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

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) OR an intranasal antihistamine (azelastine, olopatadine). 3
• Oral second-generation antihistamines are particularly effective for patients whose primary complaints are sneezing and itching, though they are less effective for nasal congestion. 1, 2
• Choose intranasal antihistamines when immediate symptom relief is needed, as they provide rapid onset of action (within hours) and are equal to or superior to oral antihistamines for seasonal allergic rhinitis. 2

Moderate to Severe Persistent Allergic Rhinitis

• Begin with an intranasal corticosteroid (fluticasone, mometasone, budesonide, triamcinolone) as monotherapy. 1, 3
• Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast) for allergic rhinitis treatment. 1
• Note that intranasal corticosteroids may take several days to reach maximum effect, so patients should be counseled on consistent daily use. 2

Combination Therapy for Inadequate Response

• For moderate to severe seasonal allergic rhinitis not responding to monotherapy, combine an intranasal corticosteroid with an intranasal antihistamine (not an oral antihistamine). 1
• This combination shows greater symptom reduction than either agent alone. 1
• Do not add an oral antihistamine to an intranasal corticosteroid, as this provides no additional benefit. 1

Additional Therapeutic Options

Adjunctive Treatments

• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 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
• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy, though they are generally less effective than intranasal corticosteroids. 1

Allergen Avoidance

• Avoidance of identified allergen triggers is fundamental to successful management and should be implemented alongside pharmacotherapy. 4
• Patients should be educated about specific avoidance measures after triggers are identified through skin testing or specific IgE testing. 4

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. 1
• Chronic use of oral or parenteral corticosteroids is inappropriate in allergic rhinitis. 4

Immunotherapy for Refractory Disease

• Refer patients with inadequate response to pharmacologic therapy for consideration of allergen immunotherapy (subcutaneous or sublingual). 1, 4
• Immunotherapy should be considered for patients with demonstrable evidence of specific IgE antibodies to clinically relevant allergens. 4
• The decision to begin immunotherapy depends on the degree to which symptoms can be reduced by avoidance and medication, the amount and type of medication required, and adverse effects of medications. 4
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk in patients with allergic rhinitis. 1

Critical Caveats and Safety Considerations

Antihistamine Selection

• Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects. 2
• Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses. 2
• Cetirizine and intranasal azelastine may cause sedation at recommended doses. 1, 2

Oral Decongestant Precautions

• Use oral decongestants (pseudoephedrine, phenylephrine) with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1, 2

Intranasal Corticosteroid Use

• For children ages 4-11, limit use to 2 months per year before checking with a doctor, as long-term use may slow growth rate. 5
• For patients age 12 or older, check with a doctor if daily use exceeds 6 months. 5
• Dysgeusia (altered taste) is the most common adverse event with intranasal corticosteroids, occurring in 2.1% to 13.5% of patients. 1
• Continue daily use as long as exposed to allergens to maintain symptom relief, even when symptoms improve. 5

Drug Interactions

• Patients taking HIV medications (such as ritonavir) or ketoconazole pills should talk to their doctor before using intranasal corticosteroids, as these may increase fluticasone levels. 5

Assessment of Comorbidities

• Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media in patients with allergic rhinitis. 1

Diagnostic Pitfall

• Do not routinely order sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1