What is the treatment for chronic rhinitis?

Treatment for Chronic Rhinitis

Intranasal corticosteroids are the most effective monotherapy for both allergic and nonallergic rhinitis and should be the first-line treatment for moderate to severe chronic rhinitis. 1

First-Line Treatments

Intranasal Corticosteroids

• Most effective single medication for both seasonal and perennial allergic rhinitis with strong evidence level 1
• Examples include fluticasone propionate, triamcinolone, budesonide, and mometasone furoate 2
• Can be used as initial treatment without prior trials of antihistamines or decongestants 1
• May start to provide relief on the first day of use, but takes several days to build up to full effectiveness 3
• Unlike decongestant sprays, intranasal corticosteroids do not cause rebound congestion and can be used for up to 6 months in patients 12 years or older 3

Oral Antihistamines

• Second-generation antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are preferred over first-generation due to less sedation and performance impairment 1
• Effective in reducing rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 4
• May be used as first-line for mild intermittent or mild persistent allergic rhinitis 2

Intranasal Antihistamines

• Effective for both allergic and nonallergic rhinitis 1
• First-line therapy for nonallergic rhinitis either as monotherapy or in combination with intranasal corticosteroids 2
• May cause sedation in some patients and can inhibit skin test reactions due to systemic absorption 1

Combination Therapies

• For moderate to severe seasonal allergic rhinitis, a combination of intranasal corticosteroid and intranasal antihistamine provides greater efficacy than either alone 1
• When used in combination, an intranasal antihistamine spray and nasal steroid provide greater symptomatic relief than monotherapy 5

Additional Treatment Options

Intranasal Anticholinergics

• Ipratropium bromide is particularly effective for rhinorrhea in nonallergic rhinitis 1
• Can be used in combination with antihistamines or intranasal corticosteroids for increased efficacy 1

Intranasal Cromolyn Sodium

• Effective in some patients for prevention and treatment of allergic rhinitis 4
• Associated with minimal side effects but less effective than corticosteroids 4
• Should be started as early as possible in an allergy season, with effects typically noted within 4-7 days 4

Leukotriene Receptor Antagonists

• Useful in the treatment of allergic rhinitis, alone or in combination with antihistamines 4
• Generally less efficacious than intranasal corticosteroids 4

Nasal Saline

• Beneficial in treating symptoms of chronic rhinorrhea and rhinosinusitis 1
• Can be used as a single modality or as adjunctive treatment 1

Treatments to Avoid or Use with Caution

Oral Corticosteroids

• Should not be administered as therapy for chronic rhinitis except for rare patients with severe intractable nasal symptoms unresponsive to other treatments 4
• A short course (5-7 days) may be appropriate for very severe symptoms or significant nasal polyposis 4
• Recurrent administration of parenteral corticosteroids is contraindicated due to potential long-term side effects 4, 1

Intranasal Decongestants

• Prolonged use can lead to rhinitis medicamentosa (rebound congestion) 1
• Use should be limited to less than 10 days 1

Special Considerations

For Nonallergic Rhinitis

• Intranasal antihistamines are first-line therapy either as monotherapy or in combination with intranasal corticosteroids 2
• Intranasal anticholinergics are particularly effective for rhinorrhea 1

For Nasal Polyps

• Intranasal corticosteroids are effective in improving sense of smell and reducing nasal congestion 4
• For severe nasal polyposis, a short course of oral prednisone may be effective in reducing symptoms and polyp size, followed by maintenance intranasal corticosteroids 4

Allergen Immunotherapy

• Only treatment that has demonstrated ability to modify the natural history of allergic rhinitis 1
• Can prevent development of new allergen sensitivities and reduce risk of future asthma development 1
• Should be considered for patients with allergic rhinitis who have demonstrable evidence of specific IgE antibodies to clinically relevant allergens 4

When to Consider Specialist Referral

• For prolonged manifestations of rhinitis 1
• Complications such as otitis media, sinusitis, or nasal polyposis 1
• Comorbid conditions like asthma or chronic sinusitis 1
• When systemic corticosteroids have been required 1
• When symptoms are inadequately controlled or quality of life is reduced 1

Common Pitfalls to Avoid

• Using first-generation antihistamines (due to sedation and anticholinergic effects) 1
• Prolonged use of intranasal decongestants leading to rhinitis medicamentosa 1
• Recurrent administration of parenteral corticosteroids 1
• Inadequate treatment of nonallergic rhinitis with oral antihistamines 1
• Failing to direct intranasal corticosteroid spray away from the nasal septum, which can lead to mucosal erosions and potential septal perforations 4