Managing Seasonal Allergies

Nasal corticosteroids

See our chart, Nasal Sprays for Allergic Rhinitis (U.S.) (Canada)

First-line for moderate to severe, persistent symptoms.^3,5

Nasal congestion.^3,5

Itchy, irritated, or watery eyes.³

Children:^9,14

• Under six years (budesonide)
• Under four years (fluticasone propionate)
• Under two years (triamcinolone, mometasone [three years in Canada], fluticasone furoate).

Oral antihistamines

See our comparison of first- and second-generation antihistamines at the end of this chart.

First-line for mild or intermittent symptoms (second generation).^3,5

Itching, sneezing, rhinorrhea (second generation).⁵

Under two years (most second generation).^9,14

• Under 12 years (fexofenadine [Canada only]).¹⁴

Elderly, risk of excessive sedation (first generation, cetirizine).⁹

Risk for decreased cognition or motor skills (first generation).⁹

Glaucoma (first generation).^9,14

Severe liver impairment.⁹

Severe renal impairment (cetirizine, desloratadine, rupatadine [Canada]).^9,14

With moderate or strong CYP3A4 inhibitors, grapefruit juice (rupatadine [Canada]).¹⁴

With orange, grapefruit, apple juice; other OATP inhibitors (fexofenadine).⁷

Prolonged QT interval (Canada: bilastine, rupatadine).¹⁴

Nasal antihistamines

Add-on therapy with nasal steroids, if needed (especially for nasal congestion).^1,3,8

Under five years (azelastine).⁹

Under six years (olopatadine).⁹

Neither available as single-ingredient nasal sprays in Canada.

Ophthalmic antihistamines

Add-on therapy for eye symptoms with nasal steroids, if needed.¹

Under three years (ketotifen, olopatadine [Canada]).^9,15,16

Under two years (olopatadine [U.S.]).⁹

Decongestants (intranasal, oral)

Inadequate response from a nasal steroid for nasal congestion.²

Use in combination with an oral antihistamine (intranasal).³

Intermittent nasal congestion.²

Hypertension, arrhythmia, coronary heart disease, hyperthyroidism, glaucoma, diabetes, and benign prostatic hypertrophy (oral).²

Prolonged use (more than three to five days) (intranasal).^2,3

With monoamine oxidase inhibitors.⁶

Monotherapy (intranasal).⁶

Cromolyn (intranasal [U.S.])

Prevention.

Inadequate response with other treatments.

Children when parents have safety concerns with other therapy.⁶

Children under two years.⁹

Leukotriene receptor antagonists (Montelukast)

Use as a last resort.¹⁰

Use if coexisting asthma.¹

For seasonal allergic rhinitis: under two years (U.S.), under 15 years (Canada).^17,18

Anxiety, depression, and psychiatric disorders.⁶

Oral corticosteroids

Use if severe rhinitis symptoms prevent sleep and/or work (last resort).⁶

Prolonged use (more than a few days).⁶

Second-generation antihistamines are often recommended over first-generation antihistamines as they are as effective and have less sedation or other adverse effects.^11-13

First-Generation Antihistamines

Second-Generation Antihistamines

Non-selective (target histamine-1 receptors, but also cholinergic, alpha-adrenergic, and serotonergic receptors).

Can have substantial adverse effects, especially in older patients (not recommended in patients >65 years old).

Most common adverse effect is sedation. May decrease cognitive and motor skills, use with caution.

Some (especially children) may have stimulating effects (e.g., insomnia, anxiety, hallucinations).

Can cause anticholinergic effects (e.g., dry mouth, dry eyes, constipation, tachycardia, etc).

Selective (more specific to peripheral histamine-1 receptors, don’t cross the blood-brain barrier).

Generally well tolerated.

Generally not sedating (note that cetirizine may be slightly more sedating than others).

Can be more expensive than first-generation antihistamines.