Azelastine and Fluticasone
(a ZEL as teen & floo TIK a sone)
- Fluticasone Propionate and Azelastine Hydrochloride
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Ticalast: Azelastine hydrochloride 0.1% [137 mcg/spray] and fluticasone propionate 0.037% [50 mcg/spray] (23 g) & sterile saline wash (117 mL) [contains benzalkonium chloride; 120 metered sprays]
Dymista: Azelastine hydrochloride 0.1% [137 mcg/spray] and fluticasone propionate 0.037% [50 mcg/spray] (23 g) [contains benzalkonium chloride; 120 metered sprays]
Brand Names: U.S.
- Corticosteroid, Nasal
- Histamine H1 Antagonist, Second Generation
Azelastine competes with histamine for H1receptor sites on effector cells and inhibits the release of histamine and other mediators involved in the allergic response; when used intranasally, reduces hyper-reactivity of the airways; increases the motility of bronchial epithelial cilia, improving mucociliary transport.
Fluticasone belongs to a group of corticosteroids which utilizes a fluorocarbothioate ester linkage at the 17 carbon position; extremely potent vasoconstrictive and anti-inflammatory activity.
Use: Labeled Indications
Seasonal allergic rhinitis: Relief of symptoms of seasonal allergic rhinitis in patients ≥6 years of age
There are no contraindications listed in the US labeling.
Canadian labeling: Hypersensitivity to azelastine, fluticasone, or any component of the formulation; untreated fungal, bacterial, or tuberculosis infections of the respiratory tract.
Seasonal allergic rhinitis: Intranasal: One spray (137 mcg azelastine/50 mcg fluticasone) per nostril twice daily
Refer to adult dosing.
Seasonal allergic rhinitis: Children ≥6 years and Adolescents: Refer to adult dosing.
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer’s labeling.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer’s labeling. Alternatively, it has been recommended that no dosage adjustment is necessary (Dymista Canadian product labeling 2017). Fluticasone undergoes extensive first-pass metabolism; use with caution.
For intranasal administration only. Prime pump (press 6 times until fine spray appears) prior to first use. If ≥14 days have elapsed since last use, then reprime pump with 1 spray or until a fine mist appears. Shake bottle gently before using. Blow nose to clear nostrils. Keep head tilted downward when spraying. Insert applicator tip 1/4 to 1/2 inch into nostril, keeping bottle upright, and close off the other nostril. Breathe in through nose. While inhaling, press pump to release spray. After each use, wipe the spray tip with a clean tissue or cloth and replace cap. Clean spray pump unit and dust cap at least 1 time each week in warm water and allow to completely dry before placing back on bottle. Avoid spraying directly into nasal septum, eyes or mouth. Discard after 120 medicated sprays have been used, even if bottle is not completely empty. The 10 mL bottle [Canadian product] should be discarded after 28 medicated sprays have been used.
Store at 20°C to 25°C (68°F to 77°F); do not refrigerate or freeze. Protect from light. Store in upright position with cap on.
Alcohol (Ethyl): May enhance the CNS depressant effect of Azelastine (Nasal). Avoid combination
CNS Depressants: May enhance the CNS depressant effect of Azelastine (Nasal). Avoid combination
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Fluticasone (Nasal). Avoid combination
Desmopressin: Corticosteroids (Nasal) may enhance the hyponatremic effect of Desmopressin. Avoid combination
Reactions/percentages reported with combination product; also see individual agents.
1% to 10%:
Central nervous system: Headache (2%)
Gastrointestinal: Dysgeusia (4%)
Respiratory: Epistaxis (4%; frequency and severity may be increased in children)
<1% (Limited to important or life-threatening): Abnormality in thinking, anosmia, anxiety, application site irritation, atrial fibrillation, blurred vision, bronchospasm, burning sensation, cataract, chest pain, confusion, conjunctivitis, diarrhea, dizziness, drowsiness, drug tolerance, dry nose, dry throat, dyspnea, erythema, generalized ache, glaucoma, hoarseness, hypersensitivity reaction, hypertension, increased heart rate, increased intraocular pressure, insomnia (initial), muscle spasm, nasal obstruction, nasal septum perforation, nasal sores, nervousness, palpitations, paresthesia, restlessness, sedation, skin rash, sore throat, swelling of eye, therapeutic response unexpected, urinary retention, vertigo, visual disturbance, weight loss, xerophthalmia
Concerns related to adverse effects:
• Adrenal suppression: May cause hypercorticism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Pediatric patients may be more susceptible to systemic toxicity. Particular care is required when patients are transferred from systemic corticosteroids to inhaled products due to possible adrenal insufficiency or withdrawal from steroids, including an increase in allergic symptoms. Patients receiving ≥20 mg per day of prednisone (or equivalent) may be most susceptible. Concurrent use of ritonavir (and potentially other strong inhibitors of CYP3A4) may increase fluticasone levels and effects on HPA suppression.
• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).
• Delayed wound healing: Avoid nasal corticosteroid use in patients with recent nasal septal ulcers, nasal surgery, or nasal trauma until healing has occurred.
• Immunosuppression: Prolonged use of corticosteroids may increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines. Exposure to chickenpox or measles should be avoided.
• Infections: Corticosteroids should be used with caution, if at all, in patients with ocular herpes simplex, latent tuberculosis, and/or TB reactivity, in patients with untreated fungal, viral, or bacterial infections, or systemic viral or parasitic infections.
• Local nasal effects: Nasal septal perforation, nasal ulceration, epistaxis, and localized Candida albicans infections of the nose and/or pharynx may occur. Monitor patients periodically for adverse nasal effects.
• Ocular disease: Increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with intranasal corticosteroid use; use with caution in patients with a history of increased intraocular pressure, cataracts, and/or glaucoma. Consider routine eye exams in chronic users or in patients who report visual changes.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Pediatric: Avoid using higher than recommended dosages; suppression of linear growth (ie, reduction of growth velocity), reduced bone mineral density, or hypercorticism (Cushing syndrome) may occur; titrate to lowest effective dose. Reduction in growth velocity may occur when corticosteroids are administered to pediatric patients, even at recommended doses via intranasal route (monitor growth).
Growth (adolescents and children); signs/symptoms of HPA axis suppression/adrenal insufficiency; possible eosinophilic conditions (including Churg-Strauss syndrome); glaucoma and/or cataracts especially in patients with a change in vision; infection; adverse nasal effects (eg, nasal septal perforation, nasal ulceration, epistaxis, localized Candida albicans infections)
Pregnancy Risk Factor
Adverse events have been observed in animal reproduction studies. Refer to individual monographs.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience headache or change in taste. Have patient report immediately to prescriber signs of infection, severe dizziness, passing out, severe nausea, severe vomiting, severe loss of strength and energy, severe nose irritation, rhinitis, wheezing, vision changes, eye pain, severe eye irritation, severe nosebleed, fatigue, or thrush (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.
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