Key points
- Nasal corticosteroid sprays (such as fluticasone, mometasone, triamcinolone and budesonide) are the most effective treatment for allergic rhinitis and work best when used every day. Full benefit can take several days.
- Second-generation antihistamine tablets (cetirizine, levocetirizine, loratadine, fexofenadine) relieve sneezing, itching, watery eyes and a runny nose, and suit symptoms that come and go. Nasal congestion is not among the labelled uses of oral cetirizine.
- Drowsiness differs by medicine. US labels warn that drowsiness may occur with cetirizine and levocetirizine. Loratadine's label says drowsiness may happen only if more than the directed dose is taken. Fexofenadine's label carries no drowsiness warning.
- Take fexofenadine with water, not fruit juice, and not at the same time as aluminium or magnesium antacids.
- Since May 2025 the FDA has required a warning that rare but severe itching can start within a few days of stopping cetirizine or levocetirizine after months or years of daily use.
- Montelukast carries an FDA boxed warning (2020) for serious mental health effects. For allergic rhinitis it is reserved for people who cannot use or do not respond to other treatments.
How they work and when to use which
Intranasal corticosteroids reduce allergic inflammation in the lining of the nose. They treat congestion, runny nose, sneezing and itchy nose, and US OTC labels also list itchy, watery eyes. The fluticasone label states that the maximum effect may take several days and that the time to relief varies between people. When a pollen season is predictable, the mometasone label recommends starting 2 to 4 weeks before the season begins. GINA advises treating allergic rhinitis with an intranasal corticosteroid in everyone with asthma, alongside asthma treatment.
Second-generation (non-sedating or less-sedating) antihistamines block histamine H1 receptors. MedlinePlus suggests them when symptoms are infrequent or short-lived. MedlinePlus notes that some antihistamines cause sleepiness while others cause little or none, and that antihistamine nasal sprays and eye drops are other options.
Decongestant nasal sprays should not be used for more than 3 days. Montelukast is a tablet that blocks leukotrienes. It is not a first choice for hay fever because of its boxed warning (see below).
Using a nasal spray correctly
The fluticasone label's patient instructions give these steps:
- Shake gently. Prime a new bottle, or one unused for a week or more, by spraying into the air away from the face (6 sprays for fluticasone; follow the instructions for each product).
- Blow your nose to clear it.
- Close one nostril, tilt your head forward slightly, keep the bottle upright and place the tip in the other nostril.
- Start breathing in through your nose and press once to release the spray.
- Breathe out through your mouth. Repeat for a second spray if prescribed, then do the other nostril.
- Wipe the tip and replace the cap. Do not share the bottle.
Spray only into the nose, never into the eyes or mouth. A short sting or sneeze straight after use is common.
Usual adult doses and children's ages (US labels)
| Medicine | Usual adult dose | Youngest age on US label |
|---|---|---|
| Fluticasone propionate nasal | 2 sprays each nostril once daily for week 1, then 1–2 sprays; maximum 200 mcg a day | 4 years |
| Triamcinolone nasal (OTC) | 2 sprays each nostril once daily, reducing to 1 when improved | 2 years |
| Budesonide nasal (OTC) | 2 sprays each nostril once daily, reducing to 1 when improved | 6 years |
| Cetirizine | 10 mg once daily (5 mg for milder symptoms) | 6 months (Rx oral solution); OTC: ask a doctor under 6 years |
| Loratadine | 10 mg tablet once daily | 6 years (tablet); 2 years (children's chewable) |
| Fexofenadine | 180 mg once daily, with water | 2 years (children's oral suspension) |
Ages and over-the-counter status differ between countries and between products from the same medicine. Check the local label. For children using a nasal steroid, US OTC labels advise using it for the shortest time needed and talking to the child's doctor if it is needed for more than 2 months a year. An adult should supervise use.
Safety: what to check
Nasal corticosteroids
- Nosebleeds and nasal damage: nosebleeds are one of the most common side effects. Nasal ulcers, Candida infection, slow healing and, rarely, a hole in the nasal septum can occur. Stop and see a doctor for severe or frequent nosebleeds, or a constant whistling sound from the nose. Do not use after nasal surgery or injury until healed.
- Eyes: glaucoma and cataracts are linked to nasal and inhaled steroids. Ask a doctor first if you have had either, and report any new vision change.
- Growth in children: intranasal steroids can slow growth rate, so a child's growth should be checked regularly on long-term use.
- Interactions: ritonavir, a strong CYP3A4 inhibitor, greatly raises fluticasone levels. Cushing's syndrome and adrenal suppression have been reported, so the combination is not recommended. The OTC label also says to ask before use with ketoconazole tablets or other steroid medicines for asthma, allergy or skin.
- Infections: people exposed to chickenpox or measles while on a steroid should seek advice. Ask a doctor if symptoms are not better within 7 days, or if severe facial pain or thick nasal discharge suggests an infection.
- Liver: fluticasone is cleared by the liver, so levels may rise in liver impairment.
- Pregnancy and breastfeeding: OTC labels say to ask a health professional before use.
Oral antihistamines
- Sedation: with cetirizine and levocetirizine, take care when driving or using machinery, and avoid alcohol, sedatives and tranquillisers. In children aged 6 to 11, sleepiness with cetirizine rose with the dose.
- Itching after stopping cetirizine or levocetirizine: the FDA reviewed 209 reports worldwide (2017 to 2023). Most people had taken the medicine daily for more than 3 months, though some had used it for under a month. Itching started within a few days of stopping and was sometimes severe and widespread. It eased in most people who restarted the medicine, and in some who then tapered off slowly. People planning long-term use should discuss this with a clinician first.
- Fexofenadine: avoid fruit juice and aluminium or magnesium antacids at the same time as a dose.
- Kidneys and liver: ask a doctor before using cetirizine or loratadine with liver or kidney disease, or fexofenadine with kidney disease, since a lower dose may be needed. Levocetirizine must not be used in end-stage kidney disease (creatinine clearance below 10 mL/min), on haemodialysis, or in children aged 6 months to 11 years with any kidney impairment.
- Urinary retention: reported with levocetirizine. Use with caution in men with an enlarged prostate.
- Allergy: do not use cetirizine or levocetirizine if you are allergic to hydroxyzine or cetirizine.
- Pregnancy and breastfeeding: ask a health professional. The US cetirizine label says it is not recommended while breastfeeding.
- Older adults: the cetirizine and fexofenadine labels advise people aged 65 and over to ask a doctor before use.
Montelukast
The boxed warning lists agitation, aggression, depression, sleep disturbance and suicidal thoughts and behaviour, including suicide. Discuss these risks before starting. Stop the medicine and contact a clinician straight away if behaviour changes or new mental health symptoms appear.
Frequently asked questions
Why does my steroid spray not work straight away?
It reduces inflammation gradually. Maximum benefit may take several days of regular daily use. Starting before a predictable pollen season gives better protection.
Which antihistamine is least likely to make me sleepy?
Based on US labels, fexofenadine has no drowsiness warning and loratadine causes drowsiness mainly above the directed dose. Cetirizine and levocetirizine carry drowsiness warnings. Individual responses vary.
Can I stop cetirizine suddenly?
Most people can. Rarely, severe itching starts a few days after stopping long-term daily use. If that happens, contact a clinician. Restarting and then tapering slowly helped most reported cases.
Are steroid nasal sprays safe for children?
They are generally safe at labelled doses from the youngest licensed age, but they can slow growth. Use the lowest effective dose for the shortest time, with an adult supervising, and have growth checked on long-term use.
Sources
- US FDA label, fluticasone propionate nasal spray (prescription). DailyMed
- US FDA label, Children's Flonase Allergy Relief (OTC Drug Facts). DailyMed
- US FDA label, mometasone furoate nasal spray. DailyMed
- US FDA label, Nasacort triamcinolone (OTC). DailyMed
- US FDA label, cetirizine HCl 10 mg capsules (OTC), 2026. accessdata.fda.gov
- US FDA label, levocetirizine dihydrochloride tablets. DailyMed
- US FDA labels, Claritin (loratadine) and Allegra (fexofenadine) OTC. DailyMed (Allegra), DailyMed (Claritin)
- US FDA. Drug Safety Communication: rare but severe itching after stopping long-term cetirizine or levocetirizine, 16 May 2025. fda.gov
- US FDA. Drug Safety Communication: boxed warning for montelukast, 4 March 2020; and current montelukast label. fda.gov
- MedlinePlus. Allergic rhinitis. medlineplus.gov
- Global Initiative for Asthma. 2026 Summary Guide. ginasthma.org
This article is for education and does not replace advice from a doctor or pharmacist who knows the person's history. Check the label of your own product, as doses and age limits differ by country and brand.
