What is the recommended treatment for nasal allergies?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for moderate to severe allergic rhinitis due to their superior efficacy in controlling the full spectrum of nasal symptoms. 1, 2

First-Line Treatment Options Based on Symptom Severity

Moderate to Severe Allergic Rhinitis

• Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of allergic rhinitis (sneezing, itching, rhinorrhea, and nasal congestion) 1, 2
• Intranasal corticosteroids are more effective than oral antihistamines or leukotriene receptor antagonists for nasal symptom reduction 1, 2
• For patients with inadequate response to intranasal corticosteroids alone, combination therapy with an intranasal corticosteroid plus an intranasal antihistamine may be considered 1, 2

Mild Allergic Rhinitis

• Second-generation/less sedating oral antihistamines are recommended for patients with primary complaints of sneezing and itching 1, 3
• Intranasal antihistamines (such as azelastine) may be offered for seasonal, perennial, or episodic allergic rhinitis 1, 4
• Intranasal antihistamines have a rapid onset of action and are especially useful for patients with episodic nasal symptoms 1

Combination Therapy for Inadequate Response

When initial monotherapy fails to adequately control symptoms:

• The combination of an intranasal corticosteroid and an intranasal antihistamine is the most effective additive therapy 1, 2
• For severe nasal obstruction, adding topical oxymetazoline to intranasal corticosteroids for a few days (less than 3 days) can provide benefit, but should be limited due to concerns about rebound congestion 1
• If nasal sprays are not tolerated, combination therapy of an oral antihistamine and decongestant is the next most effective pharmacotherapy 1

Treatments to Avoid or Use with Caution

• Oral leukotriene receptor antagonists (LTRAs) should not be offered as primary therapy for allergic rhinitis 1
• LTRAs are less effective than intranasal corticosteroids 1, 2
• First-generation antihistamines should be avoided due to significant sedation and anticholinergic effects 2, 3
• A short course of oral corticosteroids may be appropriate only for intractable nasal symptoms, but chronic use is inappropriate 1, 5

Additional Treatment Options

• For patients who have inadequate response to pharmacologic therapy, immunotherapy (sublingual or subcutaneous) should be offered 1
• Allergen avoidance and environmental controls may be advised when specific allergens correlate with clinical symptoms 1
• Inferior turbinate reduction may be offered for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management 1
• Acupuncture may be offered for patients interested in non-pharmacologic therapy 1

Important Clinical Considerations

• Intranasal antihistamines may cause somnolence in 0.4% to 3% of patients, which is only slightly greater than placebo groups 1
• Common side effects of intranasal antihistamines include bitter taste, epistaxis, somnolence, and headache 1
• The combination of an antihistamine and LTRA is superior to either therapy alone but still less effective than intranasal corticosteroids 1
• Patients with both allergic rhinitis and asthma may benefit from montelukast, though it's not the preferred agent for either condition alone 1, 6

Treatment Algorithm for Allergic Rhinitis

1. First step: Intranasal corticosteroid for moderate-severe symptoms OR second-generation oral antihistamine for mild symptoms with predominant sneezing/itching 1, 3
2. If inadequate response: Add intranasal antihistamine to intranasal corticosteroid 1, 2
3. For severe congestion: Consider short-term (less than 3 days) addition of topical decongestant 1
4. For persistent symptoms despite optimal pharmacotherapy: Consider allergen immunotherapy 1