Medical Management of Allergic Rhinitis
Intranasal corticosteroids are the most effective first-line treatment for moderate to severe allergic rhinitis, while second-generation oral antihistamines are recommended for mild symptoms or as adjunctive therapy. 1
Diagnosis and Classification
Allergic rhinitis is characterized by:
- Nasal congestion, rhinorrhea, sneezing, and itching
- Often accompanied by eye symptoms (itching, redness, tearing)
- Can be classified as:
- Seasonal (pollens)
- Perennial (dust mites, animal dander)
- Mixed (combination of seasonal and perennial)
- Episodic (intermittent exposure)
Physical examination typically reveals:
- Pale, edematous nasal mucosa in seasonal allergic rhinitis
- Erythematous, inflamed turbinates with serous secretions in perennial allergic rhinitis 2
Treatment Algorithm
Step 1: Environmental Control Measures
- Identify and avoid specific allergens
- For dust mites: use allergen-impermeable covers for bedding, wash bedding in hot water weekly
- For animal allergens: remove pets from home or restrict to specific areas
- For pollen: keep windows closed during high pollen seasons, use air conditioning 3
Step 2: Pharmacotherapy Based on Symptom Severity
For Mild Intermittent Symptoms:
- Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine)
- Intranasal antihistamines (azelastine, olopatadine) 2
- Intranasal cromolyn sodium (less effective than other options but minimal side effects) 3
For Moderate to Severe or Persistent Symptoms:
- Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone)
- Most effective monotherapy for allergic rhinitis 3
- Superior to antihistamines and leukotriene receptor antagonists
- Begin before allergen exposure for seasonal allergic rhinitis
For Inadequate Response to Single Therapy:
- Combine intranasal corticosteroid with intranasal antihistamine
- Add oral antihistamine to intranasal corticosteroid
- Consider adding leukotriene receptor antagonist (montelukast) 4
For Nasal Congestion:
- Short-term use of oral decongestants (pseudoephedrine)
- Avoid using topical decongestants for more than 3-5 days to prevent rhinitis medicamentosa 3
For Severe, Intractable Symptoms:
- Short course (5-7 days) of oral corticosteroids may be appropriate
- Avoid single or recurrent administration of parenteral corticosteroids 3
Step 3: Consider Allergen Immunotherapy
Allergen immunotherapy should be considered for patients who:
- Have demonstrable specific IgE antibodies to relevant allergens
- Experience inadequate symptom control with medications
- Have adverse reactions to medications
- Prefer to avoid long-term pharmacotherapy 3
Benefits of immunotherapy:
- Only treatment that modifies the natural history of allergic rhinitis
- Clinical benefits may persist after discontinuation
- May prevent development of new allergen sensitizations
- May reduce risk of asthma development in patients with allergic rhinitis 3
Special Considerations
Saline Irrigation
- Isotonic or hypertonic saline solutions provide modest benefit
- Minimal side effects, low cost, good patient acceptance
- Can be used as adjunctive therapy with other treatments 3
Pregnancy
- Second-generation antihistamines have accumulated sufficient safety data
- Avoid oral decongestants during first trimester
- Intranasal corticosteroids generally considered safe 3
Athletes
- Avoid first-generation antihistamines due to sedation and performance impairment
- Prefer second-generation antihistamines and/or intranasal corticosteroids
- Consider intranasal cromolyn 30 minutes before competition with high allergen exposure 3
When to Refer to an Allergist/Immunologist
Consider referral for patients with:
- Inadequately controlled symptoms despite appropriate therapy
- Comorbid conditions (asthma, recurrent sinusitis, nasal polyps)
- Reduced quality of life despite treatment
- When allergen immunotherapy is being considered 3
Allergist/immunologist care has been shown to improve quality of life, treatment compliance, and patient satisfaction 3.