What is the treatment for allergic rhinitis in adults?

Treatment of Allergic Rhinitis in Adults

Intranasal corticosteroids should be your first-line monotherapy for moderate to severe allergic rhinitis in adults, as they are the most effective single agent for controlling all nasal symptoms including congestion. 1, 2

Initial Treatment Approach

For Mild Intermittent or Mild Persistent Symptoms

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, desloratadine) OR an intranasal antihistamine (azelastine, olopatadine) as first-line therapy 3
• Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation and performance impairment 2
• These agents effectively control sneezing, itching, and rhinorrhea, though they have limited effect on nasal congestion 2

For Moderate to Severe or Persistent Symptoms

• Prescribe intranasal corticosteroid monotherapy (fluticasone, mometasone, triamcinolone, budesonide) as the initial treatment 1, 2, 3
• Intranasal corticosteroids are more effective than oral antihistamines for controlling all symptoms, particularly nasal congestion 2
• Do NOT routinely combine intranasal corticosteroids with oral antihistamines for initial treatment - the additional benefit does not justify the extra cost 1

When to Consider Combination Therapy

• For moderate to severe seasonal allergic rhinitis with inadequate response to monotherapy, add an intranasal antihistamine to the intranasal corticosteroid 1, 2
• This combination provides faster onset of action (within first 2 weeks) and greater efficacy than either agent alone 1, 2
• The combination of intranasal corticosteroid plus intranasal antihistamine is superior to intranasal corticosteroid plus oral antihistamine 1

Alternative and Adjunctive Therapies

Leukotriene Receptor Antagonists

• Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast) and should be recommended preferentially 1
• Leukotriene antagonists may be used as alternative therapy but are generally less efficacious than intranasal corticosteroids 2

Intranasal Anticholinergics

• Add ipratropium bromide 0.03% nasal spray specifically for severe rhinorrhea that persists despite other treatments 2, 4
• Particularly effective when combined with antihistamines or intranasal corticosteroids 2

Nasal Saline Irrigation

• Recommend nasal saline as beneficial adjunctive therapy for chronic rhinorrhea symptoms 2, 5
• Can be used as monotherapy or combined with pharmacotherapy 2

Allergen Immunotherapy

Consider allergen immunotherapy (subcutaneous or sublingual) for patients with documented specific IgE antibodies to relevant allergens who have inadequate symptom control despite optimal pharmacotherapy 1, 2, 5

• This is the only disease-modifying treatment that can alter the natural history of allergic rhinitis 1, 6
• Benefits may persist for years after discontinuation 1
• May prevent development of new allergen sensitivities and reduce future asthma risk 1, 2
• Typically not more costly than long-term pharmacotherapy over the projected treatment course 1

Critical Pitfalls to Avoid

Medication Errors

• Never use first-generation antihistamines due to significant sedation and performance impairment 2
• Limit topical decongestants to less than 10 days to prevent rhinitis medicamentosa (rebound congestion) 2, 5
• Avoid recurrent or long-term systemic corticosteroids due to significant adverse effects; reserve only for severe intractable symptoms unresponsive to all other treatments 2, 5

Administration Technique

• Instruct patients to direct intranasal corticosteroid spray AWAY from the nasal septum to prevent mucosal erosions and potential septal perforations 2
• Proper technique is essential for achieving full therapeutic dose 7

Treatment Duration

• Continue intranasal corticosteroids regularly throughout allergen exposure periods - do not stop when symptoms improve 7
• It may take several days to reach maximum effect, so consistent daily use is critical 7

When to Refer to Allergist/Immunologist

Refer patients when they experience: 2, 5

• Prolonged symptoms despite optimal pharmacotherapy
• Complications such as recurrent sinusitis, otitis media, or nasal polyposis
• Comorbid asthma or chronic sinusitis requiring coordinated management
• Need for repeated systemic corticosteroids
• Consideration for allergen immunotherapy

Environmental Control

Advise allergen avoidance for identified triggers (pollen, mold, dust mites, pet dander), though this is often inadequate for outdoor allergens causing seasonal symptoms 1, 5

• Complete avoidance is the most effective strategy for animal allergies when feasible 5