Small and Kim Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S3 http://www.aacijournal.com/content/7/S1/S3 Page 6 of 8 Table 3 Overview of pharmacologic treatment options for allergic rhinitis Usual adult dose Usual pediatric dose Oral antihistamines (second generation) Cetirizine (Reactine) Desloratadine (Aerius) Fexofenadine (Allegra) Loratadine (Claritin) Intranasal corticosteroids Budesonide (Rhinocort) Fluticasone propionate (Flonase) Mometasone furoate (Nasonex) Triamcinolone acetonide (Nasacort) Leukotriene receptor antagonists Montelukast EN: each nostril. Beclomethasone (Beconase) 1-2 sprays (42 µg/spray) EN, twice daily 1 spray (42 µg/spray) EN, twice daily Ciclesonide (Omnaris) 2 sprays (50 µg/spray) EN, once daily Fluticasone furoate (Avamys) 2 sprays (27.5 µg/spray) EN, once daily 1-2 tablets (5 mg) once daily 1 tablet (10 mg) once daily 1 tablet (5 mg), once daily 1 tablet (60 mg) every 12 hours (12-hour formulation) 1 tablet (120 mg), once daily (24-hour formulation) 1 tablet (10 mg), once daily 5-10 mL (1-2 teaspoons) once daily (children’s formulation) 2.5-5 mL (0.5-1.0 teaspoon) once daily (children’s formulation) Not currently indicated for children under 12 years of age 5-10 mL (1-2 teaspoons) once daily (children’s formulation) 2 sprays (64 μg/spray) EN, once daily or 1 spray EN, 2 sprays (64 μg/spray) EN, once daily or 1 spray EN, twice twice daily daily (do not exceed 256 μg) 2 sprays (50 µg/spray) EN, once daily or every 12 hours (for severe rhinitis) 2 sprays (50 µg/spray) EN, once daily 2 sprays (55 µg/spray) EN, once daily 1 spray (55 µg/spray) EN, once daily Not indicated for children under 12 years of age 1 spray (27.5 µg/spray) EN, once daily 1-2 sprays (50 µg/spray) EN, once daily 1 spray (50 µg/spray) EN, once daily 1 tablet (10 mg), once daily Not currently approved for patients under 15 years of age corticosteroids [26], longer-term studies have found intranasal corticosteroids to be more effective than the combination for reducing nighttime and nasal symptoms [12,27]. It is important to note that in Canada, montelu- kast (Singulair) is the only LTRA indicated for the treat- ment of allergic rhinitis in adults. LTRAs should be considered when oral antihistamines and/or intranasal corticosteroids are not well tolerated or are ineffective in controlling the symptoms of allergic rhinitis. If combination pharmacological therapy with oral antihistamines, intranasal corticosteroids and LTRAs is not effective or is not tolerated, then allergen immunotherapy should be considered [1,6]. Allergen immunotherapy Allergen immunotherapy involves the subcutaneous administration of gradually increasing quantities of the patient’s relevant allergens until a dose is reached that is effective in inducing immunologic tolerance to the aller- gen. This form of therapy has been shown to be effec- tive for the treatment of allergic rhinitis caused by pollens and dust mites, but has limited usefulness in treating mould and animal dander allergies [1]. Typically, allergen immunotherapy is given on a per- ennial basis with weekly incremental increases in dose over the course of 6-8 months, followed by maintenance injections of the maximum tolerated dose every 3 to 4 weeks for 3 to 5 years. After this period, many patients experience a prolonged, protective effect and, therefore, consideration can be given to stopping therapy. Pre-seasonal preparations that are adminis- tered on an annual basis are also available [1,6]. Sub- lingual preparations are also expected to be approved in Canada in the near future. These will provide patients with effective therapeutic options. Although patients will be able to self-administer the sublingual formulation, close monitoring by a physician will still be required. Allergen immunotherapy should be reserved for patients in whom optimal avoidance measures and phar- macotherapy are insufficient to control symptoms or are not well tolerated. Since this form of therapy carries the risk of anaphylactic reactions, it should only be pre- scribed by physicians who are adequately trained in the treatment of allergy and who are equipped to manage possible life-threatening anaphylaxis [1]. A simplified, stepwise algorithm for the treatment of allergic rhinitis is provided in Figure 2. Note that mild, intermittent allergic rhinitis can generally be managed effectively with avoidance measures and oral antihista- mines. However, as mentioned earlier, most patients presenting with allergic rhinitis have moderate-to-severe