What is the first line treatment for allergic rhinitis?

First-Line Treatment for 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 nasal itching. 1, 2

Treatment Selection Based on Clinical Context

For Most Patients with Moderate-to-Severe Symptoms

• Start with an intranasal corticosteroid as monotherapy (fluticasone, mometasone, triamcinolone, or budesonide), as these agents provide superior symptom control compared to all other single-agent therapies. 1, 2
• Intranasal corticosteroids are more effective than leukotriene receptor antagonists (montelukast), with clinically meaningful differences in symptom reduction. 1, 2
• These agents are also superior to oral antihistamines for controlling all four major nasal symptoms, particularly nasal congestion. 1

When Immediate Symptom Relief is the Priority

• Intranasal antihistamines (azelastine, olopatadine) should be used as first-line therapy when rapid symptom relief is needed, as they provide onset of action within hours compared to the several days required for intranasal corticosteroids to reach maximum effect. 3
• Intranasal antihistamines are equal to or superior to oral second-generation antihistamines and have significant effects on nasal congestion. 3

For Mild Intermittent Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines may be used for mild intermittent allergic rhinitis (symptoms <4 days/week or <4 weeks/year). 4
• However, oral antihistamines are less effective for nasal congestion compared to intranasal options. 3

When Initial Monotherapy Fails

Combination Therapy for Inadequate Response

• For moderate-to-severe allergic rhinitis with inadequate response to intranasal corticosteroid alone, add an intranasal antihistamine (not an oral antihistamine). 1, 2
• The combination of fluticasone propionate and azelastine shows >40% relative improvement compared to either agent alone, with greater symptom reduction than monotherapy. 1, 2
• Do not add an oral antihistamine to an intranasal corticosteroid, as this provides no additional benefit and increases the risk of adverse effects, particularly sedation with first-generation agents. 1

Critical Pitfalls to Avoid

Medication Selection Errors

• Never use first-generation antihistamines (diphenhydramine, chlorpheniramine) due to significant sedation, performance impairment, and anticholinergic effects. 3
• Do not use leukotriene receptor antagonists (montelukast) as primary therapy, as they are significantly less effective than intranasal corticosteroids, though they may be considered in patients who cannot tolerate intranasal medications or have concurrent mild persistent asthma. 1, 2
• Limit topical decongestants to 3 days maximum to avoid rhinitis medicamentosa (rebound congestion). 5

Administration and Timing Issues

• Counsel patients that intranasal corticosteroids require 12 hours to several days for onset of action and days to weeks for maximum efficacy, so they should not be used as rescue therapy. 3, 5
• For predictable seasonal patterns, initiate intranasal corticosteroids before symptom onset and continue throughout the allergen exposure period for optimal effectiveness. 5
• Teach proper spray technique: direct spray away from the nasal septum (use contralateral hand technique) to reduce epistaxis risk by four-fold. 5

Safety Considerations

• Oral decongestants (pseudoephedrine, phenylephrine) should be used with extreme caution in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 3, 2
• Among second-generation antihistamines, cetirizine and intranasal azelastine may cause sedation at recommended doses; fexofenadine, loratadine, and desloratadine do not cause sedation. 3, 2

Long-Term Management

Duration of Therapy

• Intranasal corticosteroids are safe for indefinite long-term use when clinically indicated, as they do not affect systemic cortisol levels or hypothalamic-pituitary-adrenal axis function at recommended doses. 5
• Continue treatment for a minimum of 8-12 weeks to properly assess therapeutic benefit. 5
• Periodically examine the nasal septum during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication). 5

When to Refer

• Refer patients with inadequate response to pharmacologic therapy (intranasal corticosteroid with or without intranasal antihistamine) for consideration of allergen immunotherapy (subcutaneous or sublingual). 2
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 2