What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

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

First-Line Treatment Options

• Intranasal corticosteroids (e.g., 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, 3
• Fluticasone propionate nasal spray has demonstrated superior efficacy compared to antihistamines in managing allergic rhinitis symptoms 4
• Once-daily dosing of intranasal corticosteroids like fluticasone propionate is as effective as twice-daily dosing, improving patient adherence 5
• Second-generation oral antihistamines (loratadina, desloratadina, cetirizina, fexofenadina) are recommended specifically for patients with predominant symptoms of sneezing and itching 1, 2
• Intranasal antihistamines (e.g., azelastine, olopatadine) may be used as monotherapy for mild symptoms or in combination with intranasal corticosteroids for more severe cases 2

Treatment Algorithm Based on Symptom Severity

• For mild intermittent allergic rhinitis: second-generation H1 antihistamine or intranasal antihistamine 2
• For persistent moderate to severe allergic rhinitis: intranasal corticosteroid either alone or in combination with an intranasal antihistamine 2
• For severe, intractable nasal symptoms unresponsive to other treatments: a short course (5-7 days) of oral corticosteroids may be appropriate 3, 6

Combination Therapy

• Combined therapy should 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 fluticasone propionate therapy generally produces little additional benefit 4

Environmental Control Measures

• Avoidance of identified allergens is fundamental to successful management of allergic rhinitis 6
• Environmental controls should be implemented for patients who have identified specific allergens that correlate with clinical symptoms 1
• Avoidance is the most effective way to manage sensitivity to animals 1
• Early administration of medications before exposure to seasonal allergens may reduce symptom severity 6

Allergen Immunotherapy

• Immunotherapy should be considered for patients with allergic rhinitis who have:
  • Demonstrable evidence of specific IgE antibodies to clinically relevant allergens 6, 1
  • Inadequate response to pharmacological therapy with or without environmental controls 1
• Effective immunotherapy has been associated with significant improvement in symptom scores, medication use, quality of life measures, and objective parameters such as nasal provocation challenge 6

Important Cautions and Considerations

• Chronic use of oral or parenteral corticosteroids is inappropriate for allergic rhinitis 6, 3
• Single administration of parenteral corticosteroids is discouraged, and recurrent administration is contraindicated due to potential long-term side effects 3
• When using fluticasone propionate nasal spray, patients should be aware of potential drug interactions with:
  • HIV medications (such as ritonavir)
  • Ketoconazole pills
  • Other steroid medications 7
• Common side effects of intranasal corticosteroids include nasal dryness, burning, stinging, sneezing, headache, and epistaxis in 5-10% of patients 8
• Descongestionants may help reduce nasal congestion but can cause side effects like insomnia, irritability, and palpitations 1

By following this evidence-based approach to treating allergic rhinitis, clinicians can effectively manage symptoms and improve patients' quality of life while minimizing potential adverse effects.