What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be initiated for all patients with moderate to severe symptoms, with second-generation oral antihistamines or intranasal antihistamines reserved for mild disease or as adjunctive therapy. 1, 2, 3

Treatment Algorithm by Disease Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) are appropriate first-line options for patients whose primary complaints are sneezing, itching, and rhinorrhea. 2, 4
• Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis. 2, 4
• These agents have limited effect on nasal congestion, which is a key limitation. 4

Moderate to Severe Allergic Rhinitis

• Intranasal corticosteroids (fluticasone propionate, mometasone furoate, triamcinolone acetonide, budesonide) should be initiated as first-line monotherapy, as they are the most effective medication class for controlling all symptoms including nasal congestion, rhinorrhea, sneezing, and itching. 1, 2, 3
• Fluticasone propionate is FDA-approved for adults and children ≥4 years at 1-2 sprays per nostril once daily. 5
• Triamcinolone acetonide is approved for children as young as 2 years at 1 spray per nostril once daily. 1
• Mometasone furoate is approved for children ≥2 years at 1 spray per nostril daily. 1

Combination Therapy for Inadequate Response

• Adding an intranasal antihistamine to an intranasal corticosteroid is recommended for moderate to severe allergic rhinitis that doesn't respond to monotherapy, as this combination provides greater symptom reduction than either agent alone. 2, 3
• Do NOT add oral antihistamines to intranasal corticosteroids, as multiple high-quality trials demonstrate no additional benefit. 2, 3
• Do NOT add leukotriene receptor antagonists (montelukast) to intranasal corticosteroids, as they provide no additional benefit and are less effective than intranasal corticosteroids alone. 2, 3

Adjunctive and Alternative Therapies

When Intranasal Corticosteroids Are Not Tolerated

• Second-generation oral antihistamines may be used as second-line therapy, though they are less effective than intranasal corticosteroids. 1
• Intranasal cromolyn sodium has a strong safety profile but is less effective than intranasal corticosteroids and must be started early in the allergy season. 1, 3

Additional Symptomatic Treatments

• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 2, 3
• 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. 2, 3

Refractory Disease

• Allergen immunotherapy (subcutaneous or sublingual) should be considered for patients with inadequate response to pharmacologic therapy, as it is the only treatment that modifies the natural history of allergic rhinitis and may prevent development of new allergen sensitizations and future asthma. 2, 3

Critical Pitfalls to Avoid

Medications to Avoid or Use with Extreme Caution

• First-generation antihistamines should be avoided due to sedative and anticholinergic effects. 1, 3
• Topical decongestants should only be used short-term (less than 3 days, maximum 10 days) to avoid rhinitis medicamentosa (rebound congestion). 3
• Oral decongestants should be avoided in young children (causing irritability, insomnia, loss of appetite) and used with caution in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1, 2
• Systemic corticosteroids are contraindicated for routine use due to long-term adverse effects and should only be reserved for very severe, intractable symptoms as a short 5-7 day course. 2, 3

Proper Intranasal Corticosteroid Technique

• Direct the spray away from the nasal septum to avoid mucosal erosions and potential septal perforations. 3
• Prime the pump before first use and after periods of non-use to ensure full dosing. 5
• Continue daily use as long as exposed to allergens, even when symptoms improve, to maintain relief. 5

Special Populations

Children Ages 2-11 Years

• Triamcinolone acetonide or mometasone furoate at 1 spray per nostril once daily for children ≥2 years. 1
• Fluticasone propionate at 1 spray per nostril once daily for children ≥4 years. 1, 5
• Duration should be limited to 2 months per year before checking with a doctor, as long-term intranasal corticosteroids may slow growth rate in some children. 1, 5

Duration of Treatment

• Adults may use intranasal corticosteroids for up to 6 months of daily use before checking with a doctor. 5
• For seasonal allergic rhinitis, treatment may be stopped when the allergy season ends. 5

Comprehensive Management

Allergen Avoidance

• Identify and educate patients about avoiding specific triggers (pollen, mold, dust, pet dander), as allergen avoidance is fundamental to successful management. 1, 3

Assess for Comorbid Conditions

• Always evaluate for asthma, atopic dermatitis, sleep-disordered breathing, allergic conjunctivitis, rhinosinusitis, and otitis media, which frequently coexist with allergic rhinitis. 1, 2
• Treatment of allergic rhinitis may improve asthma control in patients with coexisting asthma. 3

Referral Indications

• Refer to an allergist/immunologist for inadequate symptom control, reduced quality of life, consideration of immunotherapy, prolonged manifestations, complications (otitis media, sinusitis, nasal polyposis), or when systemic corticosteroids have been required. 3