What is the recommended treatment for allergic rhinitis and allergic conjunctivitis?

Treatment of Allergic Rhinitis and Allergic Conjunctivitis in the Emergency Department

Dual-action antihistamine/mast cell stabilizers (such as olopatadine, epinastine, ketotifen, and azelastine) are the preferred first-line therapy for allergic conjunctivitis, while second-generation oral antihistamines combined with intranasal corticosteroids are recommended as first-line treatment for allergic rhinitis. 1, 2

Initial Assessment

• Determine if symptoms suggest allergic rhinitis:

  • Pruritus and sneezing are more common in allergic than nonallergic rhinitis
  • Seasonal exacerbations suggest allergic etiology
  • Onset typically before age 20
  • Bilateral symptoms (unilateral symptoms suggest structural problems)

• Assess for allergic conjunctivitis symptoms:

  • Ocular itching, redness, tearing
  • Often accompanies allergic rhinitis

Treatment Algorithm for Allergic Rhinitis

First-Line Treatment:

• Second-generation oral antihistamines (loratadine, cetirizine, fexofenadine)

  • Effective for rhinorrhea, sneezing, itching, and allergic conjunctivitis
  • Less sedating than first-generation antihistamines
  • Limited effect on nasal congestion 2

• Intranasal corticosteroids

  • First-line for moderate-to-severe symptoms or when congestion is prominent
  • More effective than antihistamines alone 2, 3

Second-Line/Add-on Options:

• Oral decongestants (pseudoephedrine, phenylephrine)

  • Add to antihistamines for nasal congestion
  • Monitor blood pressure in hypertensive patients
  • Avoid in patients with cardiovascular disease, glaucoma, or urinary retention 2

• Leukotriene receptor antagonists (montelukast)

  • Similar efficacy to antihistamines
  • Particularly useful when patient has comorbid asthma
  • Can be combined with antihistamines for additive effect 2, 4

• Combination therapy

  • Antihistamine plus intranasal corticosteroid is more effective than either agent alone
  • Short course of systemic corticosteroids (e.g., betamethasone) may be beneficial for severe acute exacerbations 5

Topical Decongestants:

• Use only for short-term relief (≤3 days)
• Risk of rebound congestion (rhinitis medicamentosa) with prolonged use 2

Treatment Algorithm for Allergic Conjunctivitis

First-Line Treatment:

• Non-pharmacological approaches

  • Cold compresses
  • Irrigation with preservative-free artificial tears or saline 1

• Dual-action antihistamine/mast cell stabilizers (topical)

  • Olopatadine, epinastine, ketotifen, azelastine
  • Provide both immediate relief and prevention
  • Superior to oral antihistamines for isolated ocular symptoms 1, 6

Second-Line Options:

• Pure mast cell stabilizers (topical)

  • Lodoxamide, nedocromil, pemirolast, cromolyn
  • Better for prevention than acute relief
  • Most effective when used before allergen exposure 1

• Short-term topical corticosteroids (1-2 weeks)

  • For severe symptoms unresponsive to other treatments
  • Loteprednol etabonate preferred due to reduced risk of intraocular pressure elevation
  • Avoid without ophthalmologist supervision 1

Important Cautions and Pitfalls

• Avoid first-generation antihistamines due to sedation and anticholinergic effects 2

• Avoid prolonged use of topical ocular vasoconstrictors as they can cause rebound hyperemia ("conjunctivitis medicamentosa") 1

• Limit topical decongestant use to 3 days to prevent rhinitis medicamentosa 2

• Monitor blood pressure in hypertensive patients taking oral decongestants 2

• Avoid topical ocular corticosteroids without ophthalmologist supervision due to risks of increased intraocular pressure and cataract formation 1

Special Considerations

• For patients with comorbid asthma:

  • Consider leukotriene receptor antagonists (montelukast)
  • Combination therapy may provide better control of both conditions 2, 4

• For severe, refractory cases:

  • Consider referral to allergist for allergen immunotherapy evaluation
  • Allergen immunotherapy is the only disease-modifying treatment available 7

• For contact lens wearers:

  • Remove lenses before instilling drops
  • Wait at least 5 minutes before reinsertion 1

By following this evidence-based approach, emergency department clinicians can effectively manage allergic rhinitis and allergic conjunctivitis, providing symptomatic relief while avoiding common treatment pitfalls.