhinitis or sinusitis.
- Antihistamines can lose their effectiveness over time and you may need to try a different one.
Decongestants work by shrinking blood vessels in the nose. Many over-the-counter decongestants are available, which can be either taken by mouth or applied to the nose.
Nasal Decongestants. Nasal-delivery decongestants are applied directly into the nasal passages with a spray, gel, drops, or vapors. Nasal decongestants come in long-acting or short-acting forms. The effects of short-acting decongestants last about 4 hours. Long-acting decongestants last 6 to 12 hours. The active ingredients in nasal decongestants include oxymetazoline, xylometazoline, and phenylephrine.
Nasal forms work faster than oral decongestants and may not cause as much drowsiness. However, they can cause dependency and rebound congestion. The decongestant loses effectiveness and can cause increased congestion. The 12-hour brands pose a particular risk for this effect.
The following precautions are important for people taking nasal decongestants:
- When using a nasal spray, spray each nostril once. Wait a minute to allow absorption into the mucosal tissues, and then spray again.
- Do not share droppers and inhalers with other people.
- Discard sprayers, inhalers, or other decongestant delivery devices when the medication is no longer needed. Over time, these devices can become reservoirs for bacteria.
- Discard the medicine if it becomes cloudy or unclear.
- DO NOT USE NASAL DECONGESTANTS FOR LONGER THAN 3 DAYS.
Oral Decongestants. Oral decongestants also come in many brands, which have similar ingredients. The most common active ingredients are pseudoephedrine (Sudafed, other brands, generic) and phenylephrine, sometimes in combination with an antihistamine. Oral decongestants can cause side effects such as insomnia, irritability, nervousness, and heart palpitations. Taking pseudoephedrine in the morning, as opposed to later in the day or before bedtime, can help people avoid these side effects.
Decongestants should not be used in children or infants under the age of 4 years. Some health care providers recommend not giving decongestants to children under the age of 14. Children are at particular risk for central nervous system side effects including convulsions, rapid heart rates, loss of consciousness, and death.
Standard oral decongestants pose serious risks for people with high blood pressure. Your provider may recommend you take an alternative type of decongestant or avoid them all together.
If you are pregnant or have any type of medical condition that affects your blood or circulation, discuss with your provider whether decongestants are safe for you.
Oral decongestants can cause dangerous interactions when combined with certain types of medications, such as the antidepressant MAO inhibitors. They can also cause serious problems when combined with methamphetamines or diet pills. Be sure to tell your provider about any drug or herbal remedy you are taking. Caffeine can also increase the stimulant side effects of pseudoephedrine.
Leukotriene antagonists are oral drugs that block leukotrienes, powerful immune system factors that cause airway constriction and mucus production in allergy-related asthma. They are not a first-line treatment for allergic rhinitis, but are sometimes used in combination with a nasal spray steroid or oral antihistamine.
Leukotriene antagonists include zafirlukast (Accolate, generic) and montelukast (Singulair, generic). These drugs are mainly used to treat asthma. Montelukast is also approved to treat seasonal allergies and indoor allergies.
The FDA warns that these drugs have been associated with behavior and mood changes, including agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking and behavior. People who take a leukotriene antagonist drug such as montelukast should be monitored for signs of behavioral and mood changes. If you exhibit any symptoms, your health care provider should consider discontinuing the drug.
Ipratropium bromide (Atrovent, generic) is a prescription nasal spray that can help relieve runny nose. It works best when given in combination with a nasal corticosteroid. Side effects include nasal dryness, nosebleeds, and sore throat. It should not be used by people who have glaucoma or men who have an enlarged prostate gland.
Cromolyn is both an anti-inflammatory drug and a specific blocker for allergens. The standard prescription cromolyn nasal spray (NasalCrom, generic) is not as effective as steroid nasal sprays, and does not work in all people with allergic rhinitis. It may take several weeks to experience symptom relief.