What is the treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids (INCSs) are the most effective single medication class for controlling all symptoms of allergic rhinitis and should be the first-line treatment for moderate to severe cases. 1

First-Line Treatment Options

For Mild Intermittent or Mild Persistent Allergic Rhinitis:

• Second-generation H1 antihistamines (oral)
  • Examples: cetirizine, fexofenadine, desloratadine, loratadine
  • Benefits: Effective for itching, sneezing, and rhinorrhea
  • Limitations: Less effective for nasal congestion 2
• OR Intranasal antihistamines
  • Examples: azelastine, olopatadine
  • Benefits: Indicated for treatment of seasonal allergic rhinitis symptoms 3
  • Common side effect: Dysgeusia (altered taste) in 2.1-13.5% of patients 4, 1

For Moderate to Severe Persistent Allergic Rhinitis:

• Intranasal corticosteroids
  • Examples: fluticasone, triamcinolone, budesonide, mometasone
  • Benefits: Most effective for all symptoms including nasal congestion
  • Administration: Ensure patent nasal airway before use 1
  • Side effects: Typically mild - epistaxis, pharyngitis, nasal irritation, headache 1

Combination Therapy

For patients with inadequate response to monotherapy, evidence supports combination therapy:

• Intranasal corticosteroid + intranasal antihistamine

  • Provides greater symptom reduction than either agent alone
  • Studies show absolute nasal symptom reductions of -5.31 to -5.7 for combination vs. -3.84 to -5.1 for corticosteroid alone 4
  • This combination showed clinically meaningful differences in Total Nasal Symptom Score (TNSS) 4

• Intranasal corticosteroid + oral antihistamine

  • Less effective than intranasal corticosteroid + intranasal antihistamine 1
  • Consider when intranasal antihistamines aren't tolerated

Special Populations

Children:

• Second-generation oral antihistamines are recommended as first-line treatment, especially when itching, sneezing, and rhinorrhea predominate 1
• For intranasal corticosteroids, select preparations without negative impact on growth 1
• Montelukast has been studied in children and shows no significant impact on growth rates compared to placebo 5

Older Adults:

• Avoid first-generation antihistamines due to risk of psychomotor impairment, falls, and anticholinergic effects 1
• Prefer second-generation antihistamines or intranasal treatments

Pregnant Patients:

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

Additional Treatment Options

Leukotriene Receptor Antagonists:

• Montelukast may be considered, especially with comorbid asthma 1
• Less effective than intranasal corticosteroids for nasal symptom reduction 1, 5
• Can be used alone or in combination with antihistamines 1

Decongestants:

• Short-term oral or intranasal decongestants (3-5 days maximum) may help temporarily relieve severe congestion 1
• Caution: Intranasal decongestants should not be used for more than 5 days due to risk of rhinitis medicamentosa 1
• Oral decongestants should be used with caution in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 1

Allergen Immunotherapy:

• Consider for long-term management when pharmacotherapy is inadequate
• Available as sublingual or subcutaneous options 1

Treatment Algorithm

1. Assess severity and symptom pattern:

   • Mild intermittent: Second-generation antihistamine (oral or intranasal)
   • Moderate-severe or persistent: Intranasal corticosteroid

2. If inadequate response after 2-4 weeks:

   • Add intranasal antihistamine to intranasal corticosteroid
   • This combination provides superior symptom relief compared to either medication alone 4, 1

3. For patients with specific comorbidities:

   • With asthma: Consider adding montelukast 1, 5
   • With conjunctivitis: Ensure adequate treatment of ocular symptoms

4. For patients with severe congestion:

   • Consider short-term (3-5 days) decongestant use to improve nasal patency 1

5. For long-term management:

   • Consider allergen immunotherapy for patients with inadequate response to pharmacotherapy 1

Common Pitfalls to Avoid

• Using first-generation antihistamines in older adults due to anticholinergic and sedating effects 1
• Using intranasal decongestants for more than 5 days, which can lead to rebound congestion 1
• Failing to assess for comorbid conditions like asthma, atopic dermatitis, and sinusitis 1, 2
• Using intramuscular corticosteroids for rhinitis treatment due to potential serious side effects 1
• Inadequate patient education on proper intranasal medication technique, which can reduce efficacy