What is the treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids should be the first-line monotherapy for initial treatment of allergic rhinitis in patients aged 12 years or older, as they are the most effective single medication class for controlling all major symptoms including nasal congestion, rhinorrhea, sneezing, and itching. 1, 2

Initial Treatment Approach

First-Line Therapy for Most Patients

• Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are strongly recommended as monotherapy rather than combination therapy with oral antihistamines for initial treatment. 1
• These agents work directly in the nasal passages to block multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes) that cause allergic symptoms, providing superior efficacy compared to oral antihistamines that target histamine alone. 3
• Maximum efficacy requires several days of consistent daily use, so patients must understand this is not an immediate-relief medication. 3
• Critical technique: Patients must direct the spray away from the nasal septum to prevent mucosal erosions and potential septal perforation. 1, 2

Alternative First-Line Options for Mild Disease

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) may be used for patients with mild intermittent symptoms, particularly when sneezing, itching, and rhinorrhea predominate over nasal congestion. 2, 4
• First-generation antihistamines should be avoided due to sedation, performance impairment, and anticholinergic effects (dry mouth, urinary retention). 1, 5
• Intranasal antihistamines (azelastine, olopatadine) provide an effective alternative to oral antihistamines with faster onset but may cause sedation in some patients. 2, 4

Treatment Escalation for Inadequate Response

Combination Therapy

• For moderate to severe seasonal allergic rhinitis with inadequate response to intranasal corticosteroid monotherapy, add an intranasal antihistamine to the intranasal corticosteroid. 1, 2
• This combination provides greater efficacy than either agent alone, though the recommendation strength is weaker than for initial monotherapy. 1
• Intranasal anticholinergics (ipratropium) are particularly effective when rhinorrhea is the predominant symptom and can be combined with intranasal corticosteroids. 2

Medications to Avoid or Use Cautiously

• Oral decongestants (pseudoephedrine, phenylephrine) help nasal congestion but cause insomnia, irritability, and palpitations; monitor blood pressure in hypertensive patients. 1
• Topical nasal decongestants (oxymetazoline) must be limited to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 2, 5
• Oral corticosteroids should not be used for chronic rhinitis except in rare cases of severe intractable symptoms unresponsive to all other treatments, due to significant long-term adverse effects. 2, 6
• Leukotriene receptor antagonists (montelukast) are less effective than intranasal corticosteroids and should not be preferred over them. 1

Adjunctive Non-Pharmacologic Measures

• Nasal saline irrigation provides symptomatic benefit for chronic rhinorrhea and can be used as adjunctive therapy with any pharmacologic regimen. 2, 5
• Allergen avoidance should be implemented when specific triggers are identified, though this is often inadequate for outdoor allergens causing seasonal symptoms. 1

Special Populations

Children Ages 4-11 Years

• Use lower dosing: 1 spray per nostril once daily (versus up to 2 sprays in adults). 3
• Limit use to 2 months per year before consulting a physician, as long-term intranasal corticosteroids may slow growth rate in some children. 3

Competitive Athletes

• All intranasal corticosteroids are permitted by the International Olympic Committee and US Olympic Committee. 1
• All oral decongestants are banned except topical preparations (phenylephrine, oxymetazoline). 1
• Second-generation antihistamines are allowed but may be banned by specific sport federations. 1

When to Refer to Allergist/Immunologist

• Refer patients with prolonged severe disease, inadequate symptom control despite appropriate pharmacotherapy, comorbid asthma or recurrent sinusitis, or when considering allergen immunotherapy. 1, 2
• Allergen immunotherapy (subcutaneous or sublingual) is the only disease-modifying treatment that can alter the natural history of allergic rhinitis and may prevent development of new sensitizations and asthma. 1, 2, 7
• Immunotherapy should be considered for patients with demonstrable specific IgE antibodies to clinically relevant allergens who have inadequate response to pharmacotherapy. 2, 7

Common Pitfalls to Avoid

• Do not combine intranasal corticosteroid with oral antihistamine as initial therapy—monotherapy with intranasal corticosteroid is superior. 1
• Do not use antibiotics for allergic rhinitis, as they are ineffective and contribute to antimicrobial resistance. 5
• Do not allow patients to use topical decongestants beyond 3-5 days, as rhinitis medicamentosa develops rapidly. 2, 5
• Do not prescribe first-generation antihistamines due to sedation and impaired performance, especially in older adults and those operating machinery. 1, 5