How to manage allergic rhinitis?

Management of Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be initiated for patients with moderate to severe symptoms affecting quality of life. 1, 2

Initial Treatment Selection Based on Severity

For Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) as first-line therapy for patients whose primary complaints are sneezing, itching, and rhinorrhea 1, 2, 3
• Second-generation antihistamines are strongly preferred over first-generation agents (diphenhydramine, chlorpheniramine) because first-generation antihistamines cause significant sedation, performance impairment that patients may not subjectively perceive, and anticholinergic effects including dry mouth and urinary retention 1, 4
• Intranasal antihistamines (azelastine, olopatadine) are equally effective alternatives to oral antihistamines and may be offered as first-line monotherapy 2, 3

For Moderate to Severe Persistent Allergic Rhinitis

• Initiate intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as the single most effective medication class for controlling all four cardinal symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1, 2, 3
• Intranasal corticosteroids may be started without requiring a prior trial of antihistamines or decongestants 1, 5
• For optimal efficacy, continuous daily treatment is superior to intermittent use because of unavoidable ongoing allergen exposure in seasonal or perennial allergic rhinitis 1

Combination Therapy for Inadequate Response

• Combine intranasal corticosteroid with intranasal antihistamine when monotherapy fails to adequately control symptoms, as this combination provides greater efficacy than either agent alone 1, 2, 5
• Adding an oral antihistamine to intranasal corticosteroids is an alternative combination approach for patients with inadequate response to monotherapy 1
• The concomitant use of intranasal ipratropium (anticholinergic) with intranasal corticosteroids is more effective than either drug alone specifically for treating rhinorrhea 6, 2, 5

Additional Pharmacologic Options

Leukotriene Receptor Antagonists (Montelukast)

• Oral leukotriene receptor antagonists have proven useful in treating allergic rhinitis, either alone or combined with antihistamines 1, 2
• However, leukotriene receptor antagonists should NOT be offered as primary therapy for allergic rhinitis, as they are generally less efficacious than intranasal corticosteroids 1
• When combined with antihistamines, the effect may be additive, though not all studies demonstrate this benefit 1

Decongestants

• Oral decongestants (pseudoephedrine, phenylephrine) reduce nasal congestion in both allergic and nonallergic rhinitis and are beneficial when combined with antihistamines 1, 2
• Monitor hypertensive patients when using oral decongestants, though blood pressure elevation is very rarely noted in normotensive patients and only occasionally in those with controlled hypertension 1
• Topical decongestants should be limited to short-term use (maximum 3 days) to avoid rhinitis medicamentosa (rebound congestion), though some patients may develop this condition in as little as 3 days while others tolerate 4-6 weeks of use 1, 2

Nasal Cromolyn

• Nasal cromolyn is less effective than intranasal corticosteroids but can reduce symptoms in some patients when initiated before symptoms become severe 1, 2, 5
• Requires administration 4 times daily for maximum efficacy 1

Systemic Corticosteroids

• A short course (5-7 days) of oral corticosteroids may be appropriate only for very severe or intractable rhinitis or nasal polyposis 1, 6, 5
• Single-dose parenteral corticosteroids are discouraged, and recurrent parenteral corticosteroid administration is contraindicated due to greater potential for long-term systemic side effects 1, 2, 5

Allergen Avoidance and Environmental Controls

• Implement empiric avoidance of suspected allergens, irritants, and triggering medications even during early treatment 1, 5
• For severe seasonal allergic rhinitis, advise patients to stay inside air-conditioned buildings with windows and doors closed whenever possible 1
• Avoidance is the most effective management for animal allergies 6, 2
• For dust mite allergies, use a combination of humidity control, dust mite covers for bedding, HEPA vacuuming, and acaricides 2
• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea and rhinosinusitis 2, 5

Allergen Immunotherapy

• Offer immunotherapy (sublingual or subcutaneous) to patients with inadequate response to pharmacologic therapy with or without environmental controls 1, 6, 2
• Immunotherapy should be considered for patients with demonstrable evidence of specific IgE antibodies to clinically relevant allergens 1, 2, 5
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with clinical benefits maintained years after discontinuation 5
• Immunotherapy may prevent development of new allergen sensitivizations and reduce future asthma risk in patients with allergic rhinitis 5

Critical Pitfalls to Avoid

• Never use first-generation antihistamines as they cause significant sedation, performance impairment, and anticholinergic effects that outweigh any benefits 1, 2, 4
• Avoid prolonged intranasal decongestant use beyond 3-10 days to prevent rhinitis medicamentosa 1, 2, 5
• Do not use recurrent parenteral corticosteroids due to long-term systemic side effect risks 1, 2, 5
• Instruct patients to direct intranasal corticosteroid sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations 1, 5
• Periodically examine the nasal septum in patients using intranasal corticosteroids to ensure no mucosal erosions are developing 1
• In children, use intranasal corticosteroids at the lowest effective dose 1

When to Refer to Allergist/Immunologist

• Prolonged rhinitis manifestations not responding to standard therapy 2, 5
• Need for specific IgE testing (skin or blood) when diagnosis is uncertain or when knowledge of specific causative allergen is needed to target therapy 1
• Development of complications such as nasal polyps, otitis media, or sinusitis 2, 5
• Comorbid conditions like asthma or chronic sinusitis requiring coordinated management 2, 5
• When systemic corticosteroids have been required 2, 5
• Consideration of allergen immunotherapy 2, 5

Assessment of Concomitant Conditions

• Always assess and document associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Improved control of rhinitis may be associated with improvement of concomitant conditions, particularly asthma 1, 5