What is the recommended treatment for allergic rhinitis?

Recommended Treatment for Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be recommended as initial therapy for patients whose symptoms affect their quality of life. 1, 2

First-Line Treatment Options

• Intranasal corticosteroids (such as fluticasone propionate, triamcinolone, budesonide, mometasone) are the most effective medication class for controlling all four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion 1, 2
• Fluticasone propionate nasal spray has demonstrated superior efficacy compared to antihistamines in managing allergic rhinitis symptoms 3
• Once-daily dosing of intranasal corticosteroids like fluticasone propionate is as effective as twice-daily dosing, improving patient adherence 4
• Second-generation oral antihistamines (loratadina, desloratadina, cetirizina, fexofenadina) are recommended specifically for patients whose primary complaints are sneezing and itching 1, 2
• Intranasal antihistamines (azelastine, olopatadine) can be used as monotherapy or in combination with intranasal corticosteroids for enhanced symptom relief 2

Treatment Algorithm Based on Symptom Severity

• For mild intermittent or mild persistent allergic rhinitis:
  • Second-generation H1 antihistamines or intranasal antihistamines may be sufficient 2
• For moderate to severe persistent allergic rhinitis:
  • Intranasal corticosteroids should be used either alone or in combination with an intranasal antihistamine 2
• For intractable nasal symptoms:
  • A short course (5-7 days) of oral corticosteroids may be appropriate when symptoms are extremely severe and significantly impact quality of life 5, 6
  • Chronic use of oral or parenteral corticosteroids is inappropriate in allergic rhinitis 5, 6

Combination Therapies

• Combined therapy may be offered to patients with inadequate response to monotherapy 1
• The combination of intranasal ipratropium bromide with an intranasal corticosteroid is more effective than either medication alone for treating rhinorrhea 1
• Adding an antihistamine to intranasal corticosteroid therapy generally produces little additional benefit 3

Environmental Control Measures

• Avoidance of identified allergens is fundamental to successful management of allergic rhinitis 5
• Environmental controls should be implemented for patients who have identified allergens that correlate with clinical symptoms 1
• Avoidance is the most effective approach for managing sensitivity to animals 1
• Early administration of medications before exposure to seasonal allergens may reduce symptom severity 5

Allergen Immunotherapy

• Allergen immunotherapy should be considered for patients with allergic rhinitis who:
  • Have demonstrable evidence of specific IgE antibodies to clinically relevant allergens 5, 1
  • Show inadequate response to pharmacological therapy with or without environmental controls 1
• Effective immunotherapy has been associated with significant improvement in symptom scores, medication use, and quality of life measures 5

Important Considerations and Cautions

• When using fluticasone propionate nasal spray:

  • Do not use if you have had an allergic reaction to it or any of its ingredients 7
  • Consult a healthcare provider before using if taking HIV medications (like ritonavir), ketoconazole, or other steroid medications 7
  • For adults and children 12 years and older: up to 2 sprays in each nostril once daily, with medical consultation after 6 months of daily use 7
  • For children 4-11 years: 1 spray in each nostril once daily, with medical consultation after 2 months of use per year 7
  • Long-term use in children may affect growth rate, requiring monitoring 7

• Oral decongestants can reduce nasal congestion but may cause side effects like insomnia, irritability, and palpitations 1

• Patients with negative skin tests or in vitro tests for specific IgE should be considered to have nonallergic rhinitis, especially with poor correlation between allergen exposure and symptoms 5