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 initial therapy for patients with moderate to severe symptoms. 1

First-Line Treatment Options

• Intranasal corticosteroids (such as fluticasone propionate, mometasone furoate, budesonide, and triamcinolone acetonide) are the most effective medication class for controlling allergic rhinitis symptoms, providing superior relief of nasal congestion, rhinorrhea, sneezing, and itching 1, 2
• Intranasal corticosteroids work by reducing inflammation in the nasal mucosa, which helps prevent both early and late-phase allergic responses 3
• For patients with moderate to severe symptoms, intranasal corticosteroids should be the initial treatment of choice due to their superior efficacy compared to other medication classes 1, 2
• Second-generation oral antihistamines (loratadina, cetirizina, fexofenadina, desloratadina) can be considered for patients with mild symptoms, particularly when sneezing and itching are the predominant complaints 2, 4

Treatment Algorithm Based on Symptom Severity

For Mild Intermittent Symptoms:

• Second-generation oral antihistamines are appropriate first-line therapy for patients with mild symptoms, particularly when sneezing and itching are predominant 2, 4
• Avoid first-generation antihistamines due to their sedating effects and potential impact on cognitive performance 5

For Moderate to Severe or Persistent Symptoms:

• Intranasal corticosteroids should be the first choice due to their superior efficacy in controlling all nasal symptoms 1, 2
• Once-daily dosing of intranasal corticosteroids (like fluticasone propionate) is effective and may improve patient adherence 6
• As-needed use of intranasal corticosteroids has also shown efficacy for seasonal allergic rhinitis, which may be an option for some patients 7

Combination Therapy

• Adding an oral antihistamine to an intranasal corticosteroid does not provide additional benefit over intranasal corticosteroid monotherapy for initial treatment of seasonal allergic rhinitis 1
• For patients with moderate to severe symptoms who have inadequate response to intranasal corticosteroid monotherapy, the combination of an intranasal corticosteroid and an intranasal antihistamine (such as azelastine) may be recommended 1, 2
• This combination has shown greater symptom reduction than either agent alone, particularly for nasal symptoms 1

Alternative Treatments

• Leukotriene receptor antagonists (such as montelukast) are less effective than intranasal corticosteroids for nasal symptom reduction and should not be used as first-line therapy 1
• Leukotriene receptor antagonists may be considered for patients who cannot tolerate intranasal corticosteroids or prefer an oral medication, despite their lesser efficacy 1
• Patients with concurrent mild persistent asthma may benefit from leukotriene receptor antagonists, though these would not be the preferred agent for either condition alone 1

Environmental Control Measures

• Avoidance of known allergens should be recommended as an adjunct to pharmacotherapy 2
• Environmental control measures are particularly important for allergens like pet dander, where avoidance is the most effective management strategy 2

Special Considerations

• For children aged 4-11 years, a lower dose of intranasal corticosteroids is recommended, and treatment duration should be limited to 2 months before reassessment by a physician 8
• For patients aged 12 years and older, intranasal corticosteroids can be used for up to 6 months before physician reassessment 8
• When using fluticasone propionate nasal spray, proper priming of the device is essential to ensure delivery of a full dose 8
• Adverse effects of intranasal corticosteroids are generally mild and limited to local reactions such as nasal dryness, burning, stinging, and epistaxis in 5-10% of patients 3

Common Pitfalls to Avoid

• Avoid using intranasal decongestants for more than 3-5 days due to risk of rebound congestion (rhinitis medicamentosa) 5
• Do not undertreat moderate to severe symptoms with antihistamines alone when intranasal corticosteroids would provide better symptom control 2, 4
• Remember that intranasal corticosteroids may take several days to reach maximum effectiveness, so patients should be counseled about expectations for symptom relief 4
• When using combination therapy with multiple intranasal products, separate administration by 5-10 minutes to avoid washing out the first medication 2