What is the medical management of allergic rhinitis?

Medical Management of Allergic Rhinitis

First-Line Treatment Based on Severity

Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) are the most effective monotherapy for allergic rhinitis and should be first-line treatment for moderate to severe disease. 1, 2, 3

• For mild symptoms (particularly sneezing, itching, and rhinorrhea): Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are appropriate initial therapy 1, 3
• For moderate to severe symptoms: Intranasal corticosteroids should be initiated, either alone or combined with intranasal antihistamines (azelastine, olopatadine) for optimal symptom control 1, 2, 3
• Combination therapy (intranasal corticosteroid plus intranasal antihistamine) provides greater efficacy than either agent alone for patients aged 12 years or older with moderate to severe seasonal allergic rhinitis 2, 3

Critical Medication Selection Principles

Second-generation antihistamines are strongly preferred over first-generation antihistamines due to significantly less sedation and performance impairment that patients may not subjectively perceive 4, 1, 2

• Oral antihistamines effectively reduce rhinorrhea, sneezing, and itching but have little objective effect on nasal congestion 4
• Continuous daily treatment is more effective than intermittent use for seasonal or perennial allergic rhinitis due to unavoidable ongoing allergen exposure 4
• Intranasal antihistamines may be offered as an alternative to oral antihistamines for seasonal, perennial, or episodic allergic rhinitis 3

Medications to Avoid or Use With Caution

Oral leukotriene receptor antagonists should NOT be offered as primary therapy as they are generally less efficacious than intranasal corticosteroids, though they may have additive benefit when combined with antihistamines 4, 2, 3

• Oral corticosteroids are contraindicated for routine treatment due to greater potential for long-term adverse effects 2, 3
• Prolonged use of intranasal decongestants (beyond 10 days) must be avoided to prevent rhinitis medicamentosa (rebound congestion) 2, 3
• For severe nasal obstruction, topical oxymetazoline may be added for a maximum of 3 days only 2
• Do NOT routinely add oral antihistamines to intranasal corticosteroids as multiple high-quality trials show no additional benefit 2

Adjunctive Non-Pharmacologic Therapies

Nasal saline irrigation is beneficial for treating chronic rhinorrhea and rhinosinusitis symptoms, either as monotherapy or adjunctive treatment 1, 2, 3

• Allergen avoidance and environmental controls (removal of pets, air filtration systems, bed covers, acaricides) should be advised for patients with identified allergens that correlate with clinical symptoms 3
• Ipratropium (intranasal anticholinergic) is particularly effective for rhinorrhea in both allergic and nonallergic rhinitis, and may be combined with antihistamines or intranasal corticosteroids 1, 2

Allergen Immunotherapy: The Only Disease-Modifying Treatment

Allergen immunotherapy (sublingual or subcutaneous) should be offered or referred for patients with inadequate response to pharmacotherapy and environmental controls, as it is the only treatment that can modify the natural history of allergic rhinitis 1, 2, 3

• Clinical benefits may be sustained years after discontinuation of treatment 1, 2
• Immunotherapy may prevent development of new allergen sensitizations and reduce the risk for future development of asthma 1, 2, 3
• Multiple randomized, double-blind, placebo-controlled studies have demonstrated effectiveness 1

Diagnostic Testing Indications

Allergy testing (specific IgE skin or blood testing) should be performed or referred when patients do not respond to empiric treatment, when diagnosis is uncertain, or when knowledge of specific causative allergens is needed to target therapy 1, 3

• Routine sinonasal imaging should NOT be performed in patients presenting with symptoms consistent with allergic rhinitis 3

Assessment of Comorbidities

Clinicians must assess and document associated conditions that can worsen allergic rhinitis or be worsened by it, including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1, 3

• Treatment of allergic rhinitis may improve asthma control, and over 50% of patients with asthma have allergic rhinitis 1, 2

Special Considerations for Children

Children aged 4 to 11 years should use lower doses (1 spray per nostril once daily versus up to 2 sprays for those ≥12 years) 5

• Use should be limited to 2 months per year before checking with a doctor, as long-term intranasal glucocorticoids may cause slower growth rates in some children 5
• The shortest duration necessary to achieve symptom relief should be used 5

Critical Technique for Intranasal Corticosteroids

Failing to direct intranasal corticosteroid spray away from the nasal septum can lead to mucosal erosions and potential septal perforations 2, 3

When to Refer to Allergist/Immunologist

Referral should be considered for patients with prolonged and severe disease, inadequately controlled symptoms despite treatment, comorbid conditions (asthma, recurrent sinusitis, nasal polyps), symptoms interfering with quality of life or ability to function, ineffective medications or adverse reactions, or when allergen immunotherapy is being considered 4, 1, 3

Follow-Up and Monitoring

Periodic assessment of quality of life is essential, including evaluation of time lost from work or activities, sleep quality, smell and taste, fatigue level, and general well-being 1

• Tapering of medications should always be considered to lessen the risk of adverse reactions 1
• For patients ≥12 years using intranasal corticosteroids daily for longer than 6 months, or children 4-11 years using for longer than 2 months per year, check with a doctor 5