What is the treatment for rhinitis?

Treatment of Rhinitis

Intranasal corticosteroids are the most effective first-line therapy for both allergic and nonallergic rhinitis, providing superior relief of nasal symptoms compared to other medication classes. 1

Treatment Algorithm Based on Type of Rhinitis

For Allergic Rhinitis:

1. First-line treatment:

   • Intranasal corticosteroids (fluticasone propionate, mometasone furoate, budesonide, triamcinolone) 1, 2
     • Dosing: Once daily dosing is as effective as twice daily 3
     • Mechanism: Most effective for controlling sneezing, itching, rhinorrhea, and nasal congestion
     • Benefits: Reduce all major symptoms with minimal systemic effects when used as directed

2. Alternative or add-on treatments:

   • Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine) 1, 4

     • Best for: Rhinorrhea, sneezing, and itching but less effective for congestion
     • Caution: Avoid first-generation antihistamines due to sedation and anticholinergic effects

   • Intranasal antihistamines (azelastine, olopatadine) 1, 2

     • Faster onset than oral antihistamines
     • May cause bitter taste and sedation in some patients

   • Combination therapy: Intranasal corticosteroids plus antihistamines for severe symptoms 1

3. For severe, intractable symptoms:

   • Short course (5-7 days) of oral corticosteroids 1
     • Important: Single parenteral corticosteroid administration is discouraged
     • Contraindication: Recurrent parenteral corticosteroid administration

For Nonallergic Rhinitis:

1. First-line treatment:

   • Intranasal corticosteroids 1
   • Intranasal antihistamines (particularly for vasomotor rhinitis) 1

2. For predominant rhinorrhea:

   • Intranasal anticholinergics (ipratropium bromide) 1
     • Specifically effective for reducing rhinorrhea
     • Can be combined with intranasal corticosteroids for enhanced efficacy

3. For nasal congestion:

   • Oral or intranasal decongestants (short-term use only) 1
     • Caution: Limit intranasal decongestant use to ≤3 days to prevent rhinitis medicamentosa

4. For rhinitis medicamentosa:

   • Discontinue nasal decongestant sprays
   • Treat with intranasal or systemic corticosteroids 1

Important Considerations and Pitfalls

Medication Administration

• Intranasal corticosteroids:

  • Direct spray away from nasal septum to avoid irritation and bleeding 1, 5
  • Periodically examine nasal septum for mucosal erosions 1
  • Use lowest effective dose in children 1, 6
  • Common side effects: nasal dryness, burning, stinging, and epistaxis in 5-10% of patients 5, 7

• Oral antihistamines:

  • Second-generation preferred over first-generation due to less sedation 1
  • Cetirizine may cause sedation at recommended doses 4
  • Avoid concurrent use with alcohol or other CNS depressants 4

Common Pitfalls

1. Overuse of decongestant nasal sprays leading to rhinitis medicamentosa

   • Limit use to 3 days maximum 1

2. Inadequate response evaluation

   • Assess nasal symptoms, physical signs, and quality of life measures 1
   • Consider referral to specialist if symptoms persist despite appropriate therapy

3. Inappropriate use of oral corticosteroids

   • Reserve for very severe cases only
   • Avoid parenteral administration 1

4. Failure to address environmental triggers

   • Implement avoidance measures for allergens and irritants 1
   • For severe seasonal allergic rhinitis, advise staying in air-conditioned environments with windows closed 1

When to Refer to an Allergist/Immunologist

Consider specialist referral when:

• Symptoms persist despite appropriate treatment
• Patient has complications (otitis media, sinusitis, nasal polyposis)
• Comorbid conditions exist (asthma, chronic sinusitis)
• Systemic corticosteroids were required
• Symptoms significantly impact quality of life or daily functioning 1

By following this treatment algorithm and avoiding common pitfalls, most patients with rhinitis can achieve significant symptom relief and improved quality of life.