Intranasal Antihistamine Pregnancy: Use with caution — limited data; intranasal steroids (mometasone) preferred in pregnancy for allergic rhinitis

Azelastine Nasal Spray

Brand names: Rhinolast, Dymista (combined with fluticasone)

Adult dose

Dose: 140 mcg per nostril (2 sprays each nostril) twice daily

Route: Intranasal

Frequency: Twice daily

Max: 140 mcg per nostril twice daily (560 mcg/day total)

Intranasal antihistamine for seasonal and perennial allergic rhinitis. Faster onset than intranasal corticosteroids (15–30 minutes). Dymista (azelastine + fluticasone propionate) provides combined antihistamine and corticosteroid effect — superior to either alone (MOZILLA trials).

Paediatric dose

Dose: Age-based mcg/kg

Route: Intranasal

Frequency: Twice daily

Max: 140 mcg per nostril twice daily

BNFc: licensed from 6 years of age — 140 mcg (1 spray) per nostril twice daily. Dymista licensed from 12 years.

Dose adjustments

Renal

No dose adjustment required

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Patient weight (kg)

BNFc: licensed from 6 years of age — 140 mcg (1 spray) per nostril twice daily. Dymista licensed from 12 years.

Clinical pearls

Faster onset than intranasal steroids — useful for as-needed use or when immediate relief required (e.g. before outdoor exposure)
MOZILLA trials: Dymista (azelastine + fluticasone) superior to each component alone in moderate-severe seasonal AR — now recommended in BSACI step-up therapy
Unpleasant bitter taste after use — advise patients to tilt head slightly forward and sniff gently after spraying (not deeply inhaling) to reduce post-nasal drip
BSACI 2017: intranasal antihistamine is an alternative to oral antihistamine for mild AR; Dymista is preferred for moderate-severe AR
No significant systemic antihistamine effects at intranasal doses — safer in elderly and in patients who cannot tolerate oral antihistamine sedation

Contraindications

Hypersensitivity to azelastine

Side effects

Bitter/unpleasant taste (most common — due to post-nasal drip; sniff gently after each spray)
Local nasal burning or irritation
Epistaxis
Somnolence (less than oral antihistamines)

Interactions

CNS depressants — additive drowsiness (minimal at intranasal doses)
Alcohol — additive CNS depression

Monitoring

Nasal symptom score
Epistaxis frequency

Reference: BNFc; BNF 90; BNFc; MOZILLA Trials (Carr et al. J Allergy Clin Immunol 2012); BSACI Rhinitis Guidelines 2017. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways