What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

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

First-Line Treatment Options

Intranasal Corticosteroids

• Strong recommendation for use as primary therapy 1
• Superior to oral antihistamines and leukotriene receptor antagonists for nasal symptom reduction 2
• Examples include fluticasone, triamcinolone, budesonide, and mometasone
• Most effective for controlling nasal congestion, which is often the most bothersome symptom 3
• Should be used regularly rather than as needed for maximum effectiveness

Oral Second-Generation Antihistamines

• Strong recommendation for patients with primary complaints of sneezing and itching 1
• Examples include cetirizine, fexofenadine, desloratadine, and loratadine 3
• Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects 4
• Second-generation antihistamines cause minimal sedation compared to first-generation options 2

Second-Line and Adjunctive Treatments

Intranasal Antihistamines

• May be offered for seasonal, perennial, or episodic allergic rhinitis 1
• Examples include azelastine and olopatadine 3
• Can be used as monotherapy or in combination with intranasal corticosteroids

Combination Therapy

• Consider for patients with inadequate response to monotherapy 1
• Combination of intranasal corticosteroid with intranasal antihistamine may be more effective than either alone 2
• The combination of oral antihistamine with intranasal corticosteroid is not recommended as routine initial treatment 1

Leukotriene Receptor Antagonists

• Should not be offered as primary therapy for allergic rhinitis 1
• May be considered for patients with comorbid asthma 2
• Less effective than intranasal corticosteroids 3

Treatment Algorithm Based on Symptom Severity

1. Mild Intermittent Symptoms:

   • Second-generation oral antihistamine OR intranasal antihistamine 3

2. Moderate-Severe or Persistent Symptoms:

   • Intranasal corticosteroid as monotherapy 1, 3
   • If inadequate response, add intranasal antihistamine 2

3. Inadequate Response to Above Treatments:

   • Consider immunotherapy (sublingual or subcutaneous) 1
   • Consider inferior turbinate reduction for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management 1, 2

Environmental Controls and Non-Pharmacologic Approaches

• Allergen avoidance for identified allergens that correlate with clinical symptoms 1
• Environmental controls may include:
  • Removal of pets
  • Air filtration systems
  • Bed covers
  • Acaricides (chemical agents that kill dust mites) 1
• Acupuncture may be offered for patients interested in non-pharmacologic therapy 1

Special Considerations

Comorbidities

• Assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Coordinated treatment approach for patients with both allergic rhinitis and asthma 2

Medication Safety

• Avoid oral decongestants in patients with hypertension, cardiac arrhythmias, glaucoma, or hyperthyroidism 2
• Cetirizine may cause mild drowsiness in some patients (13.7% vs 6.3% with placebo) 2
• Use caution with first-generation antihistamines in older adults due to increased risk of falls and anticholinergic effects 2

Monitoring and Follow-up

• Evaluate treatment response after 4-6 weeks 2
• Consider gradual reduction of medication after 3 months if symptoms resolve completely 2
• If symptoms persist despite appropriate treatment, consider:
  1. Specific IgE testing (skin or blood) 1
  2. Referral for immunotherapy evaluation 1

By following this evidence-based approach to allergic rhinitis management, clinicians can effectively control symptoms and improve patients' quality of life while minimizing adverse effects.