What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for moderate to severe allergic rhinitis, while second-generation antihistamines or intranasal antihistamines may be used for mild symptoms. 1

Treatment Algorithm Based on Symptom Severity

Mild Intermittent or Mild Persistent Symptoms

• First-line options:
  • Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) 1, 2
  • Intranasal antihistamines (azelastine, olopatadine) 1, 2
  • These medications effectively control rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 3

Moderate to Severe or Persistent Symptoms

• First-line treatment:
  • Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) 4, 1, 2
  • These are most effective for controlling all allergic rhinitis symptoms, including nasal congestion 5
  • Fluticasone propionate has shown superior efficacy compared to leukotriene receptor antagonists like montelukast 4

Refractory Symptoms

• For inadequate response to monotherapy:
  • Consider combination of intranasal corticosteroid plus intranasal antihistamine 4, 1
  • Studies show that fluticasone propionate plus azelastine provides greater symptom reduction than either agent alone 4
  • Note: Adding an oral antihistamine to an intranasal corticosteroid shows no additional benefit 4

Medication Details and Considerations

Intranasal Corticosteroids

• Mechanism: Reduce inflammation in nasal mucosa, targeting multiple inflammatory cells and mediators 6
• Efficacy: Most effective medication class for controlling all allergic rhinitis symptoms 1
• Onset: May take several days for maximum benefit; some patients note improvement within 12 hours 6
• Common side effects: Nasal dryness, burning, stinging, sneezing, headache, and epistaxis in 5-10% of patients 6, 5
• Pediatric considerations:
  • Budesonide approved for children ≥6 years
  • Fluticasone propionate approved for children ≥4 years
  • Mometasone furoate approved for children ≥2 years 1

Antihistamines

• Second-generation oral antihistamines:

  • Less sedating than first-generation antihistamines 1
  • Dosing: Cetirizine 10 mg once daily for adults and children ≥6 years; 5 mg for less severe symptoms 1
  • Low body mass patients may need lower dosing to avoid sedation 1

• Intranasal antihistamines:

  • More effective for nasal congestion than oral antihistamines 1
  • May be considered as first-line treatment for some patients 1

Leukotriene Receptor Antagonists

• Not recommended as primary therapy due to lower efficacy compared to intranasal corticosteroids 4, 1
• May be considered when patients have coexisting asthma 1, 7
• Montelukast is approved for perennial allergic rhinitis in children ≥6 months and seasonal allergic rhinitis in children ≥2 years 1, 7

Special Considerations

Combination Therapy

• Combination of intranasal corticosteroid plus intranasal antihistamine provides additional benefit for moderate-to-severe allergic rhinitis 4, 1
• The Joint Task Force graded this recommendation as weak due to concerns about potential bias in studies, lack of add-on therapy studies, and consideration of greater potential for side effects and added cost 4
• Common side effects of combination therapy include dysgeusia (2.1-13.5% of participants) and somnolence (0.4-1.1%) 4

Associated Conditions

• Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Consider treatment options that address both allergic rhinitis and any comorbid conditions 1

Environmental Controls

• 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

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 when intranasal corticosteroids are more effective 4, 1
• Long-term use of oral decongestants, which can cause insomnia, irritability, and palpitations 1
• Failing to identify and address comorbid conditions 1
• Adding an oral antihistamine to an intranasal corticosteroid, which provides no additional benefit 4

For patients with inadequate response to pharmacologic therapy, immunotherapy may be considered as it is the only disease-modifying treatment option available 1.