What are the first-line and second-line treatment options for allergic rhinitis according to the European Position Paper on Rhinitis (EPOS) guidelines?

First-Line and Second-Line Treatment Options for Allergic Rhinitis According to EPOS Guidelines

Intranasal corticosteroids (INCSs) should be recommended as first-line therapy for patients with moderate-to-severe allergic rhinitis whose symptoms affect their quality of life. 1

First-Line Treatment Options

Intranasal Corticosteroids (INCSs)

• Most effective medication class for controlling all allergic rhinitis symptoms
• Particularly effective for nasal congestion, which other treatments may not adequately address
• Examples: fluticasone, triamcinolone, budesonide, mometasone 1, 2
• Onset of action takes a few hours to a few days 1
• Recommended dosing: once daily administration 3
• Side effects: primarily local, including nasal dryness, burning, stinging, sneezing, headache, and epistaxis in 5-10% of patients 4

Oral Second-Generation Antihistamines

• Recommended for patients with primary complaints of sneezing and itching 1
• Examples: cetirizine, fexofenadine, desloratadine, loratadine 2
• Less effective than INCSs for nasal congestion 2, 5
• Better safety profile than first-generation antihistamines (less sedation) 1
• Particularly useful for mild intermittent symptoms or when patients prefer oral medications 1

Intranasal Antihistamines

• May be offered as an alternative first-line option 1
• Examples: azelastine, olopatadine 2
• Effective within minutes (faster onset than INCSs) 1
• More effective than oral antihistamines for nasal congestion 1
• Side effects: poor taste, sedation, more frequent dosing requirements 1

Treatment Algorithm Based on Symptom Severity

For Mild Intermittent Allergic Rhinitis (VAS <5/10)

1. Oral second-generation antihistamines OR
2. Intranasal antihistamines OR
3. INCSs (if congestion is predominant) 1

For Moderate-to-Severe Allergic Rhinitis (VAS ≥5/10)

1. INCSs as first-line therapy 1
2. For persistent symptoms, consider combination therapy 1

Second-Line Treatment Options

Combination Therapy

• Recommended when monotherapy provides inadequate symptom control 1
• Options include:
  1. INCS + Intranasal Antihistamine: More effective than either medication alone for moderate-to-severe disease 1
  2. INCS + Oral Antihistamine: Generally offers no advantage over INCS alone 1
  3. Oral Antihistamine + Leukotriene Receptor Antagonist: May provide additive benefit but less effective than INCSs 6

Leukotriene Receptor Antagonists (LTRAs)

• Not recommended as primary therapy for allergic rhinitis 1
• Less effective than INCSs 1
• May be considered for patients with concomitant asthma 1, 6
• Example: montelukast 6

Immunotherapy

• Recommended for patients with inadequate response to pharmacologic therapy 1
• Options include sublingual or subcutaneous administration
• Can modify disease progression and prevent asthma development in children with allergic rhinitis 1
• Requires specialist referral and long-term commitment

Special Considerations

Environmental Control Measures

• May be advised alongside pharmacotherapy 1
• Includes allergen avoidance, air filtration systems, bed covers, and acaricides for dust mites
• Effectiveness varies based on specific allergens and implementation feasibility

Comorbid Conditions

• Assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Treatment of allergic rhinitis can improve asthma outcomes 1
• Consider combined therapeutic approach for comorbid conditions rather than targeting each separately

Common Pitfalls and Caveats

1. Poor Adherence: Most patients self-medicate and do not follow guidelines or physicians' prescriptions 1
2. Inappropriate Use of First-Generation Antihistamines: These should be avoided due to sedative effects and cognitive impairment
3. Overuse of Decongestants: Should be limited to short-term use only to avoid rebound congestion
4. Undertreatment: Many patients use on-demand treatment when symptoms are already poorly controlled 1
5. Inappropriate Use of LTRAs: Should not be used as primary therapy except in patients with concomitant asthma 1
6. Delayed Initiation of INCSs: These should be started early for moderate-to-severe symptoms rather than after failed antihistamine therapy

By following these evidence-based guidelines for allergic rhinitis management, clinicians can optimize symptom control and improve quality of life for patients suffering from this common condition.