From the Guidelines
The primary treatment for chronic rhinitis involves recommending saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief, as stated in the clinical practice guideline update for adult sinusitis 1. This approach is based on a preponderance of benefit over harm and is supported by the most recent and highest quality studies. The treatment options can be broken down into the following:
- Saline nasal irrigation to clear mucus and allergens
- Topical intranasal corticosteroids to reduce inflammation in the nasal passages Some key points to consider when implementing this treatment plan include:
- Consistent use is key for effectiveness, and it may take 1-2 weeks to see full benefits
- If symptoms are severe or don't improve after 4-6 weeks, consult an allergist or ENT specialist for further evaluation and possible additional treatments, such as immunotherapy or addressing underlying conditions
- Immunotherapy may be considered for patients with allergic rhinitis who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls, as stated in the clinical practice guideline for allergic rhinitis executive summary 1
- Allergen immunotherapy is effective for the treatment of allergic rhinitis and may prevent the development of new allergen sensitizations and reduce the risk for the future development of asthma in patients with allergic rhinitis, as stated in the diagnosis and management of rhinitis: an updated practice parameter 1
From the FDA Drug Label
The primary efficacy endpoint was the change from Baseline to Day 14 in the Total Nasal Symptom Score [TNSS] (the average of individual scores of runny nose, sneezing, itchy nose, and nasal congestion) as assessed by patients on a 0-3 categorical scale. Compared to placebo, Astelin® Nasal Spray significantly improved the TNSS. Two hundred sixteen patients with vasomotor rhinitis received Astelin® Nasal Spray two sprays per nostril twice a day in two U. S. placebo controlled trials. These patients had vasomotor rhinitis for at least one year, negative skin tests to indoor and outdoor aeroallergens, negative nasal smears for eosinophils, and negative sinus X-rays, Astelin® Nasal Spray significantly improved a symptom complex comprised of rhinorrhea, post nasal drip, nasal congestion, and sneezing. Fluticasone Propionate Nasal Spray, USP, like other corticosteroids, is an agent that does not have an immediate effect on allergic symptoms. A decrease in nasal symptoms has been noted in some patients 12 hours after initial treatment with Fluticasone Propionate Nasal Spray, USP. Maximum benefit may not be reached for several days
The treatment options for chronic rhinitis include:
- Azelastine (IN): two sprays per nostril twice daily, which has been shown to significantly improve symptoms of rhinorrhea, post nasal drip, nasal congestion, and sneezing in patients with vasomotor rhinitis 2
- Fluticasone (IN): which has been shown to decrease nasal symptoms in some patients 12 hours after initial treatment, with maximum benefit reached after several days 3 3 Key points:
- Azelastine and fluticasone are both nasal sprays that can be used to treat chronic rhinitis
- These medications have been shown to improve symptoms of rhinorrhea, post nasal drip, nasal congestion, and sneezing
- The exact mechanism of action of these medications is not fully understood, but they are thought to work by reducing inflammation in the nasal passages
From the Research
Treatment Options for Chronic Rhinitis
The treatment options for chronic rhinitis can be categorized into pharmacological and non-pharmacological approaches.
- Pharmacological Treatment:
- Antihistamines, such as terfenadine, astemizole, loratadine, and cetirizine, are effective in treating chronic rhinitis 4.
- Topical glucocorticosteroids, including beclomethasone dipropionate, flunisolide, budesonide, fluocortin butyl, and triamcinolone acetonide, are safe and highly efficacious 4.
- Topical ipratropium bromide may be beneficial for patients with rhinorrhoea as their chief complaint 4.
- Decongestants, either topically or orally administered, can help alleviate nasal congestion 4.
- Sodium cromoglycate (cromolyn sodium) or nedocromil sodium applied topically intranasally have a moderate beneficial effect and are associated with a low incidence of adverse effects 4.
- Intranasal corticosteroids are superior to antihistamines and can reduce all symptoms of rhinitis 5.
- Montelukast has been shown to be better than placebo, as effective as antihistamines, but less effective than nasal corticosteroids in improving symptoms and quality of life in patients with seasonal allergic rhinitis 5.
- Subcutaneous and sublingual immunotherapy have also reported good results 5.
- Antileukotrienes, anticholinergics, nasal decongestants, and mast cell stabilizers may be considered depending on clinical features in individual patients 6.
- A fixed combination of intranasal corticosteroid and intranasal antihistamines may be considered the most beneficial, particularly in monotherapy and in cases resistant to previous treatment 7.
- Non-Pharmacological Treatment:
- Avoiding inhalation of cigarette smoke and other irritants is essential 4.
- Patients with chronic allergic rhinitis should avoid antigens to which they have known sensitivity 4.
- Allergen avoidance should be the initial step in the management of allergic rhinitis 5.
- Immunotherapy with the offending antigen(s) may be beneficial for selected patients with allergic rhinitis 4.
Severity-Based Treatment
The treatment approach may vary based on the severity and frequency of symptoms.
- For mild intermittent or mild persistent allergic rhinitis, first-line treatment may include a second-generation H1 antihistamine or an intranasal antihistamine 8.
- For persistent moderate to severe allergic rhinitis, initial treatment should be with an intranasal corticosteroid, either alone or in combination with an intranasal antihistamine 8.
- For nonallergic rhinitis, first-line therapy consists of an intranasal antihistamine as monotherapy or in combination with an intranasal corticosteroid 8.