What are the treatment options for rhinitis?

Treatment Options for Rhinitis

Intranasal corticosteroids are the most effective monotherapy for both allergic and nonallergic rhinitis and should be the first-line treatment for moderate to severe rhinitis. 1

Types of Rhinitis and First-Line Treatments

Allergic Rhinitis

• Characterized by nasal congestion, rhinorrhea, sneezing, and itching of the eyes, nose, and throat 2
• First-line treatment options:
  • Mild intermittent or mild persistent: Second-generation H1 antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamine (azelastine, olopatadine) 2
  • Moderate to severe persistent: Intranasal corticosteroid alone or in combination with intranasal antihistamine 1, 2

Nonallergic Rhinitis

• First-line treatment: Intranasal antihistamine as monotherapy or combined with intranasal corticosteroid 2
• Intranasal anticholinergics (ipratropium) are particularly effective for rhinorrhea in nonallergic rhinitis 1

Medication Options in Detail

Intranasal Corticosteroids

• Most effective monotherapy for both seasonal and perennial allergic rhinitis 1
• May be considered for initial treatment without prior trials of antihistamines or decongestants 1
• Should be used at lowest effective dose, especially in children 1
• Monitor for mucosal erosions which may indicate risk for septal perforation 1

Oral Antihistamines

• Second-generation antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are preferred over first-generation due to less sedation and performance impairment 1
• Less effective for nasal congestion than for other nasal symptoms 1
• Not shown to be effective in nonallergic rhinitis 1

Intranasal Antihistamines

• Effective for both allergic and nonallergic rhinitis 1
• May cause sedation and can inhibit skin test reactions due to systemic absorption 1
• Have clinically significant effect on nasal congestion 1

Combination Therapy

• For moderate to severe seasonal allergic rhinitis, combination of intranasal corticosteroid and intranasal antihistamine is recommended as it provides greater efficacy than either alone 1, 3

Leukotriene Receptor Antagonists

• Montelukast is approved for both seasonal and perennial allergic rhinitis 1
• Less effective than intranasal corticosteroids for initial treatment of seasonal allergic rhinitis in patients aged 15 years or older 1
• Clinical trials showed significant reduction in daytime nasal symptoms compared to placebo 4

Intranasal Anticholinergics

• Effective for reducing rhinorrhea but minimal effect on nasal congestion or other symptoms 1
• Particularly useful in nonallergic rhinitis with predominant rhinorrhea (e.g., gustatory rhinitis) 1
• Combination with antihistamines or intranasal corticosteroids may provide increased efficacy 1

Nasal Cromolyn

• Less effective than intranasal corticosteroids 1
• Most effective if initiated before symptoms become severe 1
• For maximum efficacy, should be administered 4 times a day 1

Oral/Intranasal Decongestants

• Pseudoephedrine reduces nasal congestion 1
• Use with caution in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 1
• Intranasal decongestants risk causing rhinitis medicamentosa with prolonged use 1

Oral Corticosteroids

• A short course (5-7 days) may be appropriate for very severe or intractable rhinitis or nasal polyposis 1
• Single administration of parenteral corticosteroids is discouraged 1
• Recurrent administration of parenteral corticosteroids is contraindicated due to greater potential for long-term side effects 1

Allergen Avoidance and Non-Pharmacologic Approaches

• Empiric avoidance of suspected inciting factors (allergens, irritants, medications) should be implemented even in early treatment 1
• For severe seasonal allergic rhinitis, advise staying inside air-conditioned buildings with windows and doors closed when possible 1
• Nasal saline is beneficial in treating symptoms of chronic rhinorrhea and rhinosinusitis 1

Special Considerations

When to Refer to an Allergist/Immunologist

• Prolonged manifestations of rhinitis 1
• Complications such as otitis media, sinusitis, or nasal polyposis 1
• Comorbid conditions like asthma or chronic sinusitis 1
• When systemic corticosteroids have been required 1
• When symptoms or medication side effects interfere with functioning 1
• When treatment is ineffective or produces adverse events 1

Common Pitfalls to Avoid

• Using first-generation antihistamines which can cause sedation and performance impairment, often without subjective awareness 1
• Prolonged use of intranasal decongestants leading to rhinitis medicamentosa 1
• Recurrent administration of parenteral corticosteroids 1
• Inadequate treatment of nonallergic rhinitis with oral antihistamines, which have not shown efficacy 1

Treatment Algorithm

1. Identify rhinitis type: Allergic vs. nonallergic based on history, symptoms, and allergy testing if available 1
2. Assess severity: Mild intermittent, mild persistent, or moderate-severe persistent 2
3. For mild allergic rhinitis: Start with second-generation antihistamine (oral or intranasal) 2
4. For moderate-severe allergic rhinitis: Start with intranasal corticosteroid; consider combination with intranasal antihistamine if symptoms persist 1
5. For nonallergic rhinitis: Start with intranasal antihistamine or intranasal corticosteroid; add intranasal anticholinergic if rhinorrhea predominates 1
6. For rhinitis medicamentosa: Discontinue nasal decongestant sprays and treat with intranasal or systemic corticosteroids 1
7. For very severe or intractable symptoms: Consider short course (5-7 days) of oral corticosteroids 1
8. Evaluate response: If inadequate, consider referral to allergist/immunologist 1