Symptoms of AR include sneezing, nasal congestion, rhinorrhoea, nasal itching, and airflow obstruction, which significantly impact quality of life, sleep, exercise tolerance, productivity, and social functioning. The condition affects both adults and children, with up to 50% of adults and 45% of children experiencing disruptions in daily life and sleep due to nasal allergy symptoms.³

The direct medical costs of AR are substantial, highlighting the importance of effective management. AR also leads to lost work and school days, decreased productivity, and impaired school performance, with absenteeism and presenteeism affecting up to 10% and 25% of workers, respectively.³

AR is classified as seasonal or perennial, intermittent, or persistent based on symptom duration and frequency. Treatment is tailored to symptom severity, with allergen avoidance and environmental controls as primary strategies.⁴

The management of AR involves a tailored approach

The management of AR involves a tailored approach, considering the efficacy, safety of the agents selected, and patient preferences. The 2023 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-AR 2023) recommends allergen avoidance, which may provide some benefit in controlling AR symptoms.⁵

However, pharmacologic treatments often have to be used to control AR symptoms. These treatments are available on prescription or over-the-counter.

ICAR-AR 2023 recommends AH, CS, and their combinations, both orally and intranasally as key interventions.⁵

Newer-generation oral AH have become the cornerstone of AR treatment due to their efficacy and improved side effect profile compared to first-generation agents. They are recommended as first-line therapy, offering reduction in AR symptoms with minimal adverse effects (AEs) - particularly in the elderly population.⁵

INAH offer rapid onset and are more effective for nasal congestion than oral agents. They are considered first- or second-line therapy for AR due to their consistent efficacy and safety profile.⁵

While oral CS can attenuate AR symptoms and allergen-induced inflammation, their use is limited due to the potential for AEs, such as hypothalamic-pituitary axis suppression and growth retardation, especially in paediatric populations. Therefore, their routine use is discouraged in favour of safer alternatives like intranasal (IN) CS (INCS).⁵

INCS sprays are highly effective in reducing nasal and ocular symptoms of AR and are thus recommended as first-line therapy. Although they may cause local AEs like epistaxis, the benefits outweigh the risks.⁵

Combining oral AH with INCS has shown improved symptom control, particularly for nasal congestion. However, caution is advised, especially in patients with comorbidities, and long-term use should be avoided due to the potential for AEs. Combining INCS with INAH has demonstrated superior efficacy compared to monotherapy or placebo, making it a recommended second-line therapy for AR.⁵

Efficacy of combination azelastine/fluticasone nasal spray

The safety and efficacy of combination azelastine/fluticasone nasal spray have been studies in various settings. Ratner et al showed that the combination improved total nasal symptom score (TNSS) by improved 37.9% and Hampel et al showed that combination azelastine/fluticasone nasal spray improved TNSS, including nasal congestion, runny nose, itchy nose, and sneezing, by 28.4%.^6,7

Debbaneh et al recently conducted a systematic review and meta-analysis, revealing the superiority of combination azelastine/fluticasone nasal spray in reducing the TNSS compared to placebo (60%).⁸

The authors concluded that current evidence strongly supports both the efficacy and superiority of combination azelastine/fluticasone in reducing patient-reported symptom scores among those living with AR. Therefore, combination nasal spray should be considered as a second-line therapy for patients whose AR is not adequately controlled with monotherapy.⁸

Conclusion

Overall, effective management of AR involves a multifaceted approach incorporating patient education, allergen avoidance, and pharmacological interventions based on symptom severity and response to treatment. Referral to specialists and consideration of allergen immunotherapy may be necessary for refractory cases.

References

1. Professional information. Dymista Nasal Spray. 2024. [Internet]. Available at: https://pi-pil-repository.sahpra.org.za/wp-content/uploads/2024/03/pil_dymista_approved_oct2023.pdf
2. Wise SK, Lin SY, Toskala E, et al. International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol, 2018.
3. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol, 2020
4. Bousquet J, Schunemann HF, Togia A, et al. Next-generation Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. The Journal of Allergy and Clinical Immunology, 2020.
5. Wise SK, Damask C, Roland LT, et al. International consensus statement on allergy and rhinology: Allergic rhinitis – 2023. International Forum of Allergy and Rhinology, 2023.
6. Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol, 2008.
7. Hampel FC, Ratner PH, Van Bavel J, et al. Double-blind, placebo-controlled study of azelastine and fluticasone in a single nasal spray delivery device. Ann Allergy Asthma Immunol, 2010.
8. Debbaneh PM, Bareiss AK, Wise SK, et al. Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-analysis. Otolaryngology-Head and Neck Surgery, 2019.