What are the treatment options for chronic allergies?

Treatment Options for Chronic Allergies

For chronic allergies (allergic rhinitis), intranasal corticosteroids are the most effective first-line monotherapy and should be initiated for moderate-to-severe symptoms, while second-generation oral antihistamines or intranasal antihistamines are appropriate for mild symptoms. 1, 2, 3

Initial Treatment Selection Based on Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) are appropriate first-line options for mild symptoms 3, 4
• Intranasal antihistamines (azelastine, olopatadine) are equally effective alternatives for mild disease 3, 2
• Second-generation agents are strongly preferred over first-generation antihistamines (diphenhydramine, chlorpheniramine) because older agents cause sedation, impairment, worsen sleep architecture, and may actually worsen dry eye and allergic symptoms 5, 1

Moderate-to-Severe or Persistent Allergic Rhinitis

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be initiated as first-line therapy, either alone or combined with an intranasal antihistamine 1, 2, 3
• Intranasal corticosteroids are the single most effective monotherapy available for both seasonal and perennial allergic rhinitis 2, 4
• Combination therapy with intranasal corticosteroid plus intranasal antihistamine provides superior symptom reduction (40% relative improvement over monotherapy) for moderate-to-severe cases 6, 2

Allergen Avoidance and Environmental Controls

• Allergen avoidance should be implemented even during early treatment as an adjunctive measure 2
• Specific measures include: wearing sunglasses as allergen barrier, cold compresses, refrigerated artificial tears, avoiding eye rubbing, hypoallergenic bedding, frequent clothes washing, and showering before bedtime 1
• Environmental controls (air filtration systems, bed covers, acaricides for dust mites, pet removal) may be advised when specific allergens correlate with clinical symptoms 1

Combination and Adjunctive Therapies

When Monotherapy Fails

• Combination pharmacologic therapy should be offered when patients have inadequate response to monotherapy 1
• Intranasal anticholinergics (ipratropium bromide 0.03%) are particularly effective for rhinorrhea and can be combined with antihistamines or corticosteroids 2
• Nasal saline irrigation provides symptomatic relief and can be used as adjunctive treatment 2

Medications to Avoid or Use Cautiously

• Oral leukotriene receptor antagonists (montelukast) should NOT be offered as primary therapy for allergic rhinitis, though FDA-approved for this indication 1, 7
• Leukotriene antagonists are less effective than intranasal corticosteroids but may be considered for patients who cannot tolerate nasal sprays or have concurrent mild persistent asthma 6, 2
• Topical decongestants must be limited to less than 10 days to avoid rhinitis medicamentosa (rebound congestion) 2
• Oral corticosteroids are contraindicated for routine chronic allergic rhinitis management due to long-term adverse effects 2

Immunotherapy for Refractory Cases

• Allergen immunotherapy (subcutaneous or sublingual) should be offered when patients have inadequate response to pharmacologic therapy with or without environmental controls 1
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with benefits persisting years after discontinuation 2, 1
• Additional benefits include prevention of new allergen sensitivities and reduction in future asthma development risk in patients with allergic rhinitis 1
• Meta-analyses demonstrate that treating 4 patients with immunotherapy prevents 1 deterioration in asthma symptoms (95% CI, 3-5) 1

Diagnostic Confirmation and Testing

• Clinical diagnosis is made when patients present with history and physical examination consistent with allergic cause plus one or more symptoms: nasal congestion, runny nose, itchy nose, or sneezing 1
• Physical findings include clear rhinorrhea, nasal congestion, pale discoloration of nasal mucosa, and red watery eyes 1
• Specific IgE testing (skin or blood) should be performed when patients don't respond to empiric treatment, diagnosis is uncertain, or knowledge of specific causative allergen is needed to target therapy 1

Assessment of Comorbid Conditions

• Document presence of associated conditions: asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Treatment of allergic rhinitis can improve asthma control in patients with coexisting conditions 2, 8
• More than 75% of allergic rhinitis patients may develop asthma, while up to 40% of asthma patients have allergic rhinitis 8

Referral Indications

• Refer to allergist/immunologist for: prolonged manifestations unresponsive to treatment, complications (otitis media, sinusitis, nasal polyposis), comorbid asthma or chronic sinusitis, or when systemic corticosteroids have been required 2
• Referral should also be considered when immunotherapy is being contemplated or when patients have inadequately controlled symptoms with reduced quality of life 2, 1

Critical Pitfalls to Avoid

• Never use first-generation antihistamines as they cause sedation, impairment, and may worsen symptoms 5, 2
• Never use prolonged intranasal decongestants beyond 10 days due to rhinitis medicamentosa risk 2
• Never administer recurrent parenteral corticosteroids for chronic management 2
• Never treat nonallergic rhinitis with oral antihistamines alone as they are ineffective for non-histamine-mediated mechanisms 2
• When using intranasal corticosteroids, direct spray away from nasal septum to prevent mucosal erosions and potential septal perforations 2