What is the best course of treatment for a patient with allergic rhinitis and bilateral knee pain?

Treatment of Allergic Rhinitis and Bilateral Knee Pain

Allergic Rhinitis Management

For this patient with seasonal allergic rhinitis, intranasal corticosteroids are the most effective first-line therapy and should be prescribed as the primary treatment. 1, 2

First-line Treatment Options:

• Intranasal corticosteroids (e.g., fluticasone, triamcinolone, budesonide, mometasone) are the most effective monotherapy for allergic rhinitis, especially when nasal congestion is prominent 3, 1
• The patient's previous use of fluticasone spray for blocked nose was appropriate and should be resumed 3
• Continuous rather than intermittent use of intranasal corticosteroids provides better symptom control 3

Second-line/Adjunctive Options:

• Second-generation antihistamines are preferred over first-generation due to reduced sedation and performance impairment 1, 4
• The patient is currently taking loratadine but requires higher doses for symptom control, suggesting either:
  • Need to switch to a different second-generation antihistamine (fexofenadine, desloratadine, cetirizina) 1, 2
  • Need to add an intranasal antihistamine (azelastine, olopatadine) which may be more effective than oral antihistamines for nasal symptoms 1

Combination Therapy:

• For patients with inadequate response to monotherapy, combination therapy may be more effective 5
• Combining intranasal corticosteroids with antihistamines (oral or intranasal) provides greater symptomatic relief than either alone 6
• Consider adding a leukotriene receptor antagonist (montelukast) if symptoms persist, particularly if the patient has comorbid asthma 3

Environmental Control:

• Identify and avoid specific allergen triggers 5
• For seasonal allergies, monitor pollen counts and limit outdoor exposure during peak seasons 3
• Consider saline nasal irrigation to remove allergens and improve mucociliary clearance 3

Bilateral Knee Pain Management

Assessment:

• The patient's bilateral knee pain, triggered by squatting/bending but not walking, with normal previous X-ray, suggests mechanical knee pain 3
• Pain on full flexion of left knee on examination is consistent with mechanical knee pain 3

Treatment Recommendations:

• Continue the exercise program previously advised for mechanical knee pain 3
• Continue vitamin D supplementation as currently prescribed 3
• Use of ibuprofen/paracetamol PRN for pain is appropriate 3
• Continue wearing flat, comfortable shoes to reduce knee strain 3

Additional Considerations:

• If pain persists despite conservative management, consider referral for physical therapy 3
• Avoid activities that exacerbate symptoms (deep squatting, heavy lifting) until symptoms improve 3
• Weight management strategies if applicable, as excess weight increases knee joint stress 3

Common Pitfalls to Avoid

• Relying solely on oral antihistamines for allergic rhinitis with prominent nasal congestion, as they have limited effect on this symptom 3, 1
• Using first-generation antihistamines, which can cause significant sedation and performance impairment that patients may not subjectively perceive 1, 4
• Discontinuing intranasal corticosteroids too early once symptoms improve, leading to symptom recurrence 3
• Failing to consider allergen immunotherapy for patients with persistent symptoms despite optimal pharmacotherapy 3
• Overlooking the connection between allergic rhinitis and potential comorbidities like asthma or sinusitis 2, 6

Follow-up Recommendations

• Review effectiveness of prescribed medications after 2-4 weeks 3
• If symptoms persist despite optimal therapy, consider allergen testing to identify specific triggers 3
• For knee pain, reassess after 4-6 weeks of consistent exercise program and medication use 3
• Consider immunotherapy if allergic rhinitis symptoms remain inadequately controlled with pharmacotherapy 3