What is the recommended treatment for allergic rhinitis?

Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for chronic allergic rhinitis due to their superior efficacy in controlling all symptoms, particularly nasal congestion. 1

First-Line Treatment Options

Moderate to Severe Persistent Allergic Rhinitis

• Intranasal corticosteroids (INCs) - most effective single therapy
  • Options include fluticasone, triamcinolone, budesonide, mometasone 2
  • Effectively relieves nasal congestion, itching, rhinorrhea, and sneezing in both early and late phases of allergic response 3
  • Once daily dosing is as effective as twice daily for medications like fluticasone propionate 4
  • As-needed use can also be effective for seasonal allergic rhinitis 5

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation H1 antihistamines (oral)
  • Options include cetirizine, fexofenadine, desloratadine, loratadine 2
  • Preferred over first-generation antihistamines due to less sedation
• Intranasal antihistamines
  • Options include azelastine, olopatadine 2
  • Particularly effective for itching, sneezing, and rhinorrhea

Combination Therapy

For patients with inadequate symptom control on monotherapy:

• Intranasal corticosteroid + intranasal antihistamine

  • Provides greater symptom reduction than either agent alone
  • Absolute nasal symptom reductions of -5.31 to -5.7 for combination vs. -3.84 to -5.1 for corticosteroid alone 1
  • May cause adverse effects including dysgeusia and somnolence 6

• Short-term intranasal oxymetazoline + intranasal corticosteroids

  • For severe nasal congestion
  • Caution: limit use to less than 5 days to avoid rhinitis medicamentosa 1

• Oral antihistamine + oral decongestant

  • Alternative combination option
  • Second-generation antihistamines preferred due to less sedation 1

Adjunctive Therapies

• Saline nasal irrigations

  • Helps reduce inflammation and improve muco-ciliary clearance
  • Insufficient as primary treatment for moderate to severe symptoms 1

• Leukotriene receptor antagonists (e.g., montelukast)

  • Less effective than intranasal corticosteroids 6
  • FDA data shows significant reduction in daytime nasal symptoms compared to placebo for both seasonal and perennial allergic rhinitis 7

Long-term Management

• Allergen immunotherapy (sublingual or subcutaneous)
  • Consider for long-term management
  • May prevent development of asthma and new sensitizations
  • Can be initiated in children as young as 5 years 1

Special Populations

Children

• Second-generation oral antihistamines are recommended as first-line treatment 1
• When using intranasal steroids, choose preparations without negative impact on growth 1
• Montelukast shows no significant impact on growth rates compared to placebo 7

Elderly

• Prominent clear rhinorrhea is common due to cholinergic hyperactivity
• Avoid first-generation antihistamines due to increased risk of falls and anticholinergic effects 1

Pregnant Patients

• Intranasal corticosteroids generally have good safety profiles
• Individual risk-benefit assessment is needed 1

Treatment Algorithm

1. Assess severity and frequency of symptoms:

   • 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
   • Consider short-term decongestant for severe congestion (≤5 days)

3. If still inadequate control after 4-6 weeks:

   • Consider referral for allergen immunotherapy evaluation

Important Cautions

• Intranasal decongestants should not be used for more than 5 days due to risk of medicamentosa rhinitis 1
• Oral decongestants are not recommended for regular use due to adverse effects 1
• Intramuscular and systemic corticosteroids are not recommended for chronic management due to potential serious side effects 1