What is the recommended treatment for atopic rhinitis?

Treatment of Atopic Rhinitis

Intranasal corticosteroids are the first-line treatment for atopic rhinitis and should be recommended for patients whose symptoms affect their quality of life. 1, 2

First-Line Treatment Options

• Intranasal corticosteroids (such as fluticasone propionate) are the most effective medication class for controlling all four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion 2, 3
• Intranasal corticosteroids can be administered once daily, with improvement in symptoms often evident within three days of starting therapy 4, 5
• For adults and adolescents (12 years and older), the recommended dosage is up to 2 sprays in each nostril once daily; for children 4-11 years, the dosage is 1 spray in each nostril once daily 6
• Fluticasone propionate nasal spray works directly in the nose to block allergic reactions at the source by acting on multiple inflammatory substances, including histamine, prostaglandins, cytokines, and leukotrienes 6

Second-Line Treatment Options

• Oral second-generation/less sedating antihistamines (such as loratadine) should be recommended for patients with allergic rhinitis whose primary complaints are sneezing and itching 1, 2
• Intranasal antihistamines may be offered as an alternative for patients with seasonal, perennial, or episodic allergic rhinitis 1
• Leukotriene receptor antagonists (such as montelukast) should NOT be offered as primary therapy for allergic rhinitis, as evidence clearly shows intranasal corticosteroids are more effective 1, 2

Combination Therapy

• For moderate to severe allergic rhinitis that doesn't respond to monotherapy, combination therapy may be considered 1
• The combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment of moderate to severe seasonal allergic rhinitis, showing greater symptom reduction than either agent alone 1, 2
• Adding an oral antihistamine to an intranasal corticosteroid has NOT been proven to provide additional benefit for nasal symptom control 1, 2

Special Considerations

• Children using intranasal corticosteroids should use them for the shortest amount of time necessary to achieve symptom relief, as long-term use may affect growth rate 6
• For children ages 4-11, consult a doctor if treatment is needed for longer than 2 months per year; for those 12 and older, consult if treatment is needed for longer than 6 months 6
• Patients with inadequate response to pharmacologic therapy should be referred for consideration of immunotherapy (sublingual or subcutaneous) 1

Common Pitfalls and Caveats

• Avoid routine sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis 1
• Don't assume combination therapy is always superior to monotherapy; evidence shows intranasal corticosteroid alone is often sufficient 2
• Patients should continue using intranasal corticosteroids daily as long as they're exposed to allergens that trigger symptoms, even after initial symptom relief 6
• Dysgeusia (altered taste) is the most common adverse event with intranasal corticosteroids and antihistamines, occurring in 2.1% to 13.5% of patients 1
• Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media in patients with allergic rhinitis 1

Treatment Algorithm

1. Initial treatment: Start with intranasal corticosteroid (e.g., fluticasone propionate) as monotherapy 1, 2
2. If primary symptoms are sneezing and itching: Consider oral second-generation antihistamine 1
3. For moderate-severe symptoms with inadequate response: Consider combination of intranasal corticosteroid plus intranasal antihistamine 1, 2
4. For patients who cannot tolerate intranasal medications: Consider oral antihistamines, though they are less effective than intranasal corticosteroids 2, 3
5. For persistent symptoms despite optimal pharmacotherapy: Consider referral for allergen immunotherapy 1