What is the treatment for allergic rhinitis?

Treatment for Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be initiated as monotherapy for patients with moderate-to-severe or persistent symptoms. 1, 2, 3

Treatment Algorithm Based on Severity

Mild Intermittent Allergic Rhinitis (symptoms <4 days/week or <4 weeks/year)

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) OR an intranasal antihistamine (azelastine, olopatadine) 3
• Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation, performance impairment, and anticholinergic effects 1, 2
• Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses, while cetirizine and intranasal azelastine may cause sedation 1, 2
• Intranasal antihistamines provide rapid onset of action (within hours) and are equal to or superior to oral antihistamines for nasal congestion 1, 2

Moderate-to-Severe or Persistent Allergic Rhinitis (symptoms >4 days/week and >4 weeks/year)

• Begin with intranasal corticosteroid monotherapy (fluticasone, mometasone, triamcinolone, budesonide) 1, 2, 4, 3
• Intranasal corticosteroids are more effective than oral antihistamines for controlling all four major symptoms: nasal congestion, rhinorrhea, sneezing, and nasal itching 1, 2
• Maximum efficacy may take several days to weeks, so counsel patients to continue therapy for at least 2 weeks before assessing benefit 4
• Common dosing: fluticasone 200 mcg once daily (2 sprays per nostril), mometasone 200 mcg once daily (2 sprays per nostril for adults ≥12 years) 4

Inadequate Response to Intranasal Corticosteroid Alone

• Add intranasal antihistamine (azelastine) to the existing intranasal corticosteroid 1, 2
• The combination of fluticasone propionate plus azelastine provides >40% greater symptom reduction compared to either agent alone 1
• In clinical trials, symptom score reductions were: placebo -2.2 to -3.03, azelastine alone -3.25 to -4.54, fluticasone alone -3.84 to -5.1, and combination therapy -5.31 to -5.7 (out of 24 total points) 1
• This recommendation is graded as weak due to added cost and potential for adverse effects, but represents the best option when monotherapy fails 1

Specific Medication Considerations

Intranasal Corticosteroids

• All intranasal corticosteroids are safe for long-term use with no clinically significant effects on hypothalamic-pituitary-adrenal axis function, growth (at recommended doses), or intraocular pressure 4, 5
• Most common adverse effects: epistaxis (5-10%), nasal irritation, headache 4, 5
• Direct spray away from nasal septum to minimize epistaxis and risk of septal perforation 4
• Fluticasone propionate demonstrates clinical efficacy within 24 hours of first dose 6

Oral Antihistamines

• Second-generation agents are strongly preferred: fexofenadine, loratadine, desloratadine (non-sedating); cetirizine (may cause sedation) 1, 2
• Less effective for nasal congestion compared to intranasal corticosteroids 2, 3
• First-generation antihistamines should be avoided due to significant sedation, performance impairment, and anticholinergic effects 1, 2

Leukotriene Receptor Antagonists (Montelukast)

• Not recommended as primary therapy for allergic rhinitis 2, 7, 8
• Significantly less effective than intranasal corticosteroids 2
• May be used as adjunctive therapy in patients with concomitant asthma 1

Intranasal Anticholinergics (Ipratropium Bromide)

• Effective specifically for rhinorrhea but has no effect on other nasal symptoms (congestion, sneezing, itching) 1, 9
• Can be combined with intranasal corticosteroid for additive benefit without increased adverse events 1

Oral Decongestants

• Use with extreme caution in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 1, 2
• Not recommended for routine use due to systemic side effects 1

Topical Decongestants

• Limit use to maximum 3 days to avoid rhinitis medicamentosa (rebound congestion) 2, 4, 7

Adjunctive Therapies

Nasal Saline

• Beneficial as adjunctive treatment for chronic rhinorrhea when used alone or combined with other therapies 1, 9
• Should be performed prior to administering intranasal corticosteroid 4

Allergen Immunotherapy

• Consider for patients with inadequate symptom control despite optimal pharmacotherapy 1
• Effective for long-term treatment and may prevent development of new allergen sensitizations and reduce future asthma risk 1
• Requires demonstrable evidence of specific IgE antibodies to clinically relevant allergens 1

Critical Pitfalls to Avoid

• Do not prescribe short courses of oral corticosteroids routinely; reserve only for very severe or intractable symptoms (5-7 days maximum) 1
• Never use recurrent parenteral corticosteroids due to risk of long-term systemic side effects 1
• Do not discontinue intranasal corticosteroids when symptoms improve; these are maintenance medications, not rescue therapy 4
• Ensure proper nasal spray technique is taught to maximize efficacy and minimize local side effects 4
• Do not expect immediate results from intranasal corticosteroids; counsel patients that full benefit requires 2 weeks of consistent use 4

Environmental Control Measures

• Allergen avoidance is fundamental to successful management 7, 3
• For dust mites: use HEPA vacuuming, dust mite covers for bedding, humidity control, and acaricides 1
• For pollen: limit outdoor exposure during high pollen counts 1
• For mold: remove moisture sources, replace contaminated materials, use dilute bleach on nonporous surfaces 1
• Complete avoidance is most effective for animal sensitivity 1
• Avoid irritants such as tobacco smoke and formaldehyde 1

When to Refer to Allergist/Immunologist

• Consider referral for: inadequately controlled symptoms, reduced quality of life, adverse medication reactions, desire for allergen identification and environmental control advice, comorbid conditions (asthma, recurrent sinusitis), or when immunotherapy is being considered 1