What is the first line treatment for allergic rhinitis?

First-Line Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis in patients whose symptoms affect their quality of life. 1

Diagnosis and Assessment

Allergic rhinitis is characterized by:

• Nasal congestion
• Rhinorrhea (runny nose)
• Nasal itching
• Sneezing
• Often accompanied by eye symptoms (itching, redness, watering)

Before initiating treatment, assess:

• Symptom frequency: intermittent (<4 days/week or <4 weeks/year) vs. persistent (>4 days/week and >4 weeks/year)
• Symptom severity: mild (not interfering with daily activities) vs. moderate-severe (affecting quality of life)
• Presence of comorbidities: asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, otitis media 1

Treatment Algorithm

First-line options:

1. Intranasal corticosteroids (Strong recommendation)

   • Most effective medication class for controlling all symptoms of allergic rhinitis 1
   • Particularly effective for nasal congestion
   • Examples: fluticasone propionate, mometasone furoate 2
   • Proper technique: direct spray away from nasal septum to minimize side effects 1

2. Oral second-generation antihistamines (Strong recommendation)

   • For patients with primary complaints of sneezing and itching 1
   • Less effective for nasal congestion than intranasal corticosteroids
   • Examples: cetirizine, fexofenadine, loratadine, desloratadine 3
   • Second-generation preferred over first-generation due to less sedation 1

Additional treatment options:

1. Intranasal antihistamines (Option)

   • May be considered as first-line treatment 1
   • Equal or superior to oral antihistamines for seasonal allergic rhinitis 1
   • Less effective than intranasal corticosteroids 1
   • Examples: azelastine, olopatadine 3

2. Combination therapy (Option)

   • For patients with inadequate response to monotherapy 1
   • Intranasal corticosteroid plus intranasal antihistamine may be particularly effective 3

3. Environmental controls (Option)

   • Avoidance of known allergens
   • Air filtration systems, bed covers, removal of pets if appropriate 1

Treatment Selection Based on Symptom Pattern

• Mild intermittent symptoms: Second-generation oral antihistamine as needed 2, 3
• Moderate-severe or persistent symptoms: Intranasal corticosteroid (first-line) 1, 3
• Predominant nasal congestion: Intranasal corticosteroid 1, 3
• Predominant sneezing/itching: Oral antihistamine (though intranasal corticosteroids still more effective) 1

Important Considerations

• Avoid oral leukotriene receptor antagonists as primary therapy (Recommendation against) 1
• Avoid routine sinonasal imaging for diagnosis (Recommendation against) 1
• Consider immunotherapy for patients with inadequate response to pharmacologic therapy 1
• Short course of oral corticosteroids (5-7 days) may be appropriate for very severe symptoms, but chronic use is inappropriate 1

Common Pitfalls to Avoid

1. Using first-generation antihistamines - These cause significant sedation and anticholinergic effects 1
2. Prolonged use of topical decongestants - Can lead to rhinitis medicamentosa (rebound congestion) 1
3. Undertreatment of nasal congestion - Intranasal corticosteroids are superior to antihistamines for this symptom 1
4. Failure to identify comorbidities - Allergic rhinitis is associated with asthma, sinusitis, and otitis media 4
5. Inadequate patient education on proper use of nasal sprays - Direct away from septum to minimize bleeding 1

By following this evidence-based approach, most patients with allergic rhinitis can achieve significant symptom relief and improved quality of life.