What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis, as they are the most effective monotherapy for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) OR an intranasal antihistamine (azelastine, olopatadine). 2
• Oral second-generation antihistamines are particularly effective for patients whose primary complaints are sneezing and itching, though they are less effective for nasal congestion. 1, 2
• Choose intranasal antihistamines when immediate symptom relief is needed, as they provide rapid onset of action (within hours) and are equal to or superior to oral antihistamines for seasonal allergic rhinitis. 3

Moderate to Severe Persistent Allergic Rhinitis

• Begin with an intranasal corticosteroid (fluticasone, triamcinolone, budesonide, mometasone) as monotherapy. 1, 2
• Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast) for allergic rhinitis treatment. 1
• For moderate to severe seasonal allergic rhinitis not responding to monotherapy, combine an intranasal corticosteroid with an intranasal antihistamine, which shows greater symptom reduction than either agent alone. 1, 3
• Adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit and is not recommended. 1

Dosing Considerations

Adults and Adolescents (≥12 years)

• Fluticasone propionate: up to 2 sprays in each nostril once daily. 4
• Can use daily for up to 6 months before checking with a doctor. 4

Children (4-11 years)

• Fluticasone propionate: 1 spray in each nostril once daily. 4
• Limit use to 2 months per year before consulting a doctor, as long-term intranasal corticosteroids may slow growth rate in some children. 4

Important Timing Considerations

• Intranasal corticosteroids may take several days to reach maximum effect, so they are not ideal when immediate relief is needed. 3
• Continue using intranasal corticosteroids daily as long as you're exposed to allergens, even after symptoms improve, to maintain relief. 4
• For seasonal allergies, early administration of medications before exposure or symptom development may lessen the impact. 5

Adjunctive and Alternative Therapies

Additional Pharmacologic Options

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy, alone or combined with antihistamines, though they are less effective than intranasal corticosteroids. 1
• 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 is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 1, 3

Immunotherapy for Refractory Disease

• Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual). 5, 1
• Immunotherapy is effective for allergic rhinitis and should be considered for patients with demonstrable IgE antibodies to clinically relevant allergens. 5
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 1

Short-Term Oral Corticosteroids

• A short 5-7 day course of oral prednisone may be appropriate only for very severe or intractable symptoms that significantly impact quality of life. 1
• Chronic use of oral or parenteral corticosteroids is inappropriate in allergic rhinitis. 5

Critical Safety Considerations and Pitfalls

Antihistamine Selection

• Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects. 3
• Cetirizine and intranasal azelastine may cause sedation at recommended doses. 1, 3
• Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses. 3

Decongestant Cautions

• Use oral decongestants (pseudoephedrine, phenylephrine) with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1, 3

Drug Interactions with Intranasal Corticosteroids

• Talk to your doctor before using fluticasone if taking HIV medications (such as ritonavir) or ketoconazole pills, as these may cause fluticasone levels to become too high. 4
• Inform your doctor if using other steroid medicines for asthma, allergies, skin rash, or eye conditions. 4

Common Adverse Effects

• Dysgeusia (altered taste) is the most common adverse event with intranasal corticosteroids and antihistamines, occurring in 2.1% to 13.5% of patients. 1
• Nasal adverse effects (dryness, burning, stinging, sneezing) and epistaxis occur in 5-10% of patients regardless of intranasal corticosteroid formulation. 6

Essential Non-Pharmacologic Management

• Avoidance of identified allergens is fundamental to successful management and should be implemented alongside pharmacotherapy. 5, 2
• Educate patients about avoidance measures after triggers are identified. 5
• Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1
• Do not routinely order sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1