What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are recommended as first-line therapy for allergic rhinitis, providing superior relief for nasal congestion, rhinorrhea, sneezing, and reduced sense of smell. 1

First-Line Treatment Options

For Mild Intermittent or Mild Persistent Allergic Rhinitis:

• Second-generation H1 antihistamines (e.g., cetirizine, fexofenadine, desloratadine, loratadine) OR
• Intranasal antihistamines (e.g., azelastine, olopatadine) 2

For Moderate to Severe Persistent Allergic Rhinitis:

• Intranasal corticosteroids (e.g., fluticasone, triamcinolone, budesonide, mometasone) as monotherapy OR
• Combination therapy with intranasal corticosteroid plus intranasal antihistamine, which provides greater symptom reduction than either agent alone 1

Treatment Algorithm

1. Assess severity and frequency of symptoms

   • Intermittent: symptoms < 4 consecutive days/week or < 4 consecutive weeks/year
   • Persistent: symptoms > 4 consecutive days/week and > 4 consecutive weeks/year 2

2. Initial treatment based on severity:

   • Mild symptoms: Start with second-generation antihistamine or intranasal antihistamine
   • Moderate-severe symptoms: Start with intranasal corticosteroid

3. Evaluate response after 2-4 weeks 1

   • If inadequate response, escalate therapy:
     • Add intranasal antihistamine to intranasal corticosteroid
     • Consider short-term (5-10 days) oral corticosteroids for severe symptoms
     • Consider adding montelukast, particularly in patients with coexisting asthma 1

4. If symptoms remain inadequately controlled after 4-6 weeks of optimal pharmacotherapy:

   • Consider referral for allergen immunotherapy 1

Evidence-Based Insights

Intranasal corticosteroids have consistently demonstrated superior efficacy compared to other treatments. They effectively target the inflammatory process underlying allergic rhinitis and can be administered once daily, improving compliance 3. Studies show that fluticasone propionate administered once daily is as effective as twice-daily dosing for both seasonal and perennial allergic rhinitis 4, 3.

Combination therapy with intranasal corticosteroid plus intranasal antihistamine provides greater symptom reduction than either agent alone, with absolute nasal symptom reductions of -5.31 to -5.7 for combination vs. -3.84 to -5.1 for corticosteroid alone 1.

Montelukast has shown similar efficacy to antihistamines when used as monotherapy and may be particularly beneficial for patients with coexisting asthma and allergic rhinitis. It has an excellent safety profile and is approved for use in children as young as 6 months 1, 5.

Special Considerations

Children:

• Growth concerns should be considered when using intranasal steroids
• Use intranasal steroid preparations that have not shown negative impact on growth 1
• Montelukast has been shown not to affect growth rate in pediatric patients, with growth rates of 5.67 cm/year compared to 5.64 cm/year for placebo 5
• Sublingual immunotherapy can be initiated in children as young as 5 years and may prevent development of asthma 1

Elderly:

• More likely to experience prominent clear rhinorrhea due to cholinergic hyperactivity
• Use caution with 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

Adjunctive Therapies

• Saline nasal irrigations: Help reduce inflammation and improve muco-ciliary clearance, but insufficient as primary treatment for moderate to severe symptoms 1
• Allergen avoidance: Patients should avoid inciting allergens when possible 2
• Diet modifications: A diet rich in omega-3 fatty acids (found in fatty fish) may help manage symptoms due to anti-inflammatory properties 1

Common Pitfalls to Avoid

1. Delaying treatment escalation: Chronic inflammation can lead to complications including sinusitis, otitis media, and sleep disturbance 1

2. Prolonged use of oral decongestants: Should not be used for more than 5 days due to risk of rebound congestion 1

3. Overlooking comorbid conditions: Patients with allergic rhinitis should be assessed for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1

4. Using first-generation antihistamines: These have significant sedative and anticholinergic effects, especially problematic in elderly patients 1

5. Experimental procedures: The Vivaer Intranasal Procedure using radiofrequency to the nasal valve is considered experimental and unproven for nasal obstruction 1