What is the treatment for rhinitis?

Treatment for Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for both allergic and nonallergic rhinitis, providing superior relief for nasal congestion, rhinorrhea, sneezing, and itching compared to all other monotherapies. 1, 2

Treatment Algorithm Based on Rhinitis Type and Severity

Allergic Rhinitis

For mild intermittent or mild persistent allergic rhinitis:

• Start with second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) OR intranasal antihistamines (azelastine, olopatadine) 1, 3
• Second-generation antihistamines are strongly preferred over first-generation agents due to significantly less sedation and performance impairment 4, 1
• Oral antihistamines effectively reduce rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 5, 6

For moderate to severe persistent allergic rhinitis:

• Initiate intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as first-line therapy 4, 1, 3
• Intranasal corticosteroids can be started without prior trials of antihistamines or decongestants 2
• For maximum efficacy, combine intranasal corticosteroid with intranasal antihistamine—this combination provides greater symptom relief than either agent alone 4, 1, 7
• Maximum benefit may not be reached for several days, though some patients experience symptom reduction within 12 hours 8

Additional options for allergic rhinitis:

• Leukotriene receptor antagonists (montelukast) can be used alone or combined with antihistamines, though they are generally less effective than intranasal corticosteroids 1, 9
• Intranasal cromolyn sodium is effective with minimal side effects but less potent than corticosteroids; requires administration 4 times daily for optimal efficacy 4, 1

Nonallergic Rhinitis

First-line treatment approach:

• Start with intranasal corticosteroids as monotherapy OR intranasal antihistamines as monotherapy 10, 1
• For maximum efficacy in vasomotor rhinitis, combine intranasal corticosteroid with intranasal antihistamine 10
• Oral antihistamines should be avoided in nonallergic rhinitis as they have not been shown to be effective 4, 10, 1

Symptom-specific treatment:

• For predominant rhinorrhea: Intranasal anticholinergics (ipratropium bromide) are most effective and can be combined with intranasal corticosteroids for increased efficacy without additional adverse effects 4, 10, 1
• For gustatory rhinitis: Intranasal anticholinergics administered before meals 10
• For predominant congestion: Intranasal corticosteroids are the treatment of choice 10

Adjunctive Therapies and Environmental Control

Allergen and irritant avoidance:

• Implement empiric avoidance of suspected triggers (allergens, irritants, medications) even during early treatment 4, 2
• For severe seasonal allergic rhinitis, advise staying inside air-conditioned buildings with windows and doors closed 4
• Avoid tobacco smoke, strong odors, and extremes in temperature and humidity 4, 1

Nasal saline irrigation:

• Beneficial as adjunctive therapy for chronic rhinorrhea and rhinosinusitis 10, 1, 2

Decongestants:

• Oral decongestants (pseudoephedrine, phenylephrine) may reduce nasal congestion but use with caution in patients with hypertension, cardiac arrhythmias, glaucoma, hyperthyroidism, insomnia, or prostate hypertrophy 4, 10, 1
• Topical decongestants should only be used short-term (less than 3 days, maximum 10 days) to prevent rhinitis medicamentosa 10, 1

Special Situations

Rhinitis medicamentosa:

• Discontinue nasal decongestant sprays immediately 4, 10
• Treat with intranasal corticosteroids or, if necessary, a short course of systemic corticosteroids 4, 10

Allergen immunotherapy:

• Consider for patients with allergic rhinitis who have demonstrable specific IgE antibodies to clinically relevant allergens 4, 1
• This is the only disease-modifying intervention that can alter the natural history of allergic rhinitis and may prevent development of new allergen sensitivities and future asthma 1, 7
• Indicated for patients responding poorly to environmental control and optimal medical management 4

Critical Pitfalls to Avoid

Medication errors:

• Never use first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects 1
• Never use prolonged intranasal decongestants beyond 3-10 days to avoid rhinitis medicamentosa 10, 1
• Avoid recurrent administration of parenteral corticosteroids due to potential long-term side effects 1
• Do not prescribe oral antihistamines for nonallergic rhinitis as they are ineffective 4, 10, 1

Corticosteroid administration:

• When using intranasal corticosteroids, instruct patients to direct sprays away from the nasal septum to minimize mucosal erosions and potential septal perforations 10
• Perform periodic nasal septum examination during long-term intranasal corticosteroid use 10
• Oral corticosteroids should not be used for chronic rhinitis except for rare patients with severe intractable symptoms unresponsive to other treatments, and only as short courses (5-7 days) 10, 1

Step-Up and Step-Down Approach

Treatment escalation:

• Administer medications for 2 to 4 weeks to determine efficacy 4
• If initial medication does not sufficiently control symptoms, add or substitute another medication class 4
• Combination therapy may be particularly relevant when controlling nonnasal symptoms such as ocular or lower respiratory symptoms 4

When to Refer to Allergist/Immunologist

Referral criteria include: 4, 1, 2

• Prolonged manifestations not responding to standard therapy
• Complications such as nasal polyps, otitis media, or sinusitis
• Comorbid conditions like asthma or chronic sinusitis
• Requirement for systemic corticosteroids
• Symptoms or medication side effects interfering with sleep, work, or school performance
• Significantly decreased quality of life
• Diagnosis of rhinitis medicamentosa
• Need for allergen immunotherapy consideration
• Multiple and/or costly medications required over prolonged periods