Treatment for Allergic Rhinitis with Nasal Congestion Not Responding to Antihistamines
The answer is C. Intranasal steroids should be given to this patient, as they are the most effective pharmacologic therapy for allergic rhinitis and represent the appropriate next-line treatment when antihistamines fail to control symptoms. 1, 2
Why Intranasal Steroids Are the Correct Choice
Intranasal corticosteroids are the most effective single medication for treating allergic rhinitis and should be recommended for patients whose symptoms affect their quality of life. 1 The American Academy of Otolaryngology-Head and Neck Surgery made a strong recommendation (their highest level) that clinicians recommend intranasal steroids for patients with allergic rhinitis whose symptoms affect quality of life. 1
Mechanism and Efficacy
Intranasal steroids work by blocking multiple inflammatory substances (histamine, prostaglandins, cytokines, tryptases, chemokines, and leukotrienes), whereas antihistamines only block histamine alone. 3
They are particularly effective for nasal congestion, which is the presenting complaint in this patient and is often less responsive to antihistamines alone. 1, 4
Intranasal corticosteroids relieve all nasal symptoms including sneezing, itchy nose, runny nose, itchy/watery eyes, and nasal congestion. 3, 5
They are more effective than oral antihistamines, leukotriene receptor antagonists, and intranasal antihistamines for overall symptom control. 1
Why NOT the Other Options
Oral Decongestants (Option A) - Not Recommended
Oral decongestants like pseudoephedrine can reduce nasal congestion but have significant side effects including insomnia, irritability, palpitations, and hypertension. 1
They are not recommended as primary therapy and should only be used as adjunctive short-term therapy if needed. 1
The guidelines do not recommend oral decongestants as the next step after antihistamine failure. 1
Allergy Immunotherapy (Option B) - Premature at This Stage
Immunotherapy (sublingual or subcutaneous) should be offered for patients with allergic rhinitis who have inadequate response to pharmacologic therapy with or without environmental controls. 1, 2
This patient has only tried antihistamines and has not yet tried intranasal steroids, which are first-line therapy for moderate-to-severe symptoms. 4, 6
Immunotherapy is appropriate after failing adequate pharmacologic management, not as the immediate next step. 1
Practical Implementation
Dosing and Administration
Use intranasal corticosteroids regularly once daily (not as-needed) for optimal effect. 2, 7
Direct sprays away from the nasal septum to minimize local side effects like irritation and bleeding. 2, 7
Onset of action typically occurs within 12 hours but may take several days to reach maximum effect. 1
Common Pitfalls to Avoid
Do not continue the same antihistamine if it's not working - switch to intranasal corticosteroids as recommended by guidelines. 2
Ensure patients understand this is a daily maintenance medication, not a rescue medication. 2, 7
Adverse effects are typically limited to local nasal symptoms (dryness, burning, epistaxis in 5-10% of patients) with minimal systemic effects. 5, 8
If Initial Therapy Is Inadequate
If symptoms persist after 2-4 weeks of intranasal corticosteroids, add an intranasal antihistamine (like azelastine) for combination therapy. 2, 7
The combination provides superior symptom reduction (37.9% vs 29.1% for intranasal corticosteroid alone). 7
Consider immunotherapy only after inadequate response to optimal pharmacologic therapy. 1, 2