What is the management of allergic rhinitis?

Management of Allergic Rhinitis

Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis and should be first-line treatment for moderate to severe disease, either alone or combined with intranasal antihistamines for optimal symptom control. 1, 2

Initial Treatment Selection Based on Severity

Mild Intermittent Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are appropriate for patients with mild symptoms, particularly when sneezing, itching, and rhinorrhea predominate 2, 3
• These agents are strongly preferred over first-generation antihistamines due to significantly less sedation and performance impairment 4, 1
• Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative monotherapy option 2, 3

Moderate to Severe or Persistent Symptoms

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be the primary treatment, as they are the most effective single agents available 1, 2, 3
• For patients aged 12 years or older with moderate to severe seasonal allergic rhinitis, combination therapy with intranasal corticosteroid plus intranasal antihistamine provides greater efficacy than either agent alone and should be considered for initial treatment 2, 5
• This combination acts more rapidly than monotherapy 6

Adjunctive and Alternative Therapies

Nasal Saline Irrigation

• Beneficial for treating chronic rhinorrhea and rhinosinusitis symptoms, either as monotherapy or adjunctive treatment 1, 2
• Provides significant improvement, particularly useful in children 6

Intranasal Anticholinergics

• Ipratropium is particularly effective for rhinorrhea in both allergic and nonallergic rhinitis 1
• May be combined with antihistamines or intranasal corticosteroids for increased efficacy 1

Leukotriene Receptor Antagonists

• Should NOT be offered as primary therapy for allergic rhinitis, as they are generally less efficacious than intranasal corticosteroids 2, 7
• May be useful in combination with antihistamines for select patients 1

Intranasal Cromolyn

• Effective in some patients for prevention and treatment with minimal side effects, but less effective than corticosteroids 4, 1
• Should be started as early as possible in an allergy season 1

Allergen Avoidance and Environmental Controls

Empiric avoidance of suspected allergens should be implemented even in early treatment 1

• For pollen allergies: Keep windows and doors closed during high pollen seasons, avoid outdoor activities when pollen counts are elevated, use air conditioning rather than attic fans 8
• For dust mite allergies: Consider removal of carpeting, use air filtration systems, allergen-impermeable bed covers, and acaricides 8
• For pet allergies: Remove pets from the home when feasible, or at minimum exclude them from bedrooms 8

Allergen Immunotherapy: The Only Disease-Modifying Treatment

Allergen immunotherapy should be considered for patients with inadequate response to pharmacotherapy and environmental controls, as it is the only treatment that can modify the natural history of allergic rhinitis. 4, 2, 8

Key Benefits of Immunotherapy

• Multiple randomized, double-blind, placebo-controlled studies demonstrate effectiveness in treating allergic rhinitis 4
• Clinical benefits may be sustained years after discontinuation of treatment, unlike pharmacotherapy 4
• May prevent development of new allergen sensitizations 4, 2, 8
• Reduces the risk for future development of asthma in patients with allergic rhinitis 4, 8
• Effective in both adults and children 4
• Efficacy confirmed for pollen, fungi, animal allergens, dust mite, and cockroach 4

When to Consider Immunotherapy

• Patients with demonstrable specific IgE antibodies to clinically relevant allergens 4
• Inadequate response to pharmacotherapy with or without environmental controls 2, 8
• Symptoms interfering with quality of life and ability to function 4
• Adverse reactions to medications or patient desire to avoid long-term pharmacotherapy 4
• Coexisting asthma and allergic rhinitis (providing asthma is stable when injections are administered) 4

Immunotherapy Safety Considerations

• Estimated fatality rate is 1 per 2.5 million injections 4
• Risk factors for anaphylaxis include symptomatic asthma, injections from new vials, β-blockers, high degree of skin test reactivity, and injections during symptom exacerbations 4
• Contraindications: Severe asthma uncontrolled by pharmacotherapy and significant cardiovascular disease 4

Critical Pitfalls to Avoid

Medication-Related Errors

• Never use first-generation antihistamines as primary therapy due to sedation and performance impairment 2
• Prolonged use of intranasal decongestants beyond 10 days leads to rhinitis medicamentosa (rebound congestion) 1, 2, 8
• Recurrent administration of parenteral corticosteroids is contraindicated due to greater potential for long-term adverse effects 4, 2
• Short courses (5-7 days) of oral corticosteroids may be appropriate only for very severe or intractable symptoms or significant nasal polyposis 4
• Failing to direct intranasal corticosteroid spray away from the nasal septum can cause mucosal erosions and potential septal perforations 1, 2

Treatment Approach Errors

• Inadequate treatment of nonallergic rhinitis with oral antihistamines (these patients require intranasal antihistamines or corticosteroids) 1
• Using leukotriene receptor antagonists as primary therapy 2, 8

Assessment of Comorbidities

Clinicians must assess and document associated conditions that can worsen allergic rhinitis or be worsened by it 2, 8:

• Asthma: Over 50% of patients with asthma have allergic rhinitis; treatment of allergic rhinitis may improve asthma control 4, 8
• Atopic dermatitis 2
• Sleep-disordered breathing 2
• Conjunctivitis 2
• Rhinosinusitis 2
• Otitis media 2

When to Refer to Allergist/Immunologist

Consultation should be considered for 4, 2:

• Prolonged and severe disease with inadequately controlled symptoms
• Reduced quality of life and/or ability to function
• Adverse reactions to medications
• Comorbid conditions such as asthma, recurrent sinusitis, or nasal polyps
• When allergen immunotherapy is being considered
• Patients who have required systemic corticosteroids
• Desire to identify specific allergens for targeted environmental control

Diagnostic Testing

• Allergy testing (specific IgE skin or blood testing) should be performed or referred when patients do not respond to empiric treatment, when diagnosis is uncertain, or when knowledge of specific causative allergens is needed to target therapy 2
• Routine sinonasal imaging should NOT be performed in patients presenting with symptoms consistent with allergic rhinitis 2

Follow-Up and Monitoring

• Periodic assessment of quality of life is essential, including evaluation of time lost from work or activities, sleep quality, smell and taste, fatigue level, and general well-being 4
• Tapering of medications should always be considered to lessen the risk of adverse reactions 4
• Patient education at each visit should review environmental controls, medication use, and immunotherapy status 4
• If clinical improvement is not apparent after 1 year of maintenance immunotherapy, possible reasons for lack of efficacy should be evaluated, and discontinuation should be considered if none are found 4