Helping Patients Find the Right OTC Relief for Seasonal Allergic Rhinitis

Every spring and fall, pharmacy counters across the country begin to fill with patients asking the same familiar questions: “Which allergy medication works best?,” “Why doesn’t this one help my congestion?,” and “Can I take these together?”

Despite the wide availability of OTC options, millions of people cycle through products without achieving meaningful relief. Seasonal allergic rhinitis (SAR) is one of the most common chronic conditions in the US, affecting more than 82 million Americans, yet it remains frequently underrecognized, misdiagnosed, and ineffectively treated. Common triggers include tree, grass, and weed pollens, as well as outdoor mold spores, with symptoms that vary by season and geographic location.¹

Nearly two-thirds of US households purchased OTC allergy medications in the 12 months ending April 2024, yet inadequate symptom control remains common.² Many patients reach for products based on brand familiarity, combine medications without understanding the overlapping ingredients, or discontinue therapy after only a few days because they are unaware that some treatments require consistent use to be effective. The result is significant spending with limited symptom relief.

As more allergy products have moved to OTC status, the pharmacist has become central to the management of SAR. Patients are not simply looking for a product recommendation; they are looking for someone to help them choose the right product, avoid unnecessary risks, and understand what to expect from the treatment. Effective management of SAR begins not with a brand name, but with an accurate understanding of the patient's symptom pattern.

Start With the Symptoms

Patients with SAR typically present with bilateral nasal symptoms, including clear rhinorrhea, sneezing, nasal congestion, and ocular, ear, nasal, and throat itching. Up to 70% will also experience allergic conjunctivitis, characterized by intense ocular itching, tearing, and redness.^1,3 Because many of these symptoms overlap with the common cold, distinguishing between the 2 can be challenging. Before making a recommendation, pharmacists should ask targeted questions regarding symptom severity, timing, seasonal or outdoor triggers, prior treatment response, and relevant medical conditions or concomitant medications.

Ocular itching is a hallmark of allergic disease and rarely accompanies a cold; conversely, sore throat, fever, and body aches point toward an infectious etiology.^1,4 When the picture is unclear, asking about symptom timing, known triggers, and whether symptoms recur seasonally can help guide the conversation and the recommendation. Not every patient with allergy symptoms is a candidate for self-care, however. Referral is appropriate for patients with suspected infections, uncontrolled asthma, severe symptoms, pregnancy, or children younger than 12 years unless a health care provider has already evaluated them. ^4-6

Management Strategies

There is currently no cure for seasonal allergies. The goals of therapy include symptom relief, minimizing sleep disturbances, improving work and school performance, and improving quality of life. A successful treatment plan will incorporate both nonpharmacologic strategies and pharmacologic therapy. OTC options include intranasal corticosteroids (INCs), oral and intranasal antihistamines, decongestants, mast cell stabilizers, and ocular antihistamines, with the right choice depending on which symptoms are most bothersome, their severity, and the patient’s medical history. One of the most valuable roles of the pharmacist is helping patients understand that not all allergy products work the same way. ^1,7

Intranasal Corticosteroids

INCs are the most effective OTC treatment for allergic rhinitis and should be the first recommendation for most patients with moderate-to-severe or persistent symptoms.⁷ They are effective for relieving all symptoms of SAR, including sneezing, rhinorrhea, nasal congestion, nasal itching, and ocular symptoms, by suppressing the underlying inflammatory response.^1,4 Available OTC options include fluticasone propionate (Flonase Allergy Relief), fluticasone furoate (Flonase Sensimist), triamcinolone acetonide (Nasacort Allergy 24HR), budesonide (Rhinocort Allergy), and mometasone furoate (Nasonex 24HR Allergy).

Setting expectations about the onset is one of the most important counseling points for this class. Initial relief can begin anywhere from 3 to 36 hours after the first dose, but maximal benefit may take 2 to 4 weeks of regular use.^4,6 Continuous daily use outperforms as-needed use, and starting therapy 2 weeks before peak pollen season can help prevent symptoms. Proper technique also matters. Nearly 60% of patients who use nasal sprays are using them incorrectly, often pointing the nozzle toward the nasal septum, which can lead to irritation, epistaxis, and reduced efficacy. Advise patients to aim the nozzle away from the nasal septum, directing it toward the ear to improve delivery and reduce irritation, and to use the opposite-hand technique: right hand to spray into the left nostril, left hand to spray into the right nostril.^8,9 INCs are generally well-tolerated, and systemic adverse effects are minimal given the low bioavailability of topical administration.⁴

Antihistamines

Oral antihistamines are most effective for sneezing, itching, and rhinorrhea but have a modest effect on nasal congestion at best, a distinction worth emphasizing when counseling patients who expect complete relief from a single product.^6,10 Second-generation agents, such as cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra), and levocetirizine (Xyzal), are strongly preferred over first-generation agents, such as diphenhydramine (Benadryl), due to their improved safety and selectivity. First-generation antihistamines readily cross the blood-brain barrier, leading to sedation, decreased cognitive function, and anticholinergic effects. They are listed on the American Geriatrics Society Beers Criteria as potentially inappropriate for use in older adults.¹¹

In young children, diphenhydramine has been associated with paradoxical excitation and, more concerning, a 2024 study found that first-generation antihistamines are associated with increased seizure risk in children aged 6 to 24 months.¹² Among second-generation agents, cetirizine and levocetirizine carry a modest sedation risk, unlike the others in the class.⁶ For best results, antihistamines should be taken consistently, either prophylactically 2 to 5 hours before anticipated allergen exposure, or on a regular daily schedule rather than as needed.⁴

Since 2021, pharmacists have had a new OTC intranasal antihistamine option to discuss with patients: azelastine hydrochloride 0.15% (Astepro Allergy). Intranasal azelastine has a faster onset of action than oral agents and may provide some benefit for nasal congestion in addition to sneezing, itching, and rhinorrhea.^1,4 This makes intranasal azelastine a particularly useful option for patients who need quicker relief or find oral antihistamines insufficient.

Decongestants

Patients with nasal congestion may benefit from decongestants. Currently, there are 2 systemic decongestants available in the US: pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE). Multiple randomized controlled trials have demonstrated that oral phenylephrine is not significantly more effective than placebo for relieving nasal congestion, prompting the FDA in November 2024 to propose its removal from OTC nasal decongestant monographs.^13,14 A final order is expected after review of public comments submitted through May 2025. Products remain on pharmacy shelves in the interim.¹⁵ Pharmacists are uniquely positioned to help patients understand why pseudoephedrine, available behind the pharmacy counter, remains the only effective OTC oral decongestant.

Topical decongestants such as oxymetazoline (Afrin) provide rapid, effective congestion relief with minimal systemic absorption when used as directed. However, use must be strictly limited to 3 to 5 days. Longer use leads to rhinitis medicamentosa, a state of chronic rebound congestion that responds progressively less to treatment and can be more severe than the original symptoms.⁴

All decongestants carry cardiovascular and central nervous system stimulant risks. Their use should be avoided in patients with cardiac arrhythmia, angina, cerebrovascular disease, uncontrolled hypertension, bladder outlet obstruction, glaucoma, hyperthyroidism, or benign prostatic hypertrophy. High-dose or prolonged use has been associated with serious cardiotoxicity, including myocardial ischemia, stroke, and arrhythmias.⁴

Ocular Allergy Symptoms

Many patients with seasonal allergies have itchy, watery, or red eyes as their most bothersome symptom. Although oral antihistamines and INCs may provide some benefit, ophthalmic antihistamine drops are often the most effective option for rapid relief. Available OTC products include ketotifen (Zaditor, Alaway) and olopatadine (Pataday), both of which have dual antihistamine and mast cell stabilizing properties with a rapid onset of action. For patients seeking relief from these ocular symptoms, recommending a targeted ophthalmic antihistamine in addition to nasal therapy can meaningfully improve overall symptom control.^16,17

Artificial tears and cool compresses may provide additional symptomatic relief and can be useful in patients with mild symptoms or as adjunctive therapy. In contrast, vasoconstrictor-containing products marketed for “red eyes” may reduce redness temporarily but do not treat the underlying allergic process and may cause rebound redness with prolonged use.^16,17

Counseling Pearls

SAR management often begins at the pharmacy counter. Most patients will attempt self-care before seeing a primary care provider, and many will never see one at all. A targeted conversation, asking what symptoms are most bothersome, whether they have tried anything before, and whether they have relevant medical conditions, can make the difference between a patient who gets real relief and one who repeatedly cycles through products without success.

Setting expectations is just as important as selecting the right product. The most significant contribution a pharmacist can make to a patient using INCs is correcting their administration technique. Incorrect use is one of the most common reasons patients fail to achieve adequate symptom relief. Similarly, it is important to stress the importance of using topical decongestants for no more than 3 to 5 days to prevent rhinitis medicamentosa.

Patients suffering from SAR should also be counseled on nonpharmacologic strategies. They should be counseled to monitor local pollen counts, keep windows closed during high-pollen days, shower and change clothes after spending time outdoors, and use high-efficiency particulate air filters at home. These measures won’t replace medication, but when utilized in combination with pharmacotherapy, will reduce the allergy burden for patients.⁶

Conclusion

Seasonal allergies are common, chronic, and undertreated. For many patients, the pharmacist is the only place they seek help, which makes the pharmacist’s role in the management of this disease integral. Asking the right questions, matching products to symptoms, identifying contraindications, and ensuring patients know how to use what they're given can transform a routine counter interaction into meaningful care. The OTC allergy aisle isn't going to get simpler, and allergy seasons are only getting longer. When patients ask which allergy medication works best, the answer isn’t a single product; it’s a tailored recommendation guided by the pharmacist.

REFERENCES

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