Examples of options we may consider after evaluating you; not everyone qualifies; some uses may be off‑label; risks/contraindications will be reviewed before prescribing.

Many primary care providers stop at oral antihistamines, steroid nasal sprays, and perhaps a nasal antihistamine or Singulair. For many patients, that’s simply not enough—and if you’ve gotten this far, you likely know this firsthand. We’re comfortable prescribing a comprehensive range of safe therapies that extend well beyond traditional PCP comfort zones.

Our typical escalation approach includes:

Second-generation oral antihistamines – We favor fexofenadine (Allegra) for its strong efficacy, true non-sedating profile, and lack of cardiac effects seen with some older antihistamines.^1-3

Montelukast (Singulair) – A leukotriene receptor antagonist that blocks a different inflammatory pathway than antihistamines, particularly useful for patients with both allergic rhinitis and asthma, or those with exercise-induced symptoms.^1,4 Has boxed warning for mental health concerns so other alternatives are usually tried first when available.^4,5

Nasal antihistamines (azelastine, olopatadine) – Provide rapid, direct relief of nasal symptoms with onset in 15-30 minutes, and can be more effective than oral antihistamines for purely nasal symptoms.^1,6

Fluticasone (and other nasal corticosteroids) – The gold standard for reducing nasal inflammation.^1,7 Most effective when used consistently rather than as-needed, with maximal benefit after 1-2 weeks of regular use.^1,7,8

Nasal anticholinergics (ipratropium) – Specifically targets rhinorrhea (runny nose) by blocking parasympathetic-mediated mucus secretion.⁹ Excellent add-on for patients whose primary complaint is anterior nasal drip or discharge.^1,9

Sublingual immunotherapy (SLIT) – FDA-approved tablets for specific allergens (ragweed, grass pollen, dust mite) that you dissolve under your tongue daily.^10-12 This actually modifies your immune system’s response to allergens rather than just masking symptoms, and can provide lasting benefit even after discontinuation in appropriate patients.^10,13 Requires commitment to daily dosing for years but can be life-changing for appropriate patients.^10-13 Protocol required due to anaphylaxis risk (including first-dose observation and epinephrine prescription).^10-12

Dupixent (dupilumab) – A biologic injection targeting IL-4 and IL-13, key drivers of type 2 inflammation.¹⁴ Appropriate for patients with severe chronic rhinosinusitis with nasal polyps, or those with allergic rhinitis plus comorbid moderate-to-severe asthma or atopic dermatitis (when they meet criteria for those indications).¹⁴ Requires injections every 2 weeks (and in some pediatric indications, every 4 weeks) but can be truly transformative for patients who’ve tried everything else.¹⁴

Xolair (omalizumab) – An anti-IgE biologic given by injection every 2-4 weeks.¹⁵ Best suited for patients with documented elevated IgE levels and allergic asthma, or those with chronic spontaneous urticaria (hives).¹⁵ Particularly effective when allergies are driven by multiple environmental triggers. Protocol required due to anaphylaxis risk.¹⁵

For patients with predominant nasal obstruction that hasn’t responded to medical management, we’re also happy to refer for nasomaxillary expansion (including EASE, MARPE/MSE, FAME, SARPE, DOME, and other related techniques).^16-18 This approach can effectively improve resistant nasal obstruction in appropriately selected patients, but outcomes can vary substantially depending on technique choice and provider experience.^16-18 (For a deeper breakdown of expansion types, see our upcoming post on Nasomaxillary Expansion.) Unlike traditional septoplasty or turbinate reduction, this approach widens the nasal sidewalls themselves by expanding the upper jaw (maxilla), creating fundamentally more space for airflow.¹⁶ Think of it as moving from a studio apartment to a mansion rather than trying to rearrange the furniture. It addresses the root structural issue rather than modifying the anatomy within an already-constricted space. Due to alteration of skeletal structure, many patients may perceive cosmetic or chewing function benefits as well (not universal and varies by patient).

References

1. Dykewicz MS, Wallace DV, Baroody FM, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. doi: 10.1016/j.jaci.2020.07.007.

2. Weiler JM, Bloomfield JR, Woodworth GG, et al. Effects of fexofenadine, diphenhydramine, and alcohol on driving performance: a randomized, placebo-controlled trial in the Iowa driving simulator. Ann Intern Med. 2000;132(5):354-363. doi: 10.7326/0003-4819-132-5-200003070-00004.

3. Pratt CM, Brown AM, Rampe D, et al. Cardiovascular safety of fexofenadine HCl. Clin Exp Allergy. 1999;29(Suppl 3):212-216. doi: 10.1046/j.1365-2222.1999.0290s3212.x.

4. Merck Sharp & Dohme Corp. Singulair (montelukast sodium) tablets, chewable tablets, and oral granules: prescribing information. Revised April 2020. Accessed January 13, 2026. FDA label (PDF).

5. U.S. Food and Drug Administration. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication. March 4, 2020. Accessed January 13, 2026. FDA safety communication.

6. Patel P, D’Andrea C, Sacks HJ. Onset of action of azelastine nasal spray compared with mometasone nasal spray and placebo in subjects with seasonal allergic rhinitis evaluated in an environmental exposure chamber. Am J Rhinol. 2007;21(4):499-503. doi: 10.2500/ajr.2007.21.3058.

7. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63(10):1292-1300. doi: 10.1111/j.1398-9995.2008.01750.x.

8. Pinar E, Sadullahoglu K, Calli C, Oncel S. Efficacy of nasal corticosteroids alone or combined with antihistamines or montelukast in treatment of allergic rhinitis. Auris Nasus Larynx. 2008;35(1):61-66. doi: 10.1016/j.anl.2007.06.004.

9. Boehringer Ingelheim Pharmaceuticals, Inc. Atrovent (ipratropium bromide) nasal spray 0.03%: prescribing information. Accessed January 13, 2026. FDA label (PDF).

10. U.S. Food and Drug Administration. GRASTEK (Timothy Grass Pollen Allergen Extract) tablet for sublingual use: package insert. Accessed January 13, 2026. Package insert (PDF).

11. U.S. Food and Drug Administration. RAGWITEK (Short Ragweed Pollen Allergen Extract) tablet for sublingual use: package insert. Accessed January 13, 2026. Package insert (PDF).

12. U.S. Food and Drug Administration. ODACTRA (House Dust Mite Allergen Extract) tablet for sublingual use: package insert. Accessed January 13, 2026. Package insert (PDF).

13. Durham SR, Emminger W, Kapp A, et al. SQ-standardized sublingual grass immunotherapy: confirmation of disease modification 2 years after 3 years of treatment in a randomized trial. J Allergy Clin Immunol. 2012;129(3):717-725.e5. doi: 10.1016/j.jaci.2011.12.973.

14. Regeneron Pharmaceuticals, Inc; Sanofi. Dupixent (dupilumab) injection, for subcutaneous use: prescribing information. 2025. Accessed January 13, 2026. FDA label (PDF).

15. Genentech, Inc; Novartis Pharmaceuticals Corporation. Xolair (omalizumab) injection, for subcutaneous use: prescribing information. Revised February 2024. Accessed January 13, 2026. FDA label (PDF).

16. Calvo-Henriquez C, Megias-Barrera J, Chiesa-Estomba C, et al. The impact of maxillary expansion on adults’ nasal breathing: a systematic review and meta-analysis. Am J Rhinol Allergy. 2021;35(6):923-934. doi: 10.1177/1945892421995350.

17. Li KK, Quo S, Guilleminault C. Endoscopically-assisted surgical expansion (EASE) for the treatment of obstructive sleep apnea. Sleep Med. 2019;60:53-59. doi: 10.1016/j.sleep.2018.09.008.

18. Iwasaki T, Yoon A, Guilleminault C, Yamasaki Y, Liu SY. How does distraction osteogenesis maxillary expansion (DOME) reduce severity of obstructive sleep apnea? Sleep Breath. 2020;24(1):287-296. doi: 10.1007/s11325-019-01948-7.