Treatment of Severe Allergic Rhinitis
For severe allergic rhinitis, initiate treatment with an intranasal corticosteroid (fluticasone, mometasone, or triamcinolone) at standard dosing, and if symptoms remain inadequately controlled after 2-4 weeks, add an intranasal antihistamine (azelastine) to achieve superior symptom reduction. 1, 2
First-Line Monotherapy
Intranasal corticosteroids are the most effective single agent for controlling all four major symptoms of severe allergic rhinitis (nasal congestion, rhinorrhea, sneezing, and itching), with strong recommendation based on high-quality evidence 1, 3
Start with standard dosing: mometasone furoate 2 sprays per nostril once daily (200 mcg total) for adults and adolescents ≥12 years, or fluticasone propionate 2 sprays per nostril once daily 2, 4
For patients with severe nasal congestion unresponsive to standard dosing, consider higher initial dosing of fluticasone 2 sprays per nostril twice daily, then reduce to maintenance dosing once symptoms are controlled 2
Do not add an oral antihistamine to intranasal corticosteroid monotherapy for initial treatment—this combination provides no additional benefit over intranasal corticosteroid alone 1, 5
Combination Therapy for Moderate-to-Severe Disease
For moderate-to-severe allergic rhinitis, the combination of intranasal corticosteroid plus intranasal antihistamine (fluticasone propionate + azelastine) may be used for initial treatment, showing >40% relative improvement compared to either agent alone 1, 6, 5
This combination provides 37.9% symptom reduction versus 29.1% with intranasal corticosteroid alone 6
The combination is particularly beneficial when symptoms persist after 2-4 weeks of continuous intranasal corticosteroid monotherapy 6
Critical Administration Points
Instruct patients to use intranasal corticosteroids daily and continuously, not intermittently or "as needed"—full benefit requires 2 weeks of regular use, with maximal efficacy reached over days to weeks 2, 6
Direct the spray away from the nasal septum toward the lateral nasal wall (contralateral hand technique) to reduce epistaxis risk by four-fold 2, 6
Prime the bottle before first use, shake before spraying, have patient blow nose prior to administration, and keep head upright during use 2
What NOT to Use
Do not use leukotriene receptor antagonists (montelukast) as primary therapy for severe allergic rhinitis—they are significantly less effective than intranasal corticosteroids with only marginal symptom improvement 1, 2, 5
Avoid topical decongestants beyond 3 days due to rhinitis medicamentosa risk 6
Never use parenteral corticosteroids for allergic rhinitis—they are contraindicated due to long-term systemic adverse effects 6, 5
Adjunctive Therapies for Refractory Symptoms
For persistent rhinorrhea despite intranasal corticosteroid, add intranasal ipratropium bromide, which is specifically effective for rhinorrhea and more effective when combined with intranasal corticosteroids than either alone 6, 5
Nasal saline irrigation provides benefit as adjunctive therapy and should be performed prior to administering steroid spray 2, 6
For very severe or intractable symptoms significantly impacting quality of life, a short 5-7 day course of oral prednisone may be appropriate, but avoid repeated or long-term use 6, 5
When to Refer for Immunotherapy
Refer to allergist/immunologist if symptoms persist after 2-4 weeks of optimal pharmacotherapy (intranasal corticosteroid plus intranasal antihistamine) 6, 5
Allergen immunotherapy (subcutaneous or sublingual) is the only disease-modifying treatment and may prevent new allergic sensitizations and reduce future asthma risk 1, 6, 5
Safety Profile for Long-Term Use
Intranasal corticosteroids are safe for indefinite use at recommended doses, with no effect on hypothalamic-pituitary-adrenal axis function, growth in children (fluticasone, mometasone, budesonide), or intraocular pressure 2, 4
Most common adverse events are mild: epistaxis (4-20%), headache, pharyngitis, and nasal burning/irritation 2, 4, 7
Periodically examine the nasal septum during long-term use to detect mucosal erosions that may precede septal perforation (rare complication) 2, 6
Common Pitfalls to Avoid
Patients must understand that intranasal corticosteroids are maintenance therapy requiring continuous daily use for 8-12 weeks minimum to assess therapeutic benefit, not rescue therapy like decongestants 2, 6
Improper spray technique increases local side effects and reduces efficacy—always demonstrate proper administration 2
Do not discontinue therapy when symptoms improve during allergen season; continue throughout the entire allergen exposure period 2