What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the most effective medication for allergic rhinitis and should be the first-line treatment option, particularly for patients with moderate to severe symptoms affecting quality of life. 1, 2

First-Line Treatment Options

• Intranasal corticosteroids (such as fluticasone, triamcinolone, budesonide, mometasone) provide the greatest efficacy for controlling the full spectrum of allergic rhinitis symptoms, especially nasal congestion 2
• Second-generation oral antihistamines (loratadine, desloratadine, cetirizina, fexofenadine) are recommended for patients whose primary complaints are sneezing and itching, but they have limited effect on nasal congestion 1, 3
• Intranasal antihistamines (azelastine, olopatadine) are efficacious and equal to or superior to oral second-generation antihistamines, with the added benefit of reducing nasal congestion 3, 4

Treatment Algorithm Based on Symptom Severity

For Mild Intermittent or Mild Persistent Symptoms:

• Start with a second-generation H1 antihistamine (oral or intranasal) 4
• Avoid first-generation antihistamines due to sedation, impairment, and worsened sleep architecture 5
• Choose non-sedating options like fexofenadine, loratadine, or desloratadine which don't cause sedation at recommended doses 3

For Moderate to Severe Persistent Symptoms:

• Intranasal corticosteroid as monotherapy or in combination with an intranasal antihistamine 4, 2
• The combination of intranasal corticosteroid plus intranasal antihistamine has shown greater symptom reduction than either agent alone 2

Special Considerations

• Leukotriene receptor antagonists (montelukast) are less effective than intranasal corticosteroids but may be considered for patients who cannot tolerate intranasal corticosteroids 2, 6
• Montelukast may be particularly beneficial in patients with concurrent mild persistent asthma and allergic rhinitis 2, 6
• Oral decongestants can reduce nasal congestion but may cause side effects like insomnia, irritability, and palpitations 1, 7
• Environmental control measures should be implemented for patients with identified allergens that correlate with clinical symptoms 1

Combination Therapies for Inadequate Response

• For patients with inadequate response to monotherapy, combination therapy may be offered 1
• The combination of intranasal corticosteroid and intranasal antihistamine provides superior symptom relief compared to either medication alone 2
• Concomitant use of bromuro de ipratropio intranasal with intranasal corticosteroid is more effective than either medication alone for treating rhinorrhea 1

Common Pitfalls to Avoid

• Don't assume all second-generation antihistamines have the same sedation profile; there are important differences between agents 3, 5
• First-generation antihistamines should be avoided due to performance impairment even when patients don't feel drowsy 3, 5
• Don't overlook the importance of continuous rather than intermittent treatment for seasonal or perennial allergic rhinitis, as continuous treatment is more effective 3
• Avoid first-generation antihistamines in children under 6 years and older adults due to safety concerns and increased sensitivity to psychomotor impairment 3

Immunotherapy Considerations

• Immunotherapy should be offered to patients with allergic rhinitis who have inadequate response to pharmacologic therapy with or without environmental controls 1
• Immunotherapy is effective for treatment of allergic rhinitis in patients with demonstrable IgE antibodies to clinically relevant allergens 1