Treatment Options for Non-Allergic Rhinitis
Intranasal corticosteroids are the first-line treatment for non-allergic rhinitis, effectively relieving both congestion and rhinorrhea associated with vasomotor rhinitis. 1, 2
Primary Treatment Options
- Intranasal corticosteroids are the most effective monotherapy for non-allergic rhinitis and should be considered first-line treatment without requiring prior trials of antihistamines or decongestants 1, 2
- Intranasal antihistamines (such as azelastine) are effective for non-allergic rhinitis, particularly for vasomotor rhinitis, with dosing of two sprays per nostril twice daily for patients 12 years and older 1, 3
- Intranasal anticholinergics (ipratropium bromide) are particularly effective for treating rhinorrhea in non-allergic rhinitis and can be used in combination with other medications for increased efficacy 1, 2, 4
- Oral decongestants help reduce nasal congestion but should be used with caution in patients with hypertension, arrhythmias, insomnia, prostate hypertrophy, or glaucoma 2, 5
Treatment Algorithm Based on Predominant Symptoms
For predominant congestion:
- Start with intranasal corticosteroids 2, 1
- Add oral decongestants for short-term relief if needed, with appropriate precautions 2, 6
- Consider exercise to help relieve congestion 2
For predominant rhinorrhea:
- Intranasal anticholinergics (ipratropium bromide) are the most effective option 2, 1
- Can be combined with intranasal corticosteroids for better efficacy without increased adverse effects 2, 7
For mixed symptoms (congestion and rhinorrhea):
- Combination of intranasal corticosteroids and intranasal antihistamines provides greater relief than either alone 2, 1
- This combination is particularly effective for vasomotor rhinitis 2, 6
Specific Non-Allergic Rhinitis Subtypes
- Vasomotor rhinitis: Intranasal corticosteroids and intranasal antihistamines are effective; avoid triggering irritants 2, 3
- Gustatory rhinitis: Intranasal anticholinergics before meals are particularly effective 2, 5
- Rhinitis medicamentosa: Discontinue nasal decongestant sprays and institute intranasal corticosteroids 2, 6
- Non-allergic rhinitis with eosinophilia (NARES): Intranasal corticosteroids are the treatment of choice 2, 5
Important Considerations and Pitfalls
- Nonsedating oral antihistamines have not been shown to be effective in non-allergic rhinitis and should be avoided 2, 7
- Topical decongestants should only be used short-term (less than 3 days) to prevent rhinitis medicamentosa 2, 6
- Nasal saline irrigation can be beneficial as an adjunct therapy for symptoms of chronic rhinorrhea 1, 7
- When using intranasal corticosteroids, patients should be instructed to direct sprays away from the nasal septum to minimize local side effects 2
- Periodic examination of the nasal septum is recommended to ensure there are no mucosal erosions when using intranasal corticosteroids long-term 2
When to Consider Referral
- For prolonged manifestations of rhinitis not responding to standard therapy 1
- When complications such as nasal polyps develop 1, 2
- If systemic corticosteroids have been required, which should generally be avoided except for short courses (5-7 days) in very severe cases 2, 1
Remember that non-allergic rhinitis is characterized by sporadic or persistent perennial symptoms that do not result from IgE-mediated events, and treatment should target the specific subtype and predominant symptoms 2, 8.