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

• Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) may be used as initial therapy for patients with mild symptoms, particularly when sneezing and itching are the primary complaints. 1, 2
• Intranasal antihistamines provide rapid symptom relief and are equal to or superior to oral antihistamines for seasonal allergic rhinitis, with significant effects on nasal congestion. 3

Moderate to Severe Allergic Rhinitis

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be initiated as first-line therapy, either alone or combined with an intranasal antihistamine. 1, 2
• The combination of intranasal corticosteroid plus intranasal antihistamine provides greater symptom reduction than either agent alone for moderate to severe seasonal allergic rhinitis. 1
• Important caveat: Adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit and is not recommended. 1

Key Medication Considerations

Intranasal Corticosteroids

• These agents work by blocking multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes), not just histamine like oral antihistamines. 4
• Onset of action: May take several days to reach maximum effect, so regular daily use is essential for optimal symptom control. 3, 4
• Dosing for fluticasone propionate: Adults and children ≥12 years use up to 2 sprays per nostril once daily; children 4-11 years use 1 spray per nostril once daily. 4
• Duration limits: Adults may use for up to 6 months before checking with a doctor; children 4-11 years should use for no more than 2 months per year before medical consultation due to potential growth effects. 4

Second-Generation Antihistamines

• Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses. 3
• Caution: Cetirizine and intranasal azelastine may cause sedation even at recommended doses. 1, 3
• These agents are most effective for sneezing, itching, and rhinorrhea but less effective for nasal congestion compared to intranasal corticosteroids. 1, 3

Intranasal Antihistamines

• Provide the most rapid symptom relief when immediate control is needed, making them ideal for breakthrough symptoms or when quick relief is the priority. 3
• Effective for rhinorrhea, sneezing, nasal itching, and nasal congestion with rapid onset of action. 3

Refractory Disease Management

When Initial Pharmacotherapy Fails

• Allergen immunotherapy (subcutaneous or sublingual) should be offered to patients with inadequate response to pharmacologic therapy with or without environmental controls. 5, 1
• Immunotherapy is effective for patients with demonstrable IgE antibodies to clinically relevant allergens and may prevent development of new allergen sensitizations and reduce future asthma risk. 5, 1

Adjunctive Therapies

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy but are generally 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

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. 5, 1
• Critical warning: Chronic use of oral or parenteral corticosteroids is inappropriate in allergic rhinitis. 5

Essential Allergen Avoidance Strategies

• Avoidance of identified allergens is fundamental to successful management and should be implemented alongside pharmacotherapy. 5, 6
• When allergen exposure can be anticipated (e.g., seasonal pollen), early administration of medications before exposure or symptom development may lessen symptom impact. 5

Important Safety Considerations

Drug Interactions with Intranasal Corticosteroids

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

Oral Decongestant Precautions

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

First-Generation Antihistamines

• Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects. 3

Assessment of Comorbid 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
• Routine sinonasal imaging is not recommended for patients presenting with symptoms consistent with allergic rhinitis. 1