Preventing Recurrent Allergic Rhinitis
For patients with recurrent allergic rhinitis, continuous daily intranasal corticosteroid therapy combined with allergen avoidance and consideration of immunotherapy for inadequate responders represents the most effective prevention strategy. 1
Primary Prevention Strategy: Continuous Pharmacologic Therapy
Intranasal corticosteroids should be used continuously throughout allergen exposure periods rather than intermittently, as they are the most effective monotherapy for preventing symptom recurrence and maintaining disease control. 2, 3 This approach is particularly important for patients with persistent allergic rhinitis (symptoms >4 consecutive days/week and >4 consecutive weeks/year), where ongoing allergen exposure is unavoidable. 4, 5
- For patients aged 12 years and older: Use up to 2 sprays in each nostril once daily continuously during allergen exposure periods, with physician consultation if daily use exceeds 6 months. 6
- For children aged 4-11 years: Use 1 spray in each nostril once daily, with physician consultation if use exceeds 2 months per year due to potential effects on growth rate. 6
Second-generation antihistamines may be used continuously for mild persistent symptoms as an alternative or adjunct to intranasal corticosteroids, particularly when sneezing and itching predominate. 2, 4 Continuous treatment is preferred over intermittent use because it maintains therapeutic levels and prevents symptom breakthrough. 4
Allergen Avoidance and Environmental Controls
Clinicians should advise specific environmental controls for patients with identified allergens that correlate with clinical symptoms, though the evidence for their efficacy varies. 1
- For pollen allergies: Keep windows and doors closed during high pollen seasons, avoid outdoor activities when pollen counts are elevated, and use air conditioning rather than attic fans. 1
- For dust mite allergies: Consider removal of carpeting, use of air filtration systems, allergen-impermeable bed covers, and acaricides (chemical agents to kill dust mites). 1
- For pet allergies: Remove pets from the home when feasible, or at minimum exclude them from bedrooms. 1
A critical caveat: While environmental controls are recommended, evidence does not strongly support the efficacy of mite-proof mattress covers, air filtration systems alone, or delayed exposure to pets in childhood for primary prevention. 7 These measures should supplement, not replace, pharmacologic therapy.
Immunotherapy: The Only Disease-Modifying Treatment
Allergen immunotherapy (subcutaneous or sublingual) should be offered or referred for patients who have inadequate response to pharmacologic therapy with or without environmental controls, as it is the only treatment that can alter the natural history of allergic rhinitis and prevent recurrence long-term. 1, 2
- Immunotherapy can prevent development of new allergen sensitivities and reduce the risk of future asthma development, particularly in children. 1, 2
- Clinical benefits may persist for years after discontinuation of treatment. 3
- Immunotherapy should be tailored to the specific causative allergen identified through IgE testing (skin or blood). 1
Diagnostic Approach to Guide Prevention
Specific IgE allergy testing (skin or blood) should be performed or referred when patients do not respond to empiric treatment, when diagnosis is uncertain, or when knowledge of specific causative allergens is needed to target prevention strategies. 1, 2
This testing is essential because:
- It identifies specific allergens to avoid
- It guides immunotherapy selection
- It distinguishes allergic from nonallergic rhinitis (which requires different management)
Assessment and Management of Comorbidities
Clinicians must assess and document associated conditions that can worsen allergic rhinitis or be worsened by it, including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1
- Over 50% of patients with asthma have allergic rhinitis, and treatment of allergic rhinitis with intranasal corticosteroids can improve asthma control and reduce bronchial hyperreactivity. 1
- Children with early atopic dermatitis have increased risk of developing allergic rhinitis and asthma (the "allergic march"), making aggressive rhinitis treatment particularly important. 1
Combination Therapy for Inadequate Response
For patients with inadequate response to intranasal corticosteroid monotherapy, combination pharmacologic therapy should be offered, particularly combining intranasal corticosteroid with intranasal antihistamine. 1, 2
- This combination provides greater efficacy than either agent alone for moderate to severe symptoms. 2
- Oral antihistamines can be added for breakthrough symptoms, but should not replace intranasal corticosteroids as primary therapy. 1
Critical Pitfalls to Avoid
Do not use oral leukotriene receptor antagonists as primary prevention therapy, as they are less efficacious than intranasal corticosteroids. 1, 2
Avoid prolonged use of intranasal decongestants beyond 10 days, as this leads to rhinitis medicamentosa (rebound congestion) that worsens the underlying condition. 2, 3, 6
Do not use oral corticosteroids for routine prevention due to significant long-term adverse effects; reserve these only for rare patients with severe intractable symptoms unresponsive to all other treatments. 2, 3
Ensure proper intranasal corticosteroid technique: Direct the spray away from the nasal septum to prevent mucosal erosions and potential septal perforations. 2, 3
When to Refer to Specialist
Referral to an allergist/immunologist should be considered for patients who have required systemic corticosteroids, have inadequately controlled symptoms despite appropriate treatment, or are being considered for allergen immunotherapy. 2, 3