What is the first line treatment for allergic rhinitis?

First-Line Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis when symptoms affect quality of life, as they are the most effective medication class for controlling the full spectrum of symptoms. 1

Treatment Selection Based on Symptom Severity

For Mild Intermittent Symptoms

• Oral second-generation antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) are appropriate first-line therapy for patients whose primary complaints are sneezing and itching 1, 2
• These agents effectively reduce rhinorrhea, sneezing, and itching but have limited objective effect on nasal congestion 1, 3
• Intranasal antihistamines (azelastine, olopatadine) are equally effective alternatives and superior to oral antihistamines for nasal congestion 3, 2

For Moderate to Severe or Persistent Symptoms

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be the initial treatment when symptoms affect quality of life 1, 2
• This is a strong recommendation based on their superior efficacy across all symptom domains, particularly nasal congestion 1
• Continuous treatment is more effective than intermittent use due to ongoing allergen exposure 1, 3

Second-Generation vs First-Generation Antihistamines

Always recommend second-generation antihistamines over first-generation agents due to critical safety differences: 3, 4

• First-generation antihistamines (diphenhydramine, chlorpheniramine) cause significant sedation and performance impairment that patients may not subjectively perceive 1, 4
• Second-generation agents (fexofenadine, loratadine, desloratadine) do not cause sedation at recommended doses 3
• First-generation antihistamines should be avoided in children under 6 years and older adults who are more sensitive to psychomotor impairment 3

What NOT to Use as First-Line

Do not offer oral leukotriene receptor antagonists (montelukast) as primary therapy for allergic rhinitis 1

• Montelukast is less effective than intranasal corticosteroids, with clinically meaningful differences in nasal symptom reduction 1
• Exception: Consider in patients with concurrent mild persistent asthma, though it remains suboptimal for either condition alone 1, 5
• The combination of montelukast with antihistamines may be additive but is still less efficacious than intranasal corticosteroids 1

Combination Therapy for Inadequate Response

For patients with moderate to severe symptoms, combination therapy with intranasal corticosteroid plus intranasal antihistamine may be offered as initial treatment 1

• Studies show fluticasone propionate plus azelastine produces greater symptom reduction than either agent alone (>40% relative improvement) 1
• This represents a weak recommendation due to equilibrium of benefits versus increased cost and complexity 1

Common Pitfalls to Avoid

• Don't assume oral antihistamines will adequately treat nasal congestion—they have minimal objective effect on this symptom 1, 3
• Don't use topical decongestants chronically—this causes rhinitis medicamentosa with rebound congestion 1
• Don't overlook that performance impairment from first-generation antihistamines occurs even when patients don't feel drowsy 3, 4
• Don't forget to assess for comorbid conditions (asthma, atopic dermatitis, rhinosinusitis, conjunctivitis) as these influence treatment selection 1

Practical Algorithm

1. Assess symptom severity and impact on quality of life 1
2. If mild intermittent symptoms (sneezing/itching predominant): Start oral second-generation antihistamine or intranasal antihistamine 1, 2
3. If moderate-severe or persistent symptoms, OR nasal congestion is prominent: Start intranasal corticosteroid 1, 2
4. If inadequate response to monotherapy: Add combination therapy or refer for allergy testing and immunotherapy 1