What is the treatment for allergic rhinitis with chronic cough?

Treatment for Allergic Rhinitis with Chronic Cough

For allergic rhinitis with chronic cough, initiate treatment with an intranasal corticosteroid (such as fluticasone propionate or budesonide) combined with a first-generation antihistamine/decongestant (such as dexbrompheniramine 6 mg or azatadine 1 mg plus pseudoephedrine 120 mg, both twice daily), and once the cough resolves, continue the intranasal corticosteroid alone for 3 months to prevent recurrence. 1, 2

Initial Treatment Strategy

When allergic rhinitis presents with chronic cough (upper airway cough syndrome), the treatment approach differs from allergic rhinitis without cough:

• Start with combination therapy: Use a first-generation antihistamine/decongestant preparation (dexbrompheniramine 6 mg or azatadine 1 mg plus sustained-release pseudoephedrine 120 mg, both twice daily) alongside an intranasal corticosteroid 1, 2

• Why first-generation antihistamines matter for cough: The anticholinergic effect of older-generation antihistamines is critical for treating the cough component—newer non-sedating antihistamines like terfenadine and loratadine have been shown to be ineffective for cough associated with upper airway cough syndrome 1

• Intranasal corticosteroids are appropriate first-line for allergic rhinitis-related cough: Unlike non-allergic upper airway cough syndrome where intranasal corticosteroids are delayed, when allergic rhinitis is the identified cause, nasal corticosteroids can be started immediately alongside antihistamines 1, 2

Maintenance Phase After Cough Resolution

• Continue intranasal corticosteroids for 3 months after cough disappears: This extended maintenance therapy is critical for preventing recurrence and is recommended by the American College of Chest Physicians 2

• Do not discontinue prematurely: The 3-month continuation period is essential even after symptoms resolve 2

Moderate-to-Severe Cases

For patients with moderate-to-severe allergic rhinitis and chronic cough who don't respond adequately to initial therapy:

• Consider combination intranasal therapy: The combination of intranasal fluticasone propionate (200 mcg) plus intranasal azelastine (548 mcg) as a single spray provides superior symptom reduction compared to either agent alone, with reductions of -5.31 to -5.7 in total nasal symptom scores versus -3.84 to -5.1 for fluticasone alone 1, 3

• This represents a 40% relative improvement over monotherapy with either agent 3

• The 2017 Joint Task Force provides a weak recommendation for this combination as initial treatment for moderate-to-severe seasonal allergic rhinitis, though the recommendation is weak due to cost and side effect considerations 1, 3

Alternative and Adjunctive Options

• Leukotriene receptor antagonists (montelukast 10 mg daily) are less effective than intranasal corticosteroids but may be considered for patients who cannot tolerate nasal sprays or who have concurrent mild persistent asthma 1, 4

• Nasal cromolyn can be used as an alternative first-line agent for allergic rhinitis-related upper airway cough syndrome 1

• Ipratropium bromide nasal spray may be added if patients don't respond to the antihistamine/decongestant combination, though evidence is limited 1

Treatment Duration Considerations

• For adults and children ≥12 years: A 1-month trial is recommended for allergic rhinitis with postnasal drip, but intranasal corticosteroids should be continued for 3 months after cough resolution 2

• For children ages 4-11: Use lower doses (1 spray per nostril once daily versus up to 2 sprays for adults) and limit use to 2 months per year before consulting a physician due to potential growth effects 5

Important Clinical Caveats

• Do not use intranasal corticosteroids as monotherapy initially for upper airway cough syndrome—they should accompany combination therapy with antihistamine/decongestant 2

• Avoid second-generation antihistamines for the cough component: While cetirizine, loratadine, and fexofenadine are excellent for allergic rhinitis symptoms, they lack the anticholinergic properties needed to control cough 1, 6

• Adding oral antihistamines to intranasal corticosteroids provides no additional benefit for allergic rhinitis symptoms according to the American College of Physicians 4

• Monitor for adverse effects: Dysgeusia (altered taste) occurs in 2.1-13.5% of patients with intranasal medications, and epistaxis occurs in 5-10% regardless of formulation 3, 7

• Consider immunotherapy referral for patients with inadequate response to pharmacologic therapy after appropriate trials 4