What is the recommended treatment algorithm for allergic rhinitis?

Allergic Rhinitis Treatment Algorithm

Start with an intranasal corticosteroid (fluticasone, mometasone, budesonide, or triamcinolone) as monotherapy for all patients with moderate-to-severe allergic rhinitis, as this is the most effective single medication class for controlling all major nasal symptoms. 1, 2, 3

Initial Treatment Selection by Severity

Mild Intermittent or Mild Persistent Disease

• Second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, or loratadine) OR intranasal antihistamine (azelastine or olopatadine) as first-line options 3
• These agents provide adequate symptom control for patients with less severe disease 3

Moderate-to-Severe or Persistent Disease

• Intranasal corticosteroid monotherapy is the strongly recommended first-line treatment 1, 2, 3
• Intranasal corticosteroids control all four major symptoms: nasal congestion, rhinorrhea, sneezing, and itching 2, 4
• Symptom improvement typically begins within 3 days of starting therapy 5
• Available agents include fluticasone propionate, mometasone furoate, budesonide, and triamcinolone acetonide 4, 3

Second-Line: Escalation for Inadequate Response

If Intranasal Corticosteroid Alone is Insufficient

• Add intranasal antihistamine (azelastine) to the intranasal corticosteroid for patients with persistent moderate-to-severe symptoms 1, 6, 2
• The combination of azelastine plus fluticasone provides 40% greater symptom reduction compared to either agent alone 6
• This combination is particularly effective for patients with ocular symptoms 6
• The 2017 Joint Task Force provides a weak recommendation for this combination due to concerns about cost, potential adverse effects (dysgeusia in 2-13% of patients, somnolence in 0.4-1.1%), and study bias 1, 6

What NOT to Add

• Do NOT add an oral antihistamine to an intranasal corticosteroid for initial treatment, as this provides no additional benefit for nasal symptom control 1, 2, 7
• The Joint Task Force issued a strong recommendation against this combination based on moderate-quality evidence showing no meaningful improvement 1

Alternative Monotherapy Options (Less Effective)

Leukotriene Receptor Antagonists

• Intranasal corticosteroids are superior to montelukast for controlling allergic rhinitis symptoms 1
• The Joint Task Force found high-quality evidence supporting intranasal corticosteroids over leukotriene receptor antagonists with a strong recommendation 1
• Reserve montelukast for patients who cannot tolerate intranasal medications or have concomitant asthma 8

Oral Antihistamines as Monotherapy

• Intranasal corticosteroids are more effective than oral antihistamines for moderate-to-severe disease 2, 7
• In comparative studies, loratadine showed no statistical difference from placebo for nasal symptom scores, while fluticasone propionate demonstrated significant improvement 7

Practical Implementation Details

Dosing and Administration

• Fluticasone propionate: 200 mcg once daily (can be given as 100 mcg twice daily, but once-daily dosing improves compliance) 5
• Once-daily morning administration is as effective as twice-daily dosing for most intranasal corticosteroids 5
• Combination azelastine-fluticasone: use as a single spray device when available 6

Common Adverse Effects to Counsel Patients About

• Nasal dryness, burning, stinging, and epistaxis occur in 5-10% of patients with intranasal corticosteroids 4
• Dysgeusia (bad taste) is the most common adverse effect with azelastine-containing products (2-13% of patients) 1, 6
• Somnolence with azelastine occurs in less than 1% of patients 1, 6
• These adverse effects do NOT include systemic corticosteroid effects when used intranasally 4, 5

Critical Pitfalls to Avoid

• Never use intramuscular or oral corticosteroids (like Kenalog injections) for routine management of allergic rhinitis; reserve systemic steroids only for severe, intractable cases unresponsive to all other treatments 2, 3
• Do not assume combination therapy is always superior; intranasal corticosteroid monotherapy is sufficient for most patients and avoids additional cost and side effects 1, 2
• Do not start with combination therapy in treatment-naive patients; begin with intranasal corticosteroid monotherapy and add intranasal antihistamine only if response is inadequate 1

Adjunctive Measures

• Educate patients to avoid known allergens when possible 3, 9
• Consider allergen immunotherapy (subcutaneous or sublingual) for patients with inadequate response to pharmacotherapy or those with concomitant allergic asthma 9