What is the initial treatment for a patient with a running nose?

Initial Treatment for Running Nose

For a patient presenting with a running nose (rhinorrhea), start with an intranasal corticosteroid as first-line monotherapy, which is the most effective treatment for controlling nasal symptoms regardless of whether the cause is allergic or non-allergic rhinitis. 1

Determining the Likely Cause

Before initiating treatment, consider these key clinical features:

• Allergic rhinitis is suggested by: pruritus (itching), sneezing, seasonal patterns, and symptom onset before age 20 years 1
• Non-allergic rhinitis is more likely with: isolated rhinorrhea, symptoms triggered by strong odors (perfume, tobacco smoke), or onset after age 20 years 1
• Viral rhinitis (common cold): typically resolves within 7-10 days and may include fever, malaise, and other systemic symptoms 2

The distinction between allergic and non-allergic causes often cannot be made initially based on history and physical examination alone, as both can present with similar symptoms including rhinorrhea, nasal congestion, and sneezing 1

First-Line Treatment Approach

Intranasal Corticosteroids (Primary Recommendation)

Intranasal corticosteroids should be prescribed as initial monotherapy for patients aged 12 years or older with rhinorrhea. 1 These agents (fluticasone, triamcinolone, budesonide, mometasone) are the most effective medication class for controlling all nasal symptoms including rhinorrhea, congestion, sneezing, and itching 3, 4

• Intranasal corticosteroids work for both allergic and non-allergic rhinitis, making them ideal when the diagnosis is uncertain 5, 4
• They reduce inflammation and nasal secretions more effectively than antihistamines alone 1, 6
• Continuous treatment is more effective than intermittent use for ongoing symptoms 1

Second-Generation Oral Antihistamines (Alternative for Mild Symptoms)

If intranasal corticosteroids are not tolerated or for mild symptoms, use a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) 3, 6

• These agents effectively reduce rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 1, 6
• Second-generation antihistamines are strongly preferred over first-generation agents because they avoid sedation, performance impairment, and anticholinergic effects (dry mouth, urinary retention) 1, 5
• Avoid first-generation antihistamines (diphenhydramine) due to significant sedation and cognitive impairment that patients may not subjectively perceive 1

Combination Therapy for Inadequate Response

If monotherapy with intranasal corticosteroid fails to control symptoms after 7 days, add an intranasal antihistamine (azelastine, olopatadine) to the intranasal corticosteroid. 1, 3

• This combination provides greater symptomatic relief than either agent alone for moderate to severe symptoms 1, 4
• The combination is more effective than adding an oral antihistamine to the intranasal corticosteroid 1

Adjunctive Measures

Nasal Saline Irrigation

• Use regularly to facilitate clearance of nasal secretions and reduce congestion 7
• Can be used as complementary therapy alongside pharmacotherapy 7

Allergen and Irritant Avoidance

• Identify and avoid triggers when possible (tobacco smoke, strong perfumes, known allergens) 1, 7
• Environmental controls are particularly important for perennial allergens (dust mites, pet dander) 1

Critical Pitfalls to Avoid

Topical Decongestants (Oxymetazoline, Phenylephrine)

Do not use topical nasal decongestants for more than 3 days. 1, 7

• Rebound congestion (rhinitis medicamentosa) can develop as early as the third day of regular use 1
• These agents are appropriate only for short-term use in acute viral infections or acute exacerbations 1
• If rhinitis medicamentosa develops, discontinue the decongestant and treat with intranasal corticosteroids 1

Oral Decongestants

• Pseudoephedrine can help reduce nasal congestion but may cause insomnia, irritability, and palpitations 1, 8
• Use with caution in patients with hypertension, though blood pressure elevation is rare in normotensive patients 1
• These are adjunctive agents, not first-line therapy 1

Leukotriene Receptor Antagonists

Do not use leukotriene receptor antagonists (montelukast) as primary therapy for rhinitis. 1

• These agents are less effective than intranasal corticosteroids 1
• They may have additive benefit when combined with antihistamines, but this combination is still less effective than intranasal corticosteroids 1

Pediatric Considerations

Avoid OTC cough and cold medications in children under 6 years of age due to lack of proven efficacy and potential toxicity 1

When to Reassess or Refer

• Reassess after 7 days of treatment to evaluate symptom response and adjust therapy if needed 7
• Consider specialist referral if: symptoms persist despite appropriate treatment, complications develop (chronic sinusitis, nasal polyps), or there are associated conditions requiring specialized management (asthma, chronic rhinosinusitis) 1, 7
• Obtain sinus imaging if empiric treatment fails and chronic sinusitis is suspected 1