From the Guidelines
Allergic rhinitis should be treated with intranasal corticosteroids as the first line of treatment, as they are the most effective medication class for controlling symptoms. Treatment typically begins with identifying and avoiding triggers such as pollen, dust mites, pet dander, or mold. For symptom management, intranasal corticosteroids like fluticasone (Flonase) or mometasone (Nasonex) are most effective, used as 1-2 sprays per nostril daily 1. Oral antihistamines can also help, with second-generation options like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) preferred as they cause less drowsiness than first-generation alternatives 1. For persistent congestion, nasal decongestants like oxymetazoline may provide short-term relief but should not be used for more than 3 days to avoid rebound congestion 1. Saline nasal irrigation can help clear allergens and mucus. For severe cases unresponsive to standard treatments, allergen immunotherapy (allergy shots) may be considered to gradually desensitize the immune system 1.
Some key points to consider when treating allergic rhinitis include:
- Identifying and avoiding triggers to reduce symptom severity
- Using intranasal corticosteroids as the first line of treatment for symptom management
- Considering oral antihistamines for additional symptom relief
- Limiting the use of nasal decongestants to avoid rebound congestion
- Using saline nasal irrigation to clear allergens and mucus
- Considering allergen immunotherapy for severe cases unresponsive to standard treatments
It's also important to note that the diagnosis of allergic rhinitis should be based on a thorough medical history and physical examination, including questions about seasonal, perennial or episodic, exposure-associated itching of the nose, palate, or eyes, sneezing, nasal congestion, sniffling, clear rhinorrhea, and postnasal drip 1.
In terms of specific treatment recommendations, the 2017 Joint Task Force on Practice Parameters recommends an intranasal corticosteroid over a leukotriene receptor antagonist for the treatment of seasonal allergic rhinitis in persons aged 15 years or older 1. Additionally, the combination of an intranasal corticosteroid and an intranasal antihistamine may be considered for initial treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older 1.
From the FDA Drug Label
The efficacy of SINGULAIR tablets for the treatment of seasonal allergic rhinitis was investigated in 5 similarly designed, randomized, double-blind, parallel-group, placebo- and active-controlled (loratadine) trials conducted in North America. Four of the five trials showed a significant reduction in daytime nasal symptoms scores with SINGULAIR 10-mg tablets compared with placebo. The efficacy of SINGULAIR tablets for the treatment of perennial allergic rhinitis was investigated in 2 randomized, double-blind, placebo-controlled studies conducted in North America and Europe. In the study in which efficacy was demonstrated, SINGULAIR 10-mg tablets once daily was shown to significantly reduce symptoms of perennial allergic rhinitis over a 6-week treatment period.
Montelukast (PO) is effective in treating seasonal allergic rhinitis and perennial allergic rhinitis, as shown by significant reductions in daytime nasal symptoms scores compared to placebo in clinical trials 2.
From the Research
Definition and Prevalence of Allergic Rhinitis
- Allergic rhinitis is a highly prevalent disease affecting the quality of life of millions of people, with an estimated 15% of the US population (approximately 50 million individuals) affected 3.
- It is associated with the presence of asthma, eczema, chronic or recurrent sinusitis, cough, and both tension and migraine headaches 3.
Symptoms of Allergic Rhinitis
- Symptoms of allergic rhinitis include nasal congestion, rhinorrhea, postnasal drainage, sneezing, and itching of the eyes, nose, and throat 3.
- The most common symptoms of allergic rhinitis are rhinorrhea (90.38%) and nasal congestion (94.23%) 3.
Treatment of Allergic Rhinitis
- The management of allergic rhinitis includes allergen avoidance, pharmacotherapy, and immunotherapy 4, 5.
- Current pharmacologic options include oral and intranasal antihistamines, intranasal corticosteroids, oral and intranasal decongestants, oral and intranasal anticholinergics, and leukotriene receptor antagonists 4.
- Second-generation oral antihistamines and intranasal corticosteroids are the mainstays of treatment, with practice guidelines recommending intranasal corticosteroids as first-line treatment for moderate to severe allergic rhinitis 4, 3.
- Combination therapy of fluticasone propionate and an oral antihistamine, such as loratadine, has been found to have efficacy comparable to that of intranasal corticosteroid alone 4, 6, 7.
Comparison of Treatments
- Studies comparing fluticasone propionate with cetirizine had mixed findings, with fluticasone propionate found to have equal or greater efficacy in reducing nasal symptom scores 4.
- Intranasal glucocorticoids, such as fluticasone propionate, have been found to be more effective than an antileukotriene drug or combined antileukotriene-antihistamine for the reduction of pollen-induced nasal eosinophilic inflammation and for control of nasal symptoms 6.
- A fixed-dose combination of loratadine and montelukast has been found to be effective in alleviating nighttime and daytime nasal congestion and improving peak nasal inspiratory flow rate, with a safety profile similar to placebo and better tolerated than pseudoephedrine 7.