What is the treatment protocol for moderate allergic rhinitis?

Treatment Protocol for Moderate Allergic Rhinitis

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

First-Line Treatment

Intranasal Corticosteroids

• Most effective medication class for controlling allergic rhinitis symptoms 2, 1
• Should be used regularly rather than as-needed for optimal effect 1
• Use at lowest effective dose, especially in children 1
• Direct spray away from nasal septum to minimize irritation and bleeding 1
• Options include:
  • Fluticasone propionate (FDA approved for children ≥4 years)
  • Mometasone furoate (FDA approved for children ≥2 years)
  • Budesonide (FDA approved for children ≥6 years) 1

Administration Tips

• Periodically examine nasal septum for mucosal erosions 1
• May be considered for initial treatment without previous trial of antihistamines and/or oral decongestants 2
• Provides almost complete prevention of late-phase symptoms 3

Second-Line/Add-on Therapy

For Inadequate Response to Intranasal Corticosteroids

1. Add intranasal antihistamine 1

   • Combination of intranasal corticosteroid and intranasal antihistamine provides greater symptom reduction than either agent alone 2
   • Fluticasone propionate plus azelastine shows greatest symptom reduction compared to monotherapy 2
   • Common side effects include bitter taste (dysgeusia), epistaxis, and headache 1

2. Consider short-term intranasal decongestant for severe congestion 1

   • Limit use to less than 3 days to avoid rhinitis medicamentosa 1

Alternative Options

• Second-generation (non-sedating) oral antihistamines

  • Less effective for nasal congestion than for other symptoms 1
  • Examples: cetirizine 10mg once daily, fexofenadine, desloratadine, loratadine 4
  • Avoid first-generation antihistamines due to sedation and performance impairment 1

• Leukotriene receptor antagonists (e.g., montelukast)

  • Less effective than intranasal corticosteroids 2
  • May be considered when patients have coexisting asthma 1, 5
  • Not recommended as primary therapy 1

For Severe or Intractable Cases

Short-term Oral Corticosteroids

• A short course (5-7 days) may be appropriate for very severe or intractable rhinitis 2
• Should always consider intranasal corticosteroids before initiating systemic corticosteroids 2
• Single administration of parenteral corticosteroids is discouraged, and recurrent administration is contraindicated due to potential long-term side effects 2, 1

Immunotherapy

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

Treatment Algorithm

1. Start with intranasal corticosteroid at appropriate dose
2. If inadequate response after 2-4 weeks:
   • Add intranasal antihistamine, OR
   • Consider short-term intranasal decongestant for severe congestion
3. If still inadequate or intolerable:
   • Consider short course of oral corticosteroids, OR
   • Refer for immunotherapy evaluation 1

Common Pitfalls to Avoid

• Using first-generation antihistamines (cause sedation)
• Long-term use of intranasal decongestants (>3 days) leading to rhinitis medicamentosa
• Single or recurrent administration of parenteral corticosteroids
• Using oral antihistamine plus intranasal corticosteroid combination (offers little additional benefit over intranasal corticosteroids alone) 1
• Failing to identify comorbidities like asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1

Allergen Avoidance

• Implement empiric avoidance of suspected inciting factors (allergens, irritants, medications) 2
• For severe seasonal allergic rhinitis, advise staying inside air-conditioned buildings with windows and doors closed 2

By following this protocol, most patients with moderate allergic rhinitis should experience significant symptom improvement and better quality of life.