What are the treatments for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids should be the first-line treatment for patients with moderate to severe allergic rhinitis, as they are the most effective monotherapy available and superior to all other single agents. 1, 2

Initial Pharmacotherapy Approach

For Moderate to Severe Symptoms

• Start with intranasal corticosteroid monotherapy (fluticasone, mometasone, budesonide, or triamcinolone) rather than combination therapy with oral antihistamines 1
• Intranasal corticosteroids are superior to leukotriene receptor antagonists and should be chosen over them 1
• Maximum efficacy requires several days of consistent daily use, so counsel patients to continue even if immediate relief is not apparent 2, 3
• Critical technique point: Patients must direct the spray away from the nasal septum to prevent mucosal erosions and potential septal perforation 2

For Mild Intermittent Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are appropriate for patients whose primary complaints are sneezing, itching, and rhinorrhea 1, 4
• Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative first-line option 1
• Second-generation antihistamines are strongly preferred over first-generation agents due to significantly less sedation, performance impairment, and anticholinergic effects 1

Escalation for Inadequate Response

Combination Therapy

• For moderate to severe seasonal allergic rhinitis with inadequate response to monotherapy, combine intranasal corticosteroid with intranasal antihistamine, which provides greater efficacy than either agent alone 1, 2
• This combination may be considered for initial treatment in patients with moderate to severe symptoms 1
• Combination therapy with oral antihistamines added to intranasal corticosteroids may be offered when monotherapy fails 1

Additional Adjunctive Agents

• Intranasal anticholinergics (ipratropium bromide) are particularly effective for controlling rhinorrhea when used with intranasal corticosteroids, providing additive benefit without increased adverse events 1, 2
• Nasal saline irrigation is beneficial as adjunctive therapy to relieve congestion and facilitate clearance of secretions 1, 2

What NOT to Use

Contraindicated or Not Recommended

• Do not offer oral leukotriene receptor antagonists as primary therapy—they are less efficacious than intranasal corticosteroids 1
• Avoid topical nasal decongestants beyond 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion) 2, 5
• Do not use oral corticosteroids for chronic management except in rare cases of severe intractable symptoms unresponsive to all other treatments, due to significant long-term adverse effects 1, 2
• First-generation antihistamines should be avoided due to sedation, impaired performance, and increased accident risk 1, 5

Allergen Immunotherapy

• Offer or refer for immunotherapy (subcutaneous or sublingual) when patients have inadequate response to pharmacotherapy with or without environmental controls 1, 2
• Immunotherapy is the only disease-modifying treatment that can alter the natural history of allergic rhinitis and provide benefits lasting years after discontinuation 2, 6
• It may prevent development of new allergen sensitivities and reduce future asthma risk 2

Environmental Control Measures

• Advise avoidance of identified allergens when specific IgE testing correlates with clinical symptoms 1
• Complete avoidance is most effective for animal allergies 5
• Effective dust mite control requires combination of humidity control, allergen-impermeable bedding covers, HEPA vacuuming, and acaricides 1
• Address non-allergen irritants including tobacco smoke, strong odors, and temperature/humidity extremes 5

Special Populations

Children Ages 4-11 Years

• Use lower dosing: 1 spray per nostril once daily (versus up to 2 sprays for ages ≥12 years) 3
• Limit use to 2 months per year before consulting physician due to potential growth velocity effects with long-term intranasal corticosteroid use 3

When to Refer to Allergist

• Symptoms inadequately controlled with pharmacotherapy 2, 5
• Complications such as recurrent otitis media, sinusitis, or nasal polyposis 2
• Comorbid asthma or chronic sinusitis requiring coordinated management 1, 2
• When immunotherapy is being considered 2, 5

Diagnostic Testing Considerations

• Perform or refer for specific IgE testing (skin or blood) when patients do not respond to empiric treatment, diagnosis is uncertain, or knowledge of specific allergens is needed to target therapy 1
• Do not routinely perform sinonasal imaging in patients with symptoms consistent with allergic rhinitis 1
• Document associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1