What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

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

Treatment Algorithm by Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) OR an intranasal antihistamine (azelastine, olopatadine) as monotherapy. 2
• Oral second-generation antihistamines are particularly effective when the primary complaints are sneezing and itching rather than congestion. 1
• Intranasal antihistamines may be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis. 1

Moderate to Severe Persistent Allergic Rhinitis

• Begin treatment with an intranasal corticosteroid (fluticasone, mometasone, budesonide, triamcinolone) as monotherapy. 1, 2
• Intranasal corticosteroids are superior to leukotriene receptor antagonists for initial treatment, with high-quality evidence supporting this recommendation. 3
• These agents work by blocking multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes) rather than histamine alone, providing more comprehensive symptom control. 4
• Maximum effect may take several days, so regular daily use is essential even when symptoms improve. 4

Refractory Disease Requiring Combination Therapy

• For patients with inadequate response to intranasal corticosteroid monotherapy, add an intranasal antihistamine to create combination therapy. 1
• The combination of intranasal corticosteroid plus intranasal antihistamine shows greater symptom reduction than either agent alone for moderate to severe seasonal allergic rhinitis. 1
• Do NOT routinely add oral antihistamines to intranasal corticosteroids for initial treatment, as there is moderate-quality evidence showing no additional benefit from this combination. 3

Adjunctive and Alternative Therapies

Additional Pharmacologic Options

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy but are generally less effective than intranasal corticosteroids. 1
• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 1
• 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. 1

Immunotherapy for Refractory Cases

• Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual). 1
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 1

Short-term Systemic 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. 1

Critical Dosing and Duration Guidelines

Adults and Children ≥12 Years

• Intranasal corticosteroids: up to 2 sprays in each nostril once daily. 4
• Maximum duration before checking with a doctor: 6 months of daily use. 4

Children Ages 4-11 Years

• Use lower dose: 1 spray in each nostril once daily (not 2 sprays). 4
• Maximum duration before checking with a doctor: 2 months of use per year. 4
• This precaution exists because long-term intranasal corticosteroids may slow growth rate in some children, though the effect on ultimate adult height is unknown. 4

Common Pitfalls and Safety Considerations

Adverse Effects to Monitor

• Dysgeusia (altered taste) is the most common adverse event with intranasal corticosteroids and antihistamines, occurring in 2.1% to 13.5% of patients. 1
• Local nasal effects include dryness, burning, stinging, sneezing, and epistaxis in 5-10% of patients regardless of formulation. 5
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating. 1

Medication Precautions

• Oral decongestants (pseudoephedrine, phenylephrine) should be used with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1
• Intranasal corticosteroids do not increase blood pressure when used as directed. 4

Essential Clinical Practices

• Always assess for associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1
• Do not perform routine sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1
• Advise patients to avoid known allergens or implement environmental controls when specific allergens correlate with clinical symptoms. 1
• Continue intranasal corticosteroids regularly as long as patients are exposed to allergens, even when symptoms improve, to maintain relief. 4

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