What is the recommended treatment for allergic rhinitis?

Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis, particularly for patients whose symptoms affect their quality of life, due to their superior efficacy in controlling all symptoms including nasal congestion, rhinorrhea, sneezing, and itching. 1, 2

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective medication class for controlling all allergic rhinitis symptoms 1, 2
• Superior efficacy for nasal congestion compared to other treatments 2
• Options include:
  • Fluticasone propionate (FDA approved for children ≥4 years)
  • Mometasone furoate (FDA approved for children ≥2 years)
  • Budesonide (approved for children ≥6 years) 2

Second-Generation Antihistamines

• Recommended for patients with primary complaints of sneezing and itching 1
• Also appropriate for mild intermittent or mild persistent allergic rhinitis 3
• Preferred over first-generation antihistamines due to less sedation and fewer anticholinergic effects 1
• Options with varying sedation profiles:
  • Non-sedating at recommended doses: fexofenadine, loratadine, desloratadine 1
  • May cause sedation: cetirizine 1

Additional Treatment Options

Intranasal Antihistamines

• May be considered as first-line treatment for allergic rhinitis 1
• Equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis 1
• Have clinically significant effect on nasal congestion 1
• Options include azelastine and olopatadine (onset of action: 15-30 minutes) 2
• Disadvantages: bitter taste and potential somnolence 2

Combination Therapy

• Consider for patients with inadequate response to monotherapy 1
• Combination of intranasal corticosteroid plus intranasal antihistamine may be more effective 2
• Concomitant use of ipratropium bromide nasal spray and intranasal corticosteroid is more effective than either drug alone for rhinorrhea 1

Other Options

• Oral leukotriene receptor antagonists (e.g., montelukast):
  • Not recommended as primary therapy 1
  • Less effective than intranasal corticosteroids 2
  • May be considered when patients have coexisting asthma 2, 4
• Saline nasal irrigation: beneficial as adjunctive treatment for rhinorrhea 2
• Short course of oral corticosteroids (5-7 days): may be appropriate for very severe symptoms 2

Allergen Avoidance and Environmental Controls

• Avoidance of known allergens is the best treatment for rhinitis triggered by irritants 1
• Environmental controls may include:
  • Removal of pets
  • Air filtration systems
  • Bed covers
  • Acaricides (for dust mites) 1
• Highly pollen-allergic individuals should limit outdoor exposure during high pollen counts 1

Immunotherapy

• Should be offered to patients with inadequate response to pharmacologic therapy 1
• Only disease-modifying treatment option available 2
• May prevent progression from allergic rhinitis to asthma and prevent new allergen sensitivities 2
• Options include sublingual or subcutaneous administration 1

Treatment Algorithm Based on Symptom Severity

1. Mild intermittent symptoms: Second-generation oral antihistamine or intranasal antihistamine 3
2. Moderate-severe or persistent symptoms: Intranasal corticosteroid as first-line therapy 3
3. Inadequate response to monotherapy: Add second medication (combination therapy) 1
4. Refractory symptoms: Consider immunotherapy 1

Common Pitfalls to Avoid

• Using first-generation antihistamines without informing patients about potential sedation and performance impairment 1
• Prescribing oral leukotriene receptor antagonists as primary therapy 1
• Failing to identify comorbidities like asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1, 2
• Inadequate patient education on proper use of nasal sprays 2
• Long-term use of oral decongestants, which can cause insomnia, irritability, and palpitations 1, 2

By following this evidence-based approach to allergic rhinitis treatment, clinicians can effectively manage symptoms and improve patients' quality of life while minimizing adverse effects.