What is the first-line treatment for allergic rhinitis?

First-Line Treatment for Allergic Rhinitis

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

Treatment Algorithm Based on Disease 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. 3
• Second-generation antihistamines are preferred over first-generation agents due to significantly lower risk of sedation, performance impairment, and anticholinergic effects. 1
• Among non-sedating options, fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses, while cetirizine may cause sedation. 1, 4

Moderate to Severe Persistent Allergic Rhinitis

• Initiate treatment with an intranasal corticosteroid (fluticasone, triamcinolone, budesonide, mometasone) as monotherapy. 1, 3
• The Joint Task Force on Practice Parameters provides a strong recommendation against combining intranasal corticosteroids with oral antihistamines for initial treatment, as monotherapy with intranasal corticosteroids is sufficient. 1
• Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast), which should not be used as primary therapy. 1

When Immediate Symptom Relief is Required

• Use intranasal antihistamines as first-line treatment when rapid onset of action is needed. 4
• Intranasal antihistamines provide immediate symptom relief and are equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis. 1, 4
• Intranasal corticosteroids may take several days to reach maximum effect, making them less ideal when immediate relief is the priority. 4

Escalation for Inadequate Response

If Intranasal Corticosteroid Monotherapy Fails

• Add an intranasal antihistamine to the existing intranasal corticosteroid regimen for moderate to severe disease. 1, 4
• The combination of fluticasone propionate and azelastine shows >40% relative improvement compared to either agent alone. 4
• This combination therapy is supported by a weak recommendation from the Joint Task Force for initial treatment of moderate to severe seasonal allergic rhinitis. 1

Refractory Disease

• Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual). 5
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 5

Critical Dosing and Administration Details

Intranasal Corticosteroid Dosing

• Fluticasone propionate: Adults and children ≥12 years: 2 sprays per nostril once daily (200 mcg total); Children 4-11 years: 1 spray per nostril daily. 2
• Mometasone furoate: Adults and children ≥12 years: 2 sprays per nostril once daily (200 mcg total); Children 2-11 years: 1 spray per nostril daily. 2
• Triamcinolone acetonide: Children ≥2 years: 1 spray per nostril daily for ages 2-5 years. 2

Proper Administration Technique

• Prime the bottle before first use and shake prior to each use. 2
• Direct the spray away from the nasal septum using the contralateral hand technique (right hand for left nostril), which reduces epistaxis risk by four times. 2
• Keep head upright during administration and breathe in gently during spraying. 2

Important Caveats and Common Pitfalls

Onset of Action Expectations

• Intranasal corticosteroids may take 12 hours to several days to reach maximal efficacy—patients must be counseled to continue therapy for at least 2 weeks to properly assess benefit. 2, 4
• This delayed onset is the primary reason intranasal antihistamines may be preferred when immediate relief is needed. 4

Safety Profile

• Intranasal corticosteroids have no clinically significant effect on growth at recommended doses in children (fluticasone propionate, mometasone furoate, budesonide). 2
• Long-term use does not affect hypothalamic-pituitary-adrenal axis function or systemic cortisol levels. 2
• Common adverse effects include epistaxis (4-20%), headache, pharyngitis, and nasal irritation—all generally mild. 2, 6

Medications to Avoid

• First-generation antihistamines should be avoided due to significant sedation, performance impairment, and anticholinergic effects that are potentially dangerous. 1, 4
• Leukotriene receptor antagonists (montelukast) are significantly less effective than intranasal corticosteroids and should not be used as primary therapy. 1
• Oral decongestants should be used with extreme caution in patients with cardiac arrhythmia, angina, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1, 4

Duration of Treatment

• Intranasal corticosteroids can be used indefinitely when clinically indicated, with minimum treatment duration of 8-12 weeks to assess therapeutic benefit. 2
• For seasonal allergic rhinitis with predictable patterns, initiate treatment before symptom onset and continue throughout allergen exposure period. 2
• Periodic examination of the nasal septum is recommended during long-term use to detect mucosal erosions. 2