What is the management for allergic rhinitis with a running nose?

Management of Allergic Rhinitis with Running Nose

Intranasal corticosteroids are the most effective first-line therapy for allergic rhinitis with rhinorrhea, providing superior symptom relief compared to oral antihistamines and leukotriene receptor antagonists. 1

Diagnostic Considerations

• Allergic rhinitis diagnosis is confirmed based on:
  • History of symptoms after exposure to known allergens
  • Correlation with specific IgE testing
  • Presence of pruritus, sneezing, rhinorrhea, and nasal congestion 2, 1
• Symptoms of pruritus and sneezing are more common in allergic than nonallergic rhinitis 2
• Seasonal exacerbations suggest allergic rhinitis 2
• Allergic rhinitis typically presents with symptoms of nasal congestion (94.23%) and rhinorrhea (90.38%) 3

Treatment Algorithm

First-Line Treatment

• For moderate to severe or persistent symptoms:
  • Intranasal corticosteroids (fluticasone, budesonide, triamcinolone, mometasone) 1, 3
  • Begin working within 12 hours, and as early as 3-4 hours in some patients 1
  • Most effective for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1

For Mild Intermittent Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine) 1, 4, 3
  • Effective for relieving rhinorrhea, sneezing, and itching but less effective for nasal congestion 2
  • Second-generation antihistamines are preferred over first-generation due to less sedation and anticholinergic effects 2
• Intranasal antihistamines (azelastine, olopatadine) 1, 5
  • May be more effective than oral antihistamines for nasal symptoms 5
  • Can cause sedation in some patients 2

For Inadequate Response to Initial Therapy

• Combination therapy options:
  • Intranasal corticosteroid plus intranasal antihistamine (e.g., fluticasone plus azelastine) 1
  • Intranasal corticosteroid plus oral antihistamine 1
  • Oral antihistamine plus leukotriene receptor antagonist (e.g., montelukast) 2, 1

For Severe Nasal Congestion

• Consider short-term decongestant use (3-5 days maximum) to ensure patent nasal airway 1
• Caution: Prolonged use of topical decongestants can lead to rhinitis medicamentosa 2, 6

Special Considerations

Administration Technique

• Ensure patent nasal airway before administration of intranasal medications 1
• Proper technique is essential to ensure medication reaches target areas 1
• Allow 4-6 weeks of consistent use before determining treatment failure 1

Safety Considerations

• First-generation antihistamines (e.g., diphenhydramine) 7 can cause significant sedation and performance impairment 2
• Intranasal corticosteroids have good safety profiles with minimal systemic absorption 6
• Common side effects of intranasal corticosteroids include epistaxis, pharyngitis, nasal irritation, and headache 1
• Oral decongestants should be used with caution in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 1

Treatment Evaluation and Follow-up

• Evaluate treatment response after 4-6 weeks 1
• Consider consulting a specialist if symptoms persist despite appropriate treatment 1
• Gradual reduction of medication can be considered after 3 months if symptoms completely resolve 1

Evidence-Based Insights

• Research shows azelastine nasal spray is effective for patients who remain symptomatic after treatment with oral antihistamines like fexofenadine 8
• Continuous treatment for seasonal or perennial allergic rhinitis is more effective than intermittent use due to unavoidable, ongoing allergen exposure 2
• Combination therapy with intranasal corticosteroid plus intranasal antihistamine has shown greater symptom reduction than either agent alone 1