What is the recommended treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

For initial treatment of allergic rhinitis in patients aged 12 years or older, start with intranasal corticosteroid monotherapy as first-line therapy, as this is the most effective pharmacologic option for controlling all nasal symptoms. 1

First-Line Treatment Algorithm

For Mild to Moderate Symptoms

• Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) should be prescribed as monotherapy rather than combining with oral antihistamines initially, based on strong evidence from the Joint Task Force on Practice Parameters 1
• These agents are superior to leukotriene receptor antagonists (montelukast) for patients aged 15 years or older 1
• Intranasal corticosteroids effectively control nasal congestion, rhinorrhea, sneezing, and itching—all cardinal symptoms of allergic rhinitis 2, 3

For Patients with Predominant Sneezing and Itching

• Second-generation oral antihistamines (loratadine, desloratadine, cetirizine, fexofenadine) may be recommended when sneezing and itching are the primary complaints 2, 4, 3
• Intranasal antihistamines (azelastine, olopatadine) can be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis 4, 3

Escalation for Inadequate Response

Moderate to Severe Disease

• For moderate to severe seasonal allergic rhinitis with inadequate response to monotherapy, combine an intranasal corticosteroid with an intranasal antihistamine (not oral antihistamine), as this combination shows greater symptom reduction than either agent alone 1, 4
• Adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit and should be avoided 4

Additional Adjunctive Therapies

• Intranasal ipratropium bromide combined with intranasal corticosteroids is more effective than either alone specifically for rhinorrhea control 2, 4
• Nasal saline irrigation can be used as sole therapy or adjunctive treatment for chronic rhinorrhea 4
• Leukotriene receptor antagonists (montelukast 10 mg daily) may be added as adjunctive therapy, though they are less effective than intranasal corticosteroids 4, 5

Refractory Disease Management

• Patients with inadequate response to pharmacologic therapy should be referred for allergen immunotherapy (subcutaneous or sublingual), which is the only disease-modifying treatment 1, 2, 4
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk 4
• A short 5-7 day course of oral corticosteroids (prednisone) may be appropriate only for very severe or intractable symptoms significantly impacting quality of life 2, 4

Environmental Control Measures

• Allergen avoidance should be implemented when specific allergens correlating with clinical symptoms have been identified 2
• Avoidance is the most effective management strategy for animal sensitivity 2
• Environmental controls are particularly important for indoor allergens, though less effective for outdoor seasonal allergens 1

Critical Pitfalls to Avoid

• Do not routinely combine intranasal corticosteroids with oral antihistamines for initial treatment—this provides no additional benefit over intranasal corticosteroid monotherapy 1, 4
• Avoid prolonged use of topical nasal decongestants, as this leads to rhinitis medicamentosa 6
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating 4
• Oral decongestants (pseudoephedrine, phenylephrine) should be used with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 4
• Always assess for associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 4
• Avoid routine sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis 4

Severity-Based Treatment Selection

Mild Intermittent or Mild Persistent Disease

• Second-generation H1 antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) OR intranasal antihistamine (azelastine, olopatadine) 3

Persistent Moderate to Severe Disease

• Intranasal corticosteroid alone or in combination with intranasal antihistamine 3