What is the recommended treatment for allergic rhinitis?

Recommended Treatment for Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line therapy for allergic rhinitis and should be prescribed as monotherapy for initial treatment in patients with moderate to severe symptoms. 1

Treatment Algorithm Based on Symptom Severity

Mild Intermittent Symptoms

• First-line options:
  • Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) 1, 2
  • Intranasal antihistamines (azelastine, olopatadine) 1, 3
  • These are particularly effective for predominant symptoms of itching, sneezing, and rhinorrhea 2

Moderate to Severe or Persistent Symptoms

• First-line therapy:
  • Intranasal corticosteroids (fluticasone propionate, budesonide, mometasone) 4, 1
  • Begin working within 12 hours, and as early as 3-4 hours in some patients 1
  • Most effectively control all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1

Severe or Inadequately Controlled Symptoms

• Combination therapy options:
  • For moderate to severe symptoms: Intranasal corticosteroid plus intranasal antihistamine (e.g., fluticasone propionate plus azelastine) 4, 1
  • This combination has shown greater symptom reduction than either agent alone 1

Special Considerations

Proper Administration Technique

• Ensure patent nasal airway before administration
• For severe congestion, consider short-term decongestant use (3-5 days maximum) to improve delivery 1
• Patient education on proper technique is essential to ensure medication reaches target areas

Medication Selection Considerations

• Safety profiles:
  • Second-generation antihistamines are preferred over first-generation due to significantly less sedation and impairment 5
  • Intranasal corticosteroids have minimal systemic absorption when used at recommended doses 1
  • Common side effects of intranasal corticosteroids include epistaxis, pharyngitis, and nasal irritation 1

Population-Specific Considerations

• Children:

  • Second-generation oral antihistamines are recommended as first-line treatment in children 1
  • For intranasal corticosteroids in children, consider preparations without negative impact on growth 1
  • OTC cough and cold medications should be avoided in young children due to safety concerns 1

• Older adults:

  • Use caution with first-generation antihistamines due to increased risk of psychomotor impairment, falls, and anticholinergic effects 1

• Pregnant patients:

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

Treatment Evaluation and Adjustment

• Evaluate treatment response after 4-6 weeks of consistent use 1
• If symptoms persist despite appropriate treatment, consider:
  • Adjusting medication regimen
  • Adding additional therapies
  • Consulting with an allergist/immunologist
  • Considering allergen immunotherapy (sublingual or subcutaneous) for long-term management 4, 1

Additional Measures

• Allergen avoidance when possible, though often inadequate for outdoor allergens 4
• Nasal irrigation may provide symptomatic relief as an adjunctive therapy 2, 6
• For patients with comorbid asthma, leukotriene receptor antagonists like montelukast may be particularly beneficial 1

Common Pitfalls to Avoid

• Using first-generation antihistamines, which cause significant sedation and impair performance 5
• Relying solely on oral antihistamines for nasal congestion, as they have limited effect on this symptom 7
• Discontinuing therapy prematurely before adequate trial period (4-6 weeks)
• Overuse of nasal decongestants (>3-5 days), which can lead to rebound congestion