What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis, providing superior relief for all nasal symptoms compared to oral antihistamines and leukotriene receptor antagonists. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective single medication class for controlling all symptoms of allergic rhinitis 2, 1
• Superior to leukotriene receptor antagonists for nasal symptom reduction 2
• Begin working within 12 hours, and as early as 3-4 hours in some patients 1
• Effectively control the four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1, 3
• Options include fluticasone propionate, budesonide, mometasone furoate, and triamcinolone acetonide 3, 4
• Can be administered once daily (e.g., fluticasone 200 μg once daily) or twice daily depending on the formulation 5, 6, 7

Intranasal Antihistamines

• Effective for rhinorrhea, sneezing, and nasal itching 8
• Particularly useful for patients with nonallergic rhinitis 4
• Example: Azelastine - indicated for treatment of symptoms of seasonal allergic rhinitis such as rhinorrhea, sneezing, and nasal pruritus 8

Treatment Algorithm Based on Severity

For Mild Intermittent or Mild Persistent Allergic Rhinitis:

1. Second-generation H1 antihistamine (e.g., cetirizine, fexofenadine, loratadine) OR
2. Intranasal antihistamine (e.g., azelastine, olopatadine) 4

For Moderate to Severe Persistent Allergic Rhinitis:

1. Intranasal corticosteroid as monotherapy 2, 1, 4 OR
2. Combination of intranasal corticosteroid plus intranasal antihistamine (e.g., fluticasone propionate plus azelastine) 2, 1
   • This combination has shown greater symptom reduction than either agent alone 2, 1
   • The Joint Task Force on Practice Parameters found this combination to be clinically meaningful for Total Nasal Symptom Score (TNSS) 2

Second-Line and Adjunctive Treatments

Leukotriene Receptor Antagonists

• Less effective than intranasal corticosteroids for nasal symptom reduction 2, 1
• May be considered for patients who cannot tolerate intranasal corticosteroids 2, 1
• Particularly useful in patients with comorbid asthma 1

Ipratropium Bromide Intranasal

• Especially effective for rhinorrhea 1
• Consider as adjunctive therapy when rhinorrhea is a predominant symptom

Oral Decongestants

• Should be used with caution and for short periods only
• Not recommended for regular use due to adverse effects 1
• Contraindicated in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 1

Intranasal Decongestants

• Should not be used for more than 5 days due to risk of rhinitis medicamentosa 1

Important Clinical Considerations

Proper Administration Technique

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

Safety Considerations

• Intranasal corticosteroids have minimal systemic effects when used at recommended doses 3
• Common local adverse effects include epistaxis, pharyngitis, nasal irritation, and headache 1
• Dysgeusia (altered taste) is the most common adverse event with intranasal antihistamines, occurring in 2.1-13.5% of patients 2
• First-generation antihistamines should be avoided in older adults due to risk of psychomotor impairment 1

Treatment Evaluation

• Allow 4-6 weeks of consistent use before determining treatment failure
• If symptoms persist despite appropriate treatment, consider:
  1. Reassessing diagnosis
  2. Evaluating for comorbid conditions
  3. Adjusting medication regimen
  4. Referral to specialist

Special Populations

Children

• Second-generation oral antihistamines are recommended as first-line treatment for allergic rhinitis in children 1
• For intranasal corticosteroids in children, use preparations that have not shown negative impact on growth 1
• OTC cough and cold medications should be avoided in young children 1

Pregnancy

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

By following this evidence-based approach to treating allergic rhinitis, clinicians can effectively manage symptoms and improve quality of life for patients suffering from this common condition.