Treatment Options for 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 rhinitis. 1
First-Line Treatments
- Intranasal corticosteroids are the most effective single medication for both seasonal and perennial allergic rhinitis, providing superior relief for nasal congestion, rhinorrhea, sneezing, and itching 1
- Second-generation antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are preferred over first-generation antihistamines due to less sedation and performance impairment 2, 1
- Intranasal antihistamines (such as azelastine) may be considered for first-line treatment for both allergic and nonallergic rhinitis, with efficacy equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis 2, 1
- For moderate to severe seasonal allergic rhinitis, a combination of intranasal corticosteroid and intranasal antihistamine provides greater efficacy than either alone 1, 3
Treatment Based on Rhinitis Type
Allergic Rhinitis
- For mild intermittent or mild persistent allergic rhinitis: second-generation oral antihistamines or intranasal antihistamines 1, 4
- For moderate to severe persistent allergic rhinitis: intranasal corticosteroids alone or in combination with intranasal antihistamines 1, 4
- Oral anti-leukotriene agents (montelukast) alone or in combination with antihistamines have proven useful in treating allergic rhinitis 2, 5
- Allergen immunotherapy should be considered for patients with allergic rhinitis who have demonstrable evidence of specific IgE antibodies to clinically relevant allergens 2, 1
Nonallergic Rhinitis
- Intranasal corticosteroids and intranasal antihistamines are first-line treatments for nonallergic/vasomotor rhinitis 3
- Intranasal anticholinergics (ipratropium bromide) are particularly effective for rhinorrhea but have no effect on other nasal symptoms 2, 3
- The concomitant use of ipratropium bromide nasal spray and an intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea 2, 6
Additional Treatment Options
- Intranasal cromolyn sodium is effective in some patients for prevention and treatment of allergic rhinitis with minimal side effects, but is less effective than corticosteroids 2
- Topical saline is beneficial in treating symptoms of chronic rhinorrhea and rhinosinusitis when used as a sole modality or for adjunctive treatment 2, 1
- Oral decongestants (pseudoephedrine, phenylephrine) can reduce nasal congestion but should be used with caution in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 2, 3
- Topical decongestants should only be used short-term (less than 3-5 days) to prevent rhinitis medicamentosa (rebound congestion) 1, 3
Treatment Pitfalls to Avoid
- Using first-generation antihistamines due to their significant sedation, performance impairment, and anticholinergic effects 2, 1
- Prolonged use of intranasal decongestants leading to rhinitis medicamentosa 1, 3
- Recurrent administration of parenteral corticosteroids, which is contraindicated due to potential long-term side effects 2, 1
- Inadequate treatment of nonallergic rhinitis with oral antihistamines, which are not effective for this condition 3
- Failing to direct intranasal corticosteroid spray away from the nasal septum, which can lead to mucosal erosions and potential septal perforations 1
Environmental Control Measures
- Avoidance of allergens and irritants is an important component of rhinitis management 2, 1
- For dust mite allergies: combination of humidity control, dust mite covers for bedding, HEPA vacuuming of carpeting, and acaricides 2
- For animal allergies: avoidance is the most effective management 2
- For irritant-triggered rhinitis: avoidance of tobacco smoke, formaldehyde, and other irritants 2, 3