What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the most effective medication class for controlling allergic rhinitis symptoms and should be the first-line therapy for moderate to severe disease. 1

First-Line Treatment Options

For Mild Intermittent or Mild Persistent Allergic Rhinitis:

• Second-generation H1 antihistamines (oral):

  • Cetirizine, loratadine, fexofenadine, desloratadine 1, 2
  • Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine) due to significant sedation, performance impairment, increased risk of accidents, and anticholinergic side effects 1, 3

• Intranasal antihistamines:

  • Azelastine, olopatadine 1, 2
  • Faster onset of action than intranasal corticosteroids 1

For Moderate to Severe Persistent Allergic Rhinitis:

• Intranasal corticosteroids (preferred first-line):
  • Fluticasone, triamcinolone, budesonide, mometasone 1, 2
  • Most effective for reducing inflammation and decreasing all major symptoms 1
  • Generally have good safety profiles 1

Combination Therapies for Inadequate Response

1. Intranasal corticosteroid + intranasal antihistamine:

   • Provides superior symptom relief compared to either medication alone 1
   • Fluticasone propionate + azelastine shows clinically meaningful differences in Total Nasal Symptom Score (TNSS) 1

2. Intranasal corticosteroid + ipratropium bromide:

   • More effective than either treatment alone for rhinorrhea 1

3. Oral antihistamine + leukotriene receptor antagonist:

   • Useful combination, especially for patients with comorbid asthma 1, 4

Additional Treatment Options

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

  • Particularly useful for patients with comorbid asthma 1, 4
  • Clinical studies show efficacy for seasonal and perennial allergic rhinitis 4

• Ipratropium bromide:

  • Effectively reduces rhinorrhea but has no effect on other nasal symptoms 1
  • Particularly effective for non-allergic rhinitis 1

• Oral decongestants (pseudoephedrine, phenylephrine):

  • Can reduce nasal congestion 1
  • Use with caution in older adults and patients with cardiovascular disease, hypertension, glaucoma, or hyperthyroidism 1

• Nasal saline irrigation:

  • Beneficial for symptoms of chronic rhinorrhea 1
  • Can be used as sole modality or adjunctive treatment 1

• Allergen immunotherapy:

  • Consider for patients with inadequate response to pharmacologic therapy 1
  • Only disease-modifying treatment option available 1

Important Precautions and Caveats

• Topical decongestants should be avoided for more than 3 days due to risk of rhinitis medicamentosa (rebound congestion) 1

• First-generation antihistamines should be avoided due to sedation, impairment, and anticholinergic effects 1, 3

• For children:

  • Avoid OTC cough and cold medications in young children due to safety concerns 1
  • Use lower doses of intranasal corticosteroids 1
  • Mometasone and fluticasone furoate approved for children as young as 2 years 1
  • Second-generation antihistamines like cetirizine have been studied in children ages 2-6 years 5

• For pregnant patients:

  • Intranasal corticosteroids generally have good safety profiles but require individual risk-benefit assessment 1

• For older adults:

  • More sensitive to psychomotor impairment from first-generation antihistamines 1
  • Increased risk for falls and anticholinergic effects 1

Treatment Algorithm

1. Assess severity:

   • Mild intermittent: symptoms < 4 days/week or < 4 consecutive weeks/year 2
   • Persistent: symptoms > 4 days/week and > 4 consecutive weeks/year 2

2. For mild disease:

   • Start with second-generation antihistamine (oral or intranasal) 1, 2

3. For moderate to severe disease:

   • Start with intranasal corticosteroid 1, 6

4. If inadequate response:

   • Add intranasal antihistamine to intranasal corticosteroid 1
   • Consider adding ipratropium bromide for prominent rhinorrhea 1
   • Consider leukotriene receptor antagonist, especially with comorbid asthma 1, 4

5. For refractory cases:

   • Consider allergen immunotherapy 1
   • Consider short course (5-7 days) of oral corticosteroids for very severe symptoms 1

Always advise patients to avoid known allergens as part of the comprehensive management approach 1, 2.