What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis, particularly for patients whose symptoms affect their quality of life. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective single medication class for controlling all symptoms of allergic rhinitis 1
• Strong recommendation based on randomized controlled trials with minor limitations 2
• Examples include fluticasone, triamcinolone, budesonide, and mometasone 3
• Particularly effective for nasal congestion, which is one of the most common symptoms (affecting up to 94% of patients) 3
• Should be used regularly rather than as needed for optimal effect

Second-Generation Oral Antihistamines

• Recommended for patients with primary complaints of sneezing and itching 2
• Examples include cetirizine, fexofenadine, desloratadine, and loratadine 3
• Preferred over first-generation antihistamines due to less sedation and cognitive impairment 4
• First-line for mild intermittent or mild persistent allergic rhinitis 3
• Less effective for nasal congestion than intranasal corticosteroids 3

Intranasal Antihistamines

• Rapid onset of action compared to intranasal corticosteroids 1
• More effective than oral antihistamines for nasal congestion 2
• Common side effect is dysgeusia (altered taste), occurring in 2.1-13.5% of patients 1
• Examples include azelastine and olopatadine 3

Treatment Algorithm Based on Symptom Severity

1. Mild Intermittent Symptoms:

   • Second-generation oral antihistamine OR intranasal antihistamine 3

2. Moderate to Severe or Persistent Symptoms:

   • Intranasal corticosteroid as monotherapy 3
   • If inadequate response, add second-generation antihistamine 1

3. Severe Symptoms with Inadequate Response:

   • Combination therapy with intranasal corticosteroid plus intranasal antihistamine 1
   • This combination has shown greater symptom reduction than either agent alone 1

Special Considerations

For Patients with Comorbid Conditions

• Assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 2
• For patients with comorbid asthma, consider leukotriene receptor antagonists (e.g., montelukast) 1, 5
• Montelukast has shown efficacy for both seasonal and perennial allergic rhinitis 5

For Children

• Second-generation oral antihistamines are recommended as first-line treatment 1
• When using intranasal corticosteroids, select preparations that have not shown negative impact on growth 1
• Montelukast has been shown not to affect growth rate in pediatric patients 5
• Avoid OTC cough and cold medications in young children due to safety concerns 1

For Elderly Patients

• Use caution with first-generation antihistamines due to increased risk of psychomotor impairment, falls, and anticholinergic effects 1
• Second-generation antihistamines are safer options 4

Administration Tips

• Ensure patent nasal airway before administering intranasal medications 1
• Short-term decongestant use (3-5 days maximum) may be considered if severe congestion is present 1
• Do not use intranasal decongestants for more than 5 days due to risk of rebound congestion (rhinitis medicamentosa) 1
• Bi-directional exhalation devices may improve medication delivery to nasal passages 1

Long-Term Management

• Allergen avoidance when possible 1
• Consider allergen immunotherapy (sublingual or subcutaneous) for patients with inadequate symptom control on pharmacotherapy 1, 6
• Immunotherapy is particularly beneficial for patients with allergic rhinitis and comorbid allergic asthma 6

Common Pitfalls to Avoid

1. Using first-generation antihistamines (e.g., diphenhydramine, chlorpheniramine) which cause significant sedation and cognitive impairment 4
2. Using intranasal decongestants beyond 5 days, risking rebound congestion 1
3. Treating only with oral antihistamines when nasal congestion is a predominant symptom 3
4. Failing to identify and address comorbid conditions like asthma 2
5. Using intramuscular corticosteroids, which are not recommended due to potential serious side effects 1

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