What is the first-line treatment for allergic rhinitis?

First-Line Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis due to their superior efficacy in controlling nasal symptoms. 1, 2

Evidence-Based Treatment Algorithm

Step 1: Initial Treatment Selection

• Intranasal corticosteroids (INCs) are the most effective medication class for controlling allergic rhinitis symptoms 1, 2

  • Examples: fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide
  • Dosing: Typically once or twice daily depending on formulation
  • Mechanism: Reduce inflammation in nasal passages, decreasing all major symptoms including congestion

• Second-line options (if INCs not tolerated or preferred):

  • Oral antihistamines (second-generation preferred to avoid sedation) 2, 1
    • Examples: cetirizine, loratadine, fexofenadine, desloratadine
  • Intranasal antihistamines 2, 3
    • Examples: azelastine, olopatadine
    • Faster onset than INCs but generally less effective overall

Step 2: For Moderate to Severe Symptoms

• Combination therapy with intranasal corticosteroid plus intranasal antihistamine for patients with inadequate response to monotherapy 1, 2
  • The combination provides superior symptom relief compared to either medication alone
  • Particularly effective for patients with significant nasal congestion

Step 3: Additional Options for Specific Symptoms

• Leukotriene receptor antagonists (e.g., montelukast) may be considered but are less effective than intranasal corticosteroids 2, 4
  • The Joint Task Force on Practice Parameters strongly recommends intranasal corticosteroids over leukotriene receptor antagonists 2

Comparative Efficacy

• Intranasal corticosteroids demonstrate superior efficacy for overall symptom control compared to oral antihistamines and leukotriene receptor antagonists 2, 5
• Intranasal antihistamines have comparable efficacy to intranasal corticosteroids in some studies, particularly for ocular symptoms 6
• Once-daily dosing of intranasal corticosteroids is as effective as twice-daily dosing, which may improve adherence 7

Important Considerations and Caveats

• Onset of action: Intranasal antihistamines work faster (minutes to hours) compared to intranasal corticosteroids (hours to days) 1, 6
• Patient preferences: Some patients prefer oral medications over intranasal sprays, which may affect adherence 2
• Adverse effects:
  • Intranasal corticosteroids: Local irritation, epistaxis, headache in 5-10% of patients 5
  • Intranasal antihistamines: Poor taste, sedation (less common with newer agents) 2
  • Avoid first-generation antihistamines due to sedating effects 1
  • Avoid topical decongestants for more than 3 days due to risk of rebound congestion 1

Special Populations

• Children: Lower doses of intranasal corticosteroids are typically recommended, with mometasone and fluticasone furoate approved for children as young as 2 years 1
• Comorbid conditions: Consider the presence of asthma, which may benefit from coordinated treatment approach 2, 1

Intranasal corticosteroids remain the gold standard first-line treatment for allergic rhinitis based on the most recent and highest quality evidence, with oral or intranasal antihistamines as reasonable alternatives based on patient-specific factors and preferences.