Steroid nasal spray vs antihistamine tablets for hay fever

Hay fever, or seasonal allergic rhinitis, is an inflammatory reaction in the nose and eyes to pollen. Histamine produces quick-onset itching, sneezing and runny nose, while ongoing inflammation produces congestion and a persistent feeling of a blocked nose. Antihistamines target histamine; steroid sprays dampen local inflammation.

Because the mechanisms differ, it makes sense that the best treatment depends on which symptoms are troubling you. This is why pharmacists ask about your symptom pattern, not only about whether you have hay fever.

Second-generation antihistamines such as cetirizine and loratadine are widely used. They are taken once daily, start working in hours, and are convenient for people with itching, sneezing and runny nose, and for use when symptoms are intermittent. Drowsiness is less common than with older antihistamines but can occur.

They are less effective for a blocked nose, and some people find they are not enough on their own during a high pollen period. Taking them regularly through the season is more effective than only when symptoms flare.

Intranasal corticosteroid sprays deliver a very small dose of steroid directly to the nasal lining. At these doses, the amount absorbed into the body is low. They reduce inflammation, so they relieve congestion, sneezing, itch and runny nose, and are often considered the most effective single treatment for moderate to severe allergic rhinitis.

They work best with regular daily use and correct technique: aiming the nozzle away from the centre of the nose, towards the outer wall, and not sniffing hard. Possible effects include nasal dryness, irritation and occasional nosebleeds. Persistent nosebleeds, or use in children over a long period, should be discussed with a pharmacist or doctor.

NICE Clinical Knowledge Summaries on allergic rhinitis recommend that treatment is chosen according to symptoms, severity and preference: an intranasal corticosteroid for moderate to severe symptoms or when nasal congestion is prominent, and an oral or intranasal antihistamine for mild to moderate symptoms, with combinations used if a single treatment is insufficient. Allergen avoidance measures are also suggested where practical.

Pharmacists commonly advise using treatments regularly through the pollen season, checking technique for sprays, trying one product for a couple of weeks before judging it, and seeing a GP if symptoms are persistent, unusually severe, or accompanied by wheeze or sinus infections.

• Itchy, sneezy, runny-nosed with intermittent symptoms: an antihistamine tablet is a reasonable first step.

• Mainly a blocked nose or symptoms through the whole season: ask about a steroid nasal spray and use it regularly.

• Symptoms not controlled by one product after a couple of weeks: ask a pharmacist about combining a spray and a tablet, or adding eye drops.

• Eye symptoms are the main problem: ask about antihistamine eye drops.

• Wheeze, cough or breathing difficulty during pollen season: see a GP, since hay fever can coexist with asthma.

• One-sided blockage, bleeding, loss of smell or symptoms all year: these need medical review.

Steroid nasal sprays are not the same as oral steroid tablets, and at standard doses the amount absorbed is very small. They are also not instant, so people sometimes stop them too early. Antihistamines do not clear a blocked nose well. And nasal decongestant sprays are different again: they should not be used for more than a few days, because of rebound congestion.

Another misconception is that hay fever treatment is only needed on bad days. Regular use in the season usually gives better control.