What is the best course of treatment for a patient complaining of an allergic reaction with symptoms of throat tickle, sinus pressure, and cough, who has slightly elevated blood pressure but denies any history of blood pressure problems?

Treatment of Allergic Rhinitis with Throat Tickle, Sinus Pressure, and Cough

Start with a first-generation antihistamine/decongestant combination (such as dexbrompheniramine 6 mg or azatadine 1 mg plus sustained-release pseudoephedrine 120 mg, both twice daily) as the initial empiric therapy for this patient's upper airway cough syndrome (UACS) secondary to allergic rhinitis. 1

Initial Treatment Approach

• First-generation antihistamine/decongestant (A/D) combinations are the evidence-based first-line treatment for UACS-induced cough when the specific etiology is not immediately apparent, with expected improvement within days to 2 weeks. 1

• The combination works through both antihistaminic effects (mitigating mast-cell degranulation) and vasoconstriction (limiting secretory response and inflammatory cell access), with the anticholinergic properties of first-generation antihistamines being particularly effective for non-histamine-mediated rhinitis. 1

• Newer generation antihistamines (such as terfenadine or loratadine) have been shown to be ineffective for treating acute cough associated with this type of rhinitis and should not be used as monotherapy for cough symptoms. 1

Alternative and Adjunctive Therapies

• Intranasal corticosteroids (such as fluticasone propionate 200 mcg daily or mometasone furoate) should be added if symptoms persist after initial A/D therapy or can be used as first-line therapy for persistent moderate-to-severe allergic rhinitis. 2, 3, 4

• Intranasal corticosteroids demonstrate maximum effect within several days, with some symptom relief occurring as early as 12 hours after the first 200-mcg dose. 3

• Leukotriene blockers have been shown to decrease symptoms of allergic rhinitis and can be considered as adjunctive therapy, though they should not be offered as primary monotherapy. 1, 2

• Nasal cromolyn, nasal antihistamines (azelastine, olopatadine), or ipratropium bromide nasal spray may be added if response to A/D therapy is incomplete. 1, 4

Management of Slightly Elevated Blood Pressure

• The slightly elevated blood pressure is likely related to the allergic rhinitis itself rather than a contraindication to treatment. Nasal congestion causes hypoxia and sympathetic system activation, which can increase blood pressure levels. 5

• Treatment of allergic rhinitis with intranasal corticosteroids (specifically mometasone furoate) has been shown to significantly decrease daytime systolic blood pressure (120 vs. 117 mmHg, p=0.024), diastolic blood pressure (73 vs. 71 mmHg, p=0.027), and mean blood pressure (86 vs. 83 mmHg, p=0.007) in patients with allergic rhinitis. 5

• Avoid using decongestants if blood pressure remains persistently elevated (>140/90 mmHg), as pseudoephedrine can cause vasoconstriction and further elevate blood pressure. In such cases, use intranasal corticosteroids alone or with intranasal antihistamines. 4

Expected Timeline and Follow-up

• Expect at least some noticeable improvement in cough within days to 1-2 weeks of initiating A/D therapy, with marked improvement or complete resolution potentially taking several weeks to a few months. 1

• If resolution is only partial after 1-2 weeks, add topical nasal corticosteroid therapy while continuing the A/D combination. 1

• If symptoms persist beyond 10 days or worsen after initial improvement, consider sinus imaging to evaluate for acute bacterial rhinosinusitis, which would require antibiotic therapy. 1, 6

Critical Pitfalls to Avoid

• Do not use second-generation antihistamines alone for cough symptoms associated with UACS, as they lack the anticholinergic properties necessary to reduce secretions and have been proven ineffective in controlled studies. 1

• Do not delay treatment waiting for allergy testing—empiric therapy should be initiated immediately based on clinical presentation, with allergy testing reserved for cases where diagnosis is uncertain or empiric treatment fails. 2

• The 2-3 day symptom duration is too short to represent bacterial sinusitis, which requires either symptoms persisting ≥10 days, worsening within 10 days after initial improvement, or severe symptoms (fever >39°C with purulent discharge and facial pain) in the first 3-4 days. 6

• Monitor blood pressure during treatment, as appropriate therapy for allergic rhinitis may actually improve blood pressure control rather than worsen it. 5