What is the recommended treatment regimen for recurrent allergic rhinitis?

Treatment Regimen for Recurrent Allergic Rhinitis

Intranasal corticosteroids should be your first-line treatment for recurrent allergic rhinitis, as they are the most effective monotherapy for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Initial Treatment Strategy

For mild recurrent allergic rhinitis:

• Start with either an intranasal corticosteroid (fluticasone, mometasone, budesonide, or triamcinolone) OR a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, or desloratadine) 1, 3
• Second-generation antihistamines are particularly effective when the primary complaints are sneezing and itching rather than congestion 2, 4

For moderate to severe recurrent allergic rhinitis:

• Begin with an intranasal corticosteroid as monotherapy 1, 2
• If monotherapy fails, add an intranasal antihistamine (azelastine or olopatadine) to the intranasal corticosteroid—this combination provides greater symptom reduction than either agent alone 5, 2, 3

When Initial Therapy Fails

If intranasal corticosteroids alone don't adequately control symptoms, follow this hierarchy:

1. Add intranasal antihistamine (most effective combination) 5, 2
2. For severe nasal obstruction only: Add topical oxymetazoline for a maximum of 3 days to avoid rhinitis medicamentosa 5, 1
3. For persistent rhinorrhea: Add intranasal ipratropium bromide, which specifically targets rhinorrhea but doesn't affect other symptoms 1, 6
4. If nasal sprays are not tolerated: Switch to combination oral antihistamine plus oral decongestant 5

Important Caveats

Avoid these common pitfalls:

• Do NOT routinely add oral antihistamines to intranasal corticosteroids—multiple high-quality trials show no additional benefit 5, 2
• Do NOT add leukotriene receptor antagonists (montelukast) to intranasal corticosteroids—they provide no additional benefit and are less effective than intranasal corticosteroids alone 5, 2, 7
• Do NOT use intranasal decongestants (oxymetazoline) for more than 3 days due to risk of rebound congestion 5, 1
• Do NOT use first-generation antihistamines (diphenhydramine, chlorpheniramine) due to sedation and performance impairment 1, 8

Adjunctive Measures

• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea 1, 2
• Allergen avoidance should be implemented early, even before confirming specific allergens 1, 4

When to Refer for Immunotherapy

Refer patients to an allergist for consideration of immunotherapy (subcutaneous or sublingual) when: 5, 1, 2

• Symptoms remain inadequately controlled despite optimal pharmacotherapy
• Quality of life is significantly impaired
• Patient desires disease-modifying treatment rather than chronic medication use
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis and may prevent development of asthma and new allergen sensitizations 5, 1

Special Considerations

For patients with coexisting asthma:

• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control 5, 1

Proper technique matters:

• Direct intranasal corticosteroid spray away from the nasal septum to avoid mucosal erosions and potential septal perforations 1

Oral corticosteroids:

• Should NOT be used for chronic rhinitis except in rare cases of severe intractable symptoms unresponsive to all other treatments 1, 2