What are the treatment options for rhinitis?

Treatment Options for Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for moderate to severe rhinitis, both allergic and nonallergic, and should be initiated without requiring prior trials of antihistamines or decongestants. 1, 2

Treatment Algorithm by Severity and Type

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are preferred as first-line therapy due to significantly less sedation and performance impairment compared to first-generation agents 1, 2, 3
• Intranasal antihistamines (azelastine, olopatadine) are equally effective alternatives with efficacy equal to or superior to oral antihistamines for seasonal allergic rhinitis 2, 3

Moderate to Severe Persistent Allergic Rhinitis

• Combination therapy with intranasal corticosteroid plus intranasal antihistamine provides superior efficacy compared to either agent alone and is the recommended approach 1, 2
• Intranasal corticosteroids as monotherapy (fluticasone, triamcinolone, budesonide, mometasone) remain highly effective if combination therapy is not feasible 1, 2, 3
• Oral anti-leukotriene agents (montelukast) can be added to antihistamines but are generally less efficacious than intranasal corticosteroids 1, 2

Nonallergic Rhinitis

• Intranasal corticosteroids and intranasal antihistamines are first-line treatments, as oral antihistamines are ineffective for nonallergic rhinitis since the mechanism is not histamine-mediated 2, 3, 4
• Intranasal anticholinergics (ipratropium bromide 0.03%) are particularly effective for rhinorrhea but have no effect on other nasal symptoms 1, 2, 4
• The FDA-approved dosing for ipratropium bromide 0.06% is two sprays (84 mcg) per nostril three to four times daily for rhinorrhea 5
• Combination of ipratropium bromide with intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea 2, 6

Adjunctive and Supportive Therapies

Nasal Saline

• Topical saline irrigation is beneficial for chronic rhinorrhea and rhinosinusitis symptoms when used alone or as adjunctive treatment 1, 2, 4

Allergen Immunotherapy

• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with benefits persisting years after discontinuation 1, 2
• It can prevent development of new allergen sensitivities and reduce future asthma risk in patients with allergic rhinitis 1
• Should be considered for patients with demonstrable specific IgE antibodies to clinically relevant allergens 1, 2

Oral Decongestants

• Pseudoephedrine and phenylephrine can reduce nasal congestion but should be used cautiously in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 2

Less Effective Options

• Intranasal cromolyn sodium has minimal side effects but is less effective than corticosteroids and requires frequent dosing 1, 2

Critical Pitfalls to Avoid

Medication Errors

• Never use first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects 1, 2
• Limit intranasal decongestants to less than 10 days to prevent rhinitis medicamentosa (rebound congestion) 1, 2
• Avoid recurrent parenteral or oral corticosteroids due to long-term systemic side effects; they are contraindicated except for rare severe intractable cases 1, 2
• Do not prescribe oral antihistamines for nonallergic rhinitis as they are ineffective when histamine is not the mediator 2, 6

Administration Technique

• Direct intranasal corticosteroid spray away from the nasal septum to prevent mucosal erosions and potential septal perforations 1

Environmental Control Measures

• Empiric avoidance of suspected allergens and irritants should be implemented early in treatment 1, 2
• For dust mite allergies, combine humidity control, dust mite covers for bedding, HEPA vacuuming, and acaricides 2
• For animal allergies, complete avoidance is most effective 2
• Avoid tobacco smoke, formaldehyde, and other irritants for irritant-triggered rhinitis 2

When to Refer to Allergist/Immunologist

• Prolonged manifestations not responding to standard therapy 1, 2
• Complications including nasal polyps, otitis media, sinusitis, or eustachian tube dysfunction 1, 2
• Comorbid conditions like asthma or chronic sinusitis 1
• When systemic corticosteroids have been required 1, 2
• Consideration of allergen immunotherapy 2
• Inadequately controlled symptoms with reduced quality of life or functional capacity 1

Special Populations

Postprandial/Gustatory Rhinitis

• Intranasal ipratropium bromide 0.03% is the most effective first-line treatment, specifically targeting cholinergic-mediated rhinorrhea triggered by eating hot or spicy foods 6
• Oral antihistamines are ineffective for this subtype 6

Pediatric Patients (Ages 5-11)

• For common cold-associated rhinorrhea, ipratropium bromide 0.06% dosing is two sprays per nostril three times daily (total 504 mcg/day) 5
• For seasonal allergic rhinitis, dosing is two sprays per nostril four times daily (total 672 mcg/day) 5
• Safety and effectiveness in children under 5 years have not been established 5