What is the recommended treatment for chronic allergic rhinitis?

Treatment of Chronic Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for chronic allergic rhinitis, as they are the most effective medication class for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Treatment Algorithm by Severity

Mild Persistent Symptoms

• Start with intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) as first-line therapy, administered once daily. 1, 3
• Alternatively, oral second-generation antihistamines (loratadine, cetirizine, fexofenadine, desloratadine) may be used if the primary complaints are sneezing and itching rather than congestion. 1, 3
• Intranasal antihistamines (azelastine, olopatadine) can be offered as an alternative first-line option and are equal to or superior to oral antihistamines for nasal symptoms. 4, 1

Moderate to Severe Persistent Symptoms

• Begin with intranasal corticosteroids as monotherapy, which are more effective than oral antihistamines or leukotriene receptor antagonists for all nasal symptoms, particularly congestion. 2
• If inadequate response to intranasal corticosteroids alone, add an intranasal antihistamine for combination therapy, which provides greater symptom reduction than either agent alone. 1, 2
• The combination of intranasal corticosteroid plus intranasal antihistamine may be considered as initial treatment for moderate to severe disease. 1

Additional Treatment Options

Adjunctive Therapies

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used alone or combined with antihistamines, though they are generally less effective than intranasal corticosteroids. 4, 5
• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 4
• Intranasal ipratropium bromide effectively reduces rhinorrhea but has no effect on other nasal symptoms; combining it with intranasal corticosteroids is more effective than either alone. 4

Ocular Symptoms

• If ocular symptoms (itching, tearing, redness) are prominent, add topical ophthalmic agents (azelastine, olopatadine, ketotifen, or epinastine), which are more effective than oral antihistamines for eye symptoms. 2
• Simple measures like cold compresses and refrigerated artificial tears provide symptomatic relief. 2

Refractory Disease Management

Immunotherapy Referral

• Refer patients with inadequate response to pharmacologic therapy for consideration of allergen immunotherapy (subcutaneous or sublingual), which is effective for allergic rhinitis treatment. 1, 4
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk in patients with allergic rhinitis. 4

Short-term Oral Corticosteroids

• A short 5-7 day course of oral prednisone may be appropriate only for very severe or intractable symptoms that significantly impact quality of life. 4, 6
• Single or recurrent parenteral corticosteroid administration is contraindicated due to greater potential for long-term side effects including adrenal suppression. 4, 6

Important Caveats and Pitfalls

Medication Selection Considerations

• Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects. 2
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating. 4
• Oral antihistamines can worsen dry eye syndrome and potentially exacerbate allergic conjunctivitis. 2

Decongestant Precautions

• Use oral decongestants (pseudoephedrine, phenylephrine) with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 4

Corticosteroid Safety

• Intranasal corticosteroids have minimal systemic effects; the most common adverse event is dysgeusia (altered taste) occurring in 2.1-13.5% of patients. 1
• Local nasal side effects (dryness, burning, epistaxis) occur in 5-10% of patients regardless of formulation. 7
• Ocular corticosteroids should be reserved for severe symptoms only due to vision-threatening side effects including cataracts, elevated intraocular pressure, and secondary infections. 2

Associated Conditions

• Always assess for comorbid conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1
• Do not routinely order sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1