Treatment Guidelines for Allergic Rhinitis
First-Line Pharmacologic Treatment
Intranasal corticosteroids should be recommended as first-line therapy for patients with allergic rhinitis whose symptoms affect their quality of life. 1, 2 This represents a strong recommendation based on randomized controlled trials demonstrating superiority over other medication classes for controlling all nasal symptoms, particularly nasal congestion. 3, 4
Intranasal Corticosteroid Specifics
Available agents include: fluticasone propionate, fluticasone furoate, mometasone furoate, budesonide, triamcinolone acetonide, and ciclesonide. 5, 6
Dosing for adults and children ≥12 years: Start with 2 sprays per nostril once daily for week 1, then reduce to 1-2 sprays per nostril once daily as needed for weeks 2 through 6 months. 7
Dosing for children 4-11 years: Use 1 spray per nostril once daily, with adult supervision. 7 Children should use the shortest duration necessary to achieve symptom relief, ideally less than 2 months per year due to potential growth rate effects. 7
Onset of action: Takes a few hours to a few days (ciclesonide has faster onset), so patients must understand this is not immediate relief. 1
Common adverse effects: Nasal dryness, burning, stinging, epistaxis (5-10% of patients), and dysgeusia (altered taste in 2.1-13.5%). 5, 2 Systemic effects are minimal with topical administration. 5, 6
Second-Line Options for Specific Symptom Patterns
Oral Second-Generation Antihistamines
Recommend oral second-generation antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) for patients whose primary complaints are sneezing and itching. 1, 2
Dosing for cetirizine: 10 mg once daily for adults and children ≥6 years; 5 mg once daily for children 2-5 years. 8
Key limitation: Less effective than intranasal corticosteroids for nasal congestion and overall symptom control. 1, 3
Sedation risk: Cetirizine may cause more sedation than fexofenadine, loratadine, or desloratadine (somnolence rates 0.4-3% at recommended doses). 8 Consider morning dosing or alternative agents if sedation is a concern. 8
Real-world evidence: Patients using oral antihistamine monotherapy have poorer symptom control compared to those using intranasal corticosteroids. 1
Intranasal Antihistamines
Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative, particularly for patients seeking rapid symptom relief. 1, 2
Onset of action: Effective within minutes, unlike intranasal corticosteroids. 1
Efficacy: Less effective than intranasal corticosteroids as monotherapy. 1
Adverse effects: Poor taste, epistaxis, local irritation, and potential sedation. 1
Comparative study: Azelastine 137 μg/spray showed comparable efficacy to fluticasone propionate 50 μg/spray for overall symptom control in moderate-to-severe seasonal allergic rhinitis, though fluticasone was superior for rhinorrhea specifically. 9
Combination Therapy
Offer combination pharmacologic therapy for patients with inadequate response to monotherapy. 1, 2
Most effective combination: Intranasal corticosteroid plus intranasal antihistamine is more effective than intranasal corticosteroids alone in patients with moderate-to-severe disease. 1, 2
Combination onset: Provides rapid relief (within minutes from antihistamine component) plus sustained control (from corticosteroid component). 1
Intranasal corticosteroid plus oral antihistamine: Offers no advantage over intranasal corticosteroids alone. 1
Ipratropium bromide addition: Concomitant use of intranasal ipratropium bromide with intranasal corticosteroid is more effective than either alone specifically for rhinorrhea. 10
Medications NOT Recommended as Primary Therapy
Do not offer oral leukotriene receptor antagonists (montelukast) as primary therapy. 1 These agents are less potent than intranasal corticosteroids and should be reserved for patients with both allergic rhinitis and asthma, or those intolerant of first-line therapies. 1
Diagnostic Approach
Clinical Diagnosis
Make the clinical diagnosis when patients present with nasal congestion, runny nose, itchy nose, or sneezing, plus physical findings consistent with allergic etiology. 1
Key physical findings: Clear rhinorrhea, nasal congestion, pale discoloration of nasal mucosa (seasonal allergic rhinitis) or erythematous/inflamed turbinates (perennial allergic rhinitis), and red/watery eyes. 1, 3
Seasonal pattern: Edematous and pale turbinates. 3
Perennial pattern: Erythematous and inflamed turbinates with serous secretions. 3
When to Perform Allergy Testing
Perform or refer for specific IgE testing (skin or blood) when: 1
- Patients do not respond to empiric treatment
- Diagnosis is uncertain
- Knowledge of specific causative allergen is needed to target therapy (especially for immunotherapy consideration)
Imaging
Do not routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1, 2 This represents a recommendation against routine imaging.
Assessment of Comorbidities
Always assess and document associated conditions: asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1, 2 These comorbidities are common and may alter treatment recommendations. 1
Environmental Controls
Advise avoidance of known allergens or environmental controls (pet removal, air filtration systems, bed covers, acaricides) in patients who have identified allergens correlating with clinical symptoms. 1
Most effective measure: Complete avoidance is the most effective management for animal sensitivity. 10
Evidence limitation: Studies do not support routine use of mite-proof mattress/pillow covers, air filtration systems alone, or delayed exposure to solid foods or pets in childhood as preventive measures. 4
Immunotherapy
Offer or refer for immunotherapy (sublingual or subcutaneous) for patients with inadequate response to pharmacologic therapy with or without environmental controls. 1, 2
Indication: Should be considered for patients with demonstrable allergen-specific IgE antibodies to clinically relevant allergens. 10
Effectiveness: Proven effective for allergic rhinitis treatment. 10, 4
Consideration with asthma: Particularly important for patients with concomitant allergic asthma. 4
Surgical Options
Inferior turbinate reduction may be offered or referred for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. 1
Real-World Treatment Patterns and Adherence
Critical pitfall: Patient adherence to treatment is extremely poor, with less than 5% of patients adherent (medication possession ratio >70%). 1
Patient behavior: Most patients self-medicate on-demand when symptoms are poorly controlled rather than following prescribed regimens. 1
Comedication patterns: Patients reporting intranasal corticosteroids use comedication on 45-60% of days, while those using combination intranasal corticosteroid/antihistamine (MPAzeFlu) use comedication on only 30-35% of days, suggesting better control with combination therapy. 1
Treatment escalation paradox: Most patients have worse control with increasing medications, contradicting guideline recommendations to escalate therapy. 1 This reflects on-demand use during uncontrolled periods rather than preventive therapy.
Alternative Therapies
Acupuncture: May be offered or referred for patients interested in nonpharmacologic therapy. 1
Herbal therapy: No recommendation can be made due to insufficient evidence. 1
Oral corticosteroids: A short course (3-7 days) may be appropriate for very severe or intractable nasal symptoms. 10
Oral decongestants: Can reduce nasal congestion but may cause insomnia, irritability, and palpitations. 10
Treatment Algorithm by Severity
Mild Intermittent or Mild Persistent Allergic Rhinitis
- First choice: Second-generation oral antihistamine OR intranasal antihistamine. 3
- Alternative: Intranasal corticosteroid if congestion is prominent. 1