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 with moderate to severe symptoms that affect their quality of life. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective medication class for controlling all allergic rhinitis symptoms, including nasal congestion, rhinorrhea, sneezing, and itching 1
• Examples include fluticasone propionate, triamcinolone, budesonide, and mometasone 2
• Provide superior efficacy compared to other medication classes 3
• Appropriate for persistent symptoms and moderate-to-severe cases 1

Second-Generation Oral Antihistamines

• Recommended for patients with mild symptoms or when sneezing and itching are the predominant complaints 3
• Examples include cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine 1
• Less sedating than first-generation antihistamines 3
• Effective in reducing rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 3

Intranasal Antihistamines

• May be considered as first-line treatment for some patients 1
• Examples include azelastine and olopatadine 1
• More effective for nasal congestion than oral antihistamines 1
• Faster onset of action than intranasal corticosteroids 1

Treatment Algorithm Based on Symptom Severity

For Mild Intermittent Symptoms:

1. Second-generation oral antihistamine OR intranasal antihistamine 1
2. Consider allergen avoidance measures 1

For Moderate-to-Severe or Persistent Symptoms:

1. Intranasal corticosteroid as first-line therapy 3, 1
2. If inadequate response, consider combination therapy 1

For Inadequate Response to Monotherapy:

1. Combination of intranasal corticosteroid plus intranasal antihistamine 3, 1
2. For severe rhinorrhea, consider adding ipratropium bromide nasal spray 1

Special Considerations

Avoiding Common Pitfalls:

• Avoid first-generation antihistamines due to sedation and performance impairment 3, 4
• Avoid oral leukotriene receptor antagonists (like montelukast) as primary therapy due to lower efficacy compared to intranasal corticosteroids 3, 1
• Limit use of oral decongestants, which can cause insomnia, irritability, and palpitations 3, 1
• Avoid long-term use of topical decongestants (>3 days) to prevent rhinitis medicamentosa 3

Pediatric Considerations:

• Fluticasone propionate is FDA approved for children ≥4 years 1
• Mometasone furoate is FDA approved for children ≥2 years 1
• Budesonide is approved for children ≥6 years 1
• Second-generation antihistamines have well-established safety profiles in children 1

Comorbid Conditions:

• Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 3
• For patients with both allergic rhinitis and asthma, consider treatment options that address both conditions 3, 1

Non-Pharmacologic Approaches

Allergen Avoidance:

• Recommended as an adjunct to pharmacotherapy 1
• Highly pollen-allergic individuals should limit outdoor exposure during high pollen counts 1
• Environmental controls may include air filtration systems and bed covers for dust mite allergies 1

Immunotherapy:

• Consider for patients with inadequate response to pharmacologic therapy 1
• Only disease-modifying treatment option available 1
• May prevent progression from allergic rhinitis to asthma and prevent new allergen sensitivities 1
• Can be administered subcutaneously or sublingually 5

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