What are the treatment options for nasal congestion caused by immunotherapy?

Treatment of Nasal Congestion Due to Immunotherapy

For nasal congestion occurring as a side effect during allergen immunotherapy, intranasal corticosteroids are the most effective treatment and should be initiated first, as they provide the most potent anti-inflammatory control of nasal congestion. 1, 2

Understanding the Clinical Context

Nasal congestion can occur as a local reaction during allergen immunotherapy (both subcutaneous and sublingual forms). This represents a localized inflammatory response to the allergen exposure and requires symptomatic management while continuing the immunotherapy, as the long-term benefits of immunotherapy include disease modification and prevention of asthma development. 3

First-Line Treatment Approach

Intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) should be started immediately as they are the most effective pharmacologic treatment for nasal congestion associated with allergic inflammation. 1, 2, 4 These agents have broad anti-inflammatory activities and provide superior symptom control compared to all other medication classes. 2, 5

• Maximum efficacy requires several days of consistent use, so patients must be counseled on adherence. 6
• The spray must be directed away from the nasal septum to prevent mucosal erosions and potential septal perforation. 1, 6

Second-Line and Adjunctive Options

If intranasal corticosteroids alone provide inadequate relief:

Add an intranasal antihistamine (azelastine or olopatadine) to the intranasal corticosteroid regimen, as this combination provides greater efficacy than either agent alone for moderate to severe symptoms. 3, 1, 2

• Intranasal antihistamines have clinically significant effects on nasal congestion, superior to oral antihistamines. 3
• Be aware that systemic absorption can cause sedation and may inhibit skin test reactions. 3

Do NOT routinely add oral antihistamines to intranasal corticosteroids, as multiple high-quality trials demonstrate no additional benefit from this combination. 3, 1

Do NOT add leukotriene receptor antagonists to intranasal corticosteroids, as they provide no additional benefit and are less effective than intranasal corticosteroids alone. 3, 1

Short-Term Rescue for Severe Congestion

For severe nasal obstruction requiring immediate relief:

Topical oxymetazoline may be added for a maximum of 3 days only to avoid rhinitis medicamentosa (rebound congestion). 3, 1, 2

• The combination of intranasal corticosteroid plus intranasal oxymetazoline is more effective than either monotherapy for severe symptoms. 3
• Prolonged use beyond 3-5 days will cause rebound congestion that worsens the underlying problem. 1, 2, 6

Oral decongestants (pseudoephedrine or phenylephrine) can reduce nasal congestion but must be used with extreme caution. 3, 4

• Contraindications include cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 3
• Side effects include insomnia, irritability, and palpitations. 3

Non-Pharmacologic Adjuncts

Nasal saline irrigation should be recommended as it is beneficial for treating nasal congestion and rhinorrhea, either as monotherapy or adjunctive treatment. 3, 1, 2, 6

• This has minimal side effects and good patient acceptance. 3
• Various concentrations and delivery methods are available; isotonic to hypertonic solutions can be used. 3

Critical Management Decisions

Continue the immunotherapy regimen unless systemic reactions occur, as immunotherapy is the only treatment that modifies the natural history of allergic disease and provides long-term benefits that persist after discontinuation. 3, 1

• Clinical improvement typically occurs after reaching maintenance dose. 3
• Lack of improvement after 1 year of maintenance treatment should prompt review of the immunotherapy program. 3

Review the immunotherapy dosing schedule with the administering physician, as dose adjustments may reduce local reactions while maintaining efficacy. 3

Treatments to Avoid

Never use oral corticosteroids for routine management of nasal congestion during immunotherapy, as recurrent administration is contraindicated due to greater potential for long-term adverse effects. 3, 1

Avoid first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects. 3, 1, 2

When to Reassess the Immunotherapy Program

If nasal congestion persists despite optimal pharmacologic management:

• Consult with the allergist/immunologist administering the immunotherapy to review the treatment protocol. 3
• Consider whether the patient is experiencing true immunotherapy-related congestion versus inadequately controlled underlying allergic rhinitis. 3
• Evaluate for structural causes of obstruction (septal deviation, turbinate hypertrophy) that may be contributing to symptoms. 3