What is the recommended treatment for severe allergic rhinitis?

Treatment for Severe Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for severe allergic rhinitis and should be recommended as initial therapy. 1

First-Line Treatment Options

Intranasal Corticosteroids (INS)

• Most effective monotherapy for controlling all symptoms of allergic rhinitis, including nasal congestion, rhinorrhea, sneezing, and itching 1
• Examples include fluticasone propionate, mometasone furoate, budesonide, and triamcinolone
• Dosing:
  • Adults: 200 mcg daily (either as once daily or 100 mcg twice daily) 2
  • Children ≥4 years: Start with 100 mcg daily, increase to 200 mcg if needed 3, 2
• Onset of action typically within 12 hours, with maximum effect after several days 2
• Should be used regularly rather than as-needed for optimal effect 1

Administration Tips

• Direct spray away from nasal septum to minimize irritation and bleeding 1
• Periodically examine nasal septum for mucosal erosions 1
• Use at lowest effective dose, especially in children 1

Second-Line/Add-on Therapies

When INS alone is insufficient, consider the following options:

Intranasal Antihistamine + INS

• For moderate to severe allergic rhinitis with inadequate response to INS alone 1
• Combination provides greater symptomatic relief than either agent alone 4
• Examples: azelastine or olopatadine 3
• Particularly effective for episodic symptoms or pretreatment before allergen exposure 3
• Side effects include bitter taste and potential somnolence 1, 3

Oral Antihistamines

• Second-generation (non-sedating) antihistamines preferred over first-generation 1
• Examples: cetirizine, desloratadine, fexofenadine, loratadine 5
• Less effective for nasal congestion than for other symptoms 1
• Not recommended as routine add-on therapy to INS 1

Leukotriene Receptor Antagonists (LTRAs)

• Not recommended as routine add-on therapy to INS 1
• Montelukast may be considered for patients with both allergic rhinitis and asthma 1, 3
• Less effective than INS when used as monotherapy 1

Short-term Options for Severe Congestion

• Short course (5-7 days) of oral corticosteroids may be appropriate for very severe or intractable rhinitis 1
• Combination of INS and intranasal oxymetazoline for severe nasal congestion, but limit oxymetazoline use to less than 3 days to avoid rhinitis medicamentosa (rebound congestion) 1

For Patients Unable to Tolerate Nasal Sprays

• Oral antihistamine plus oral decongestant combination 1
• Caution with oral decongestants: can cause insomnia, irritability, palpitations, and elevated blood pressure 1, 3
• Not recommended for children under 6 years 3

Immunotherapy Considerations

• Should be offered to patients with inadequate response to pharmacologic therapy 1
• Only disease-modifying treatment option available 4
• Available as sublingual or subcutaneous administration 1

Common Pitfalls to Avoid

1. Using first-generation antihistamines, which cause sedation and performance impairment 1
2. Long-term use of intranasal decongestants (>3 days), which can lead to rhinitis medicamentosa 1
3. Single or recurrent administration of parenteral corticosteroids, which is discouraged due to potential long-term side effects 1
4. Failing to identify comorbidities like asthma, sinusitis, or sleep-disordered breathing 3
5. Using oral antihistamine plus INS combination, which offers little additional benefit over INS alone 1

Treatment Algorithm for Severe Allergic Rhinitis

1. Start with intranasal corticosteroid at appropriate dose
2. If inadequate response after 2-4 weeks:
   • Add intranasal antihistamine
   • For severe congestion, consider short-term (≤3 days) intranasal oxymetazoline
3. If still inadequate or intolerable:
   • Consider short course of oral corticosteroids (5-7 days)
   • Consider referral for immunotherapy evaluation

Remember that environmental control measures should be implemented concurrently with pharmacotherapy for optimal symptom management.