What is the treatment for chronic rhinitis (CR) in aeroallergy?

Treatment of Chronic Rhinitis in Aeroallergy

Intranasal corticosteroids are the most effective first-line monotherapy for chronic rhinitis due to aeroallergens and should be initiated immediately for moderate to severe symptoms, providing superior relief for all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Initial Treatment Algorithm

For Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, desloratadine) or an intranasal antihistamine (azelastine, olopatadine) 1, 3
• Second-generation antihistamines are strongly preferred over first-generation agents due to significantly less sedation and performance impairment 1, 2
• Intranasal antihistamines provide rapid onset of action and are equal to or superior to oral antihistamines for seasonal allergic rhinitis 1, 3

For Moderate to Severe Persistent Allergic Rhinitis

• Initiate intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as first-line therapy 1, 2, 4
• Intranasal corticosteroids may be started without prior trials of antihistamines or decongestants 5, 2
• For maximum efficacy, combine intranasal corticosteroid with intranasal antihistamine, which provides greater symptom relief than either agent alone 1, 2

Adjunctive and Alternative Therapies

Additional Pharmacologic Options

• Intranasal anticholinergics (ipratropium bromide) are highly effective specifically for rhinorrhea but have minimal effect on other nasal symptoms 5, 1
• Combining ipratropium with intranasal corticosteroids provides increased efficacy for rhinorrhea without additional adverse effects 5, 1
• Leukotriene receptor antagonists (montelukast) can be used alone or combined with antihistamines, though they are generally less effective than intranasal corticosteroids 2, 6
• Nasal cromolyn is less effective than intranasal corticosteroids but can reduce symptoms if initiated before they become severe, requiring 4 times daily administration 5, 2

Environmental Control Measures

• Implement allergen avoidance strategies even during early treatment, including staying indoors in air-conditioned environments during peak pollen seasons with windows and doors closed 5, 1
• For dust mite allergies, use humidity control, dust mite covers for bedding, HEPA vacuuming, and acaricides 1
• For animal allergies, complete avoidance is the most effective management 1

Advanced Treatment Considerations

Immunotherapy

• Consider allergen immunotherapy (subcutaneous or sublingual) for patients with inadequate response to pharmacotherapy or when knowledge of specific causative allergens is needed 5, 1
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with benefits persisting years after discontinuation 2
• It can prevent development of new allergen sensitivities and reduce future asthma risk 2

Systemic Corticosteroids

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

Critical Pitfalls to Avoid

Medication Errors

• Never use first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects 1, 3, 2
• Limit intranasal decongestants to less than 10 days to prevent rhinitis medicamentosa (rebound congestion) 1, 2
• Avoid oral antihistamines for nonallergic rhinitis as they are ineffective for this condition 5, 1

Administration Technique

• Direct intranasal corticosteroid sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations 5, 2
• Periodically examine the nasal septum to ensure no mucosal erosions are developing 5
• In children, use intranasal corticosteroids at the lowest effective dose 5

When to Refer to Allergist/Immunologist

Refer patients who have: 1, 2

• Prolonged manifestations not responding to standard therapy
• Complications such as nasal polyps, otitis media, or sinusitis
• Required systemic corticosteroids for symptom control
• Comorbid conditions like asthma or chronic sinusitis
• Need for consideration of allergen immunotherapy

Monitoring Treatment Response

Assess multiple parameters including: 5

• Nasal symptoms (congestion, itching, rhinorrhea, sneezing)
• Physical signs (edema of nasal turbinates)
• Quality of life measures (sleep quality, work/school function, driving ability)
• Control of concomitant conditions (asthma improvement often follows improved rhinitis control)