Azelastine

Aka: Azelastine, Azelastine Hydrochloride, Azelastine Ophthalmic, Azelastine Nasal, Astelin, Astepro, Optivar

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II. Indications

  1. Allergic Rhinitis or Vasomotor Rhinitis (intranasal Azelastine)
    1. Second-line agent
    2. FDA Approved for age >5 years (seasonal allergies) and >6 years (perennial allergies)
  2. Allergic Conjunctivitis
    1. FDA Approved for age >=3 years

III. Mechanism

  1. See Antihistamine
  2. Second-generation Antihistamine (phthalazinone)

IV. Medications

  1. Azelastine Nasal (Astelin, Astepro): 0.1% and 0.15% (with 200 sprays/bottle)
  2. Azelastine Ophthalmic (Optivar): 0.05% solution (6 ml bottle)
  3. Combination: Fluticasone with Azelastine (Dymista)
    1. Expensive (up to $200/month) and add little to benefit of generic nasal Corticosteroids alone
    2. Alternatively, use OTC Azelastine (Astepro) and a generic generic nasal Corticosteroid
    3. (2022) Presc Lett 29(5): 25-6

V. Dosing

  1. Nasal (age >5-6 years old)
    1. One spray per nostril twice daily
    2. Adults and children age >12 years may increase to 2 sprays per nostril if needed
    3. Shake well before each use
  2. Ocular (age >= 3 years old)
    1. Use 1 drop in each each eye twice daily

VI. Adverse Effects: Nasal

  1. Somnolence (11%)
    1. May affect safety in driving and hazardous activities
  2. Bitter Taste (20%)
  3. Headache (15%)
  4. Nasal burning (4%)
  5. Pharyngitis (4%)

VII. Adverse Effects: Ophthalmic

  1. Eye burning or stinging (30%, transient)
  2. Headaches (15%)
  3. Bitter taste (10%)

VIII. Safety

  1. Pregnancy Category C
  2. Unknown safety in Lactation

IX. Efficacy

  1. Azelastine in Covid19 Prevention
    1. Single study in Germany reported lower Incidence of Covid19 with longterm use of Azelastine
    2. Required high dose use during cold symptoms in mostly vaccinated, young adults with an NNT 23
    3. Not recommended for routine use (get the Vaccine instead for single shot, lower cost with better efficacy)
    4. (2025) Presc Insights 32(11): 64-5
    5. Lehr (2025) JAMA Intern Med +PMID: 40892398 [PubMed]

X. Resources

  1. Azelastine Hydrochloride Nasal Spray (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7902605c-944a-4d7e-a7d4-eb4a71bcacdb
  2. Azelastine Hydrochloride Ophthalmic Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6945fb86-27fb-4bab-8908-98772c6269c5

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Cost: Medications

azelastine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
AZELASTINE 0.1% (137 MCG) SPRY Generic $0.29 per ml
AZELASTINE 0.15% NASAL SPRAY Generic $0.92 per ml
AZELASTINE HCL 0.05% DROPS Generic $1.06 per ml
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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