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

Treatment Algorithm Based on Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with either a second-generation oral antihistamine (loratadine, cetirizine, fexofenadine, desloratadine) OR an intranasal antihistamine (azelastine, olopatadine). 1, 2
• Second-generation oral antihistamines are particularly effective for patients whose primary complaints are sneezing and itching, though they are less effective for nasal congestion. 1, 3
• If immediate symptom relief is needed, intranasal antihistamines are superior to oral antihistamines because they provide rapid onset of action and are equally or more effective for all nasal symptoms including congestion. 3

Moderate to Severe or Persistent Allergic Rhinitis

• Begin with an intranasal corticosteroid (fluticasone, mometasone, budesonide, triamcinolone) as monotherapy. 1, 2
• Intranasal corticosteroids work on multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes) rather than histamine alone, making them more comprehensive than antihistamines. 4
• For moderate to severe seasonal allergic rhinitis not responding to monotherapy, combine an intranasal corticosteroid with an intranasal antihistamine—this combination provides greater symptom reduction than either agent alone. 1
• Adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit and is not recommended. 1

Dosing Specifics for Intranasal Corticosteroids

Adults and Adolescents (≥12 years)

• Fluticasone propionate: 1-2 sprays per nostril once daily (100-200 mcg total daily dose). 4
• Continue daily use as long as exposed to triggering allergens. 4
• If used continuously for more than 6 months, consult a physician. 4

Children (4-11 years)

• Fluticasone propionate: 1 spray per nostril once daily (100 mcg total daily dose). 4
• Limit use to 2 months per year before consulting a physician, as long-term intranasal corticosteroids may slow growth rate in children. 4

Important Timing Considerations

• Intranasal corticosteroids may take several days to reach maximum effect, so early administration before anticipated allergen exposure or symptom onset is beneficial. 5, 4
• Continue regular daily use rather than stopping when symptoms improve to maintain sustained relief. 4
• For immediate relief needs, intranasal antihistamines work within hours while intranasal corticosteroids require days. 3

Adjunctive and Alternative Therapies

Additional Pharmacologic Options

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy but are less effective than intranasal corticosteroids. 1
• Intranasal ipratropium bromide effectively reduces rhinorrhea but has no effect on other 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

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 for allergic rhinitis. 5

Refractory Disease Management

• 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 specific IgE antibodies to clinically relevant allergens. 5
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 1
• The decision to begin immunotherapy depends on the degree to which symptoms can be reduced by avoidance and medication, medication requirements, adverse effects, symptom severity and duration, and quality of life impact. 5

Allergen Avoidance

• Avoidance of identified allergen triggers (pollen, mold, dust, pet dander) is fundamental to successful management and should be implemented alongside pharmacotherapy. 5, 2
• Educate patients about specific avoidance measures after triggers are identified through skin testing or specific IgE testing. 5

Critical Safety Considerations

Drug Interactions

• Patients taking HIV medications (ritonavir), ketoconazole pills, or other systemic corticosteroids must consult their physician before using intranasal corticosteroids due to potential for elevated drug levels. 4

Adverse Effects

• Intranasal corticosteroids and antihistamines commonly cause dysgeusia (altered taste) in 2.1-13.5% of patients. 1
• Nasal adverse effects (dryness, burning, stinging, epistaxis) occur in 5-10% of patients but are generally mild. 6
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; fexofenadine, loratadine, and desloratadine are non-sedating. 1, 3
• Oral decongestants should be used with extreme caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder obstruction, glaucoma, or hyperthyroidism. 1
• First-generation antihistamines should be avoided entirely due to significant sedation, performance impairment, and anticholinergic effects. 3

Assessment of Coexisting Conditions

• Always evaluate for associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as these commonly coexist with allergic rhinitis. 1