What is the treatment for allergic rhinitis in adults?

Treatment of Allergic Rhinitis in Adults

Intranasal corticosteroids are the first-line treatment for allergic rhinitis in adults due to their superior effectiveness in controlling symptoms. 1

First-Line Treatment Options

• Intranasal corticosteroids (INCs): Most effective single medication class for controlling allergic rhinitis symptoms

  • Examples: fluticasone propionate, budesonide, mometasone furoate
  • Dosage: 200 micrograms per day 1
  • Mechanism: Reduce nasal inflammation, congestion, rhinorrhea, sneezing, and itching
  • Onset of action: 3-12 hours, with maximal effect after several days of use

• Intranasal antihistamines: Effective alternative first-line treatment, especially for patients who cannot tolerate INCs

  • Examples: azelastine, olopatadine
  • More effective than oral antihistamines for nasal congestion 1
  • Faster onset of action than INCs (15-30 minutes)

Treatment Algorithm Based on Severity

For Mild Intermittent Symptoms:

1. Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) 2

   • Avoid first-generation antihistamines due to sedating effects 1
   • Dosage: cetirizine 10 mg once daily (can use 5 mg for less severe symptoms) 1

2. OR intranasal antihistamine

For Moderate-Severe or Persistent Symptoms:

1. Intranasal corticosteroid as monotherapy 2
2. For inadequate response, add intranasal antihistamine to intranasal corticosteroid
   • The combination of fluticasone propionate plus azelastine provides greater symptom reduction than either agent alone 3, 1

For Specific Symptom Management:

• Predominant rhinorrhea: Consider adding ipratropium bromide nasal spray 1
• Severe congestion: Short-term nasal decongestant (limit to <3-5 days to avoid rebound congestion) 1
• Coexisting asthma: Consider montelukast (leukotriene receptor antagonist) 1, 4
  • Note: Montelukast is less effective than intranasal corticosteroids for allergic rhinitis 1

Important Considerations

• Allergen avoidance should be implemented when possible 2, 5
• Saline nasal sprays can be beneficial as adjunctive therapy 1
• Immunotherapy (sublingual or subcutaneous) should be considered for patients with inadequate response to pharmacologic therapy 1, 6
  • Only disease-modifying treatment option available 6
  • May reduce development of asthma in patients with allergic rhinitis 3

Combination Therapies

• INC + intranasal antihistamine: Most effective combination for moderate-severe symptoms 3, 1

  • Studies show fluticasone propionate plus azelastine provides greater symptom reduction than either agent alone 3
  • Absolute improvements represent >40% relative improvement for combination therapy versus monotherapy 3

• INC + ipratropium bromide: More effective than either treatment alone for rhinorrhea 1

Treatment Pitfalls to Avoid

• Using first-generation antihistamines (cause drowsiness and impaired performance) 1
• Using nasal decongestants for more than 3-5 days (causes rebound congestion) 1
• Intramuscular corticosteroid injections (potential side effects) 1
• Failing to identify comorbidities like asthma, atopic dermatitis, conjunctivitis, rhinosinusitis 1
• Overlooking the potential of immunotherapy for patients with inadequate response to medications 1, 6

The treatment approach should be adjusted based on symptom severity, predominant symptoms, patient preferences, and response to initial therapy, with intranasal corticosteroids remaining the cornerstone of treatment for most patients with allergic rhinitis.