Treatment of Allergic Rhinitis
Intranasal corticosteroids are the first-line treatment for allergic rhinitis, as they are the most effective agents for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itching. 1
First-Line Pharmacotherapy
Intranasal Corticosteroids (Preferred Initial Treatment)
Intranasal corticosteroids should be used as monotherapy for initial treatment of allergic rhinitis, particularly for patients with moderate to severe symptoms or those whose quality of life is significantly affected. 1
These agents work directly in the nasal mucosa to block multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes, chemokines) rather than just histamine alone, providing superior symptom control compared to oral antihistamines. 2
Common intranasal corticosteroids include fluticasone propionate, mometasone furoate, budesonide, and triamcinolone acetonide. 3, 4
Maximum therapeutic effect may take several days to develop, so patients should be counseled to use these medications regularly and continuously during allergen exposure rather than on an as-needed basis. 2
Dosing Considerations
Adults and children ≥12 years: Up to 2 sprays per nostril once daily. 2
Children ages 4-11 years: 1 spray per nostril once daily, with use limited to 2 months per year before consulting a physician due to potential effects on growth rate. 2
Second-Line Monotherapy Options
Oral Second-Generation Antihistamines
Oral second-generation antihistamines (loratadine, desloratadine, cetirizine, fexofenadine) should be recommended for patients whose primary complaints are sneezing and itching, particularly those with mild intermittent symptoms. 1, 4
These agents are less effective than intranasal corticosteroids for nasal congestion but may be preferred by some patients for convenience. 4, 5
Cetirizine and some intranasal antihistamines may cause sedation at recommended doses, while other second-generation agents are generally non-sedating. 1
Intranasal Antihistamines
Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative for patients with seasonal, perennial, or episodic allergic rhinitis. 1, 4
These provide faster onset of action than intranasal corticosteroids but are generally less effective for comprehensive symptom control. 4
Combination Therapy for Inadequate Response
When to Escalate
Combination therapy should be considered for moderate to severe allergic rhinitis that doesn't respond adequately to monotherapy. 1
The 2017 Joint Task Force found that adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit and is not recommended. 6
Intranasal Corticosteroid + Intranasal Antihistamine
The combination of an intranasal corticosteroid with an intranasal antihistamine may be recommended for initial treatment of moderate to severe seasonal allergic rhinitis, showing greater symptom reduction than either agent alone. 1
This combination was found more effective than monotherapy in high-quality evidence, though the recommendation is weak due to concerns about increased adverse effects including dysgeusia (altered taste in 2.1-13.5% of patients) and potential somnolence. 6, 1
Comparison with Leukotriene Receptor Antagonists
Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast) for allergic rhinitis treatment based on high-quality evidence. 6
Leukotriene receptor antagonists (montelukast 10 mg once daily) may be used as adjunctive therapy but are generally less effective than intranasal corticosteroids. 1
Additional Adjunctive Therapies
For Persistent Rhinorrhea
- 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
Nasal Saline Irrigation
- Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 1
Immunotherapy for Refractory Disease
Patients with inadequate response to pharmacologic therapy should be referred for consideration of allergen immunotherapy (subcutaneous or sublingual). 1
Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk in patients with allergic rhinitis. 1
Important Caveats and Pitfalls
Medication Safety
Patients taking HIV medications (ritonavir), antifungal medications (ketoconazole), or other systemic corticosteroids should consult their physician before using intranasal corticosteroids due to potential drug interactions that may increase systemic corticosteroid levels. 2
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
Pediatric Considerations
- Long-term use of intranasal corticosteroids in children ages 4-11 may slow growth rate, though whether this affects ultimate adult height is unknown; use the shortest duration necessary for symptom control. 2
Associated Conditions
Always assess for associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media in patients with allergic rhinitis. 1
Routine sinonasal imaging is not recommended in patients presenting with symptoms consistent with allergic rhinitis. 1