What are the treatment options for allergic rhinitis management?

Allergic Rhinitis Management

First-Line Treatment Based on Severity

For moderate to severe allergic rhinitis, intranasal corticosteroids (fluticasone, triamcinolone, budesonide, or mometasone) are the most effective first-line therapy and should be initiated immediately. 1, 2

• Intranasal corticosteroids provide superior efficacy for overall symptom control compared to all other monotherapies and should be considered without requiring prior trials of antihistamines or decongestants. 1, 2
• Patients must direct sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations, and maximum efficacy requires several days of consistent use. 1, 2
• For seasonal allergic rhinitis, starting intranasal corticosteroids before the season begins provides optimal prophylaxis. 1

For mild intermittent allergic rhinitis, second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) or intranasal antihistamines (azelastine, olopatadine) are effective for sneezing, itching, and rhinorrhea. 1, 3

• Second-generation antihistamines are strongly preferred over first-generation agents due to significantly less sedation, reduced impairment of work performance, and decreased accident risk. 1, 2
• First-generation antihistamines should be avoided in most patients, with extreme caution required in older adults due to increased sensitivity to psychomotor impairment and anticholinergic effects. 1

Combination Therapy for Inadequate Response

For moderate to severe allergic rhinitis not adequately controlled with intranasal corticosteroids alone, add an intranasal antihistamine rather than an oral antihistamine. 2

• The combination of intranasal corticosteroid plus intranasal antihistamine provides greater symptom reduction than either agent alone and is more effective than adding oral antihistamines. 2
• Multiple high-quality trials demonstrate no additional benefit from adding oral antihistamines to intranasal corticosteroids. 2
• Leukotriene receptor antagonists (montelukast) should not be added to intranasal corticosteroids, as they provide no additional benefit and are less effective than intranasal corticosteroids alone. 2, 4

Adjunctive Therapies and Symptom-Specific Treatment

For severe nasal congestion, oral decongestants provide symptomatic relief but require careful patient screening for contraindications including hypertension, anxiety, cardiac conditions, prostate hypertrophy, or glaucoma. 1, 5

• Topical nasal decongestants must be strictly limited to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 1, 2
• If topical decongestants are needed for severe obstruction, use oxymetazoline for a maximum of 3 days only. 2

For predominant rhinorrhea, intranasal anticholinergics (ipratropium bromide) are particularly effective and can be combined with intranasal corticosteroids without increased adverse effects. 2, 5

• Nasal saline irrigation is recommended as adjunctive non-pharmacological therapy to relieve congestion and facilitate clearance of nasal secretions. 1, 2

Environmental Control and Allergen Avoidance

Identifying specific allergens through testing and implementing targeted avoidance strategies should be initiated early in treatment. 1, 2

• Complete avoidance of animals is the most effective strategy for managing animal allergies. 1
• Addressing non-allergen irritants such as tobacco smoke, strong odors, and temperature/humidity extremes helps manage symptoms. 1

Allergen Immunotherapy

Allergen immunotherapy is the only treatment that modifies the natural history of allergic rhinitis and should be offered to patients with documented specific IgE antibodies to clinically relevant allergens who fail pharmacotherapy with or without environmental controls. 1, 2

• Immunotherapy can prevent development of new allergen sensitizations and reduce the risk of future asthma development in patients with allergic rhinitis. 2
• Clinical benefits may persist for years after discontinuation of treatment. 2

Special Population Considerations

• In children under 3 years, decongestants and antihistamines should be avoided due to risks outweighing benefits. 1
• In older adults, extreme caution is required with first-generation antihistamines due to increased sensitivity to adverse effects. 1
• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma. 2

Critical Pitfalls to Avoid

Antibiotics are completely ineffective for allergic rhinitis and contribute to antimicrobial resistance—they should never be used. 1

• Prolonged use of intranasal decongestants beyond 3-5 days leads to rhinitis medicamentosa. 1, 2
• Recurrent administration of parenteral or oral corticosteroids should be avoided due to significant long-term adverse effects. 2
• Failing to counsel patients on proper intranasal spray technique (directing away from septum) can lead to septal complications. 1, 2

When to Refer to Allergist/Immunologist

Referral is indicated for symptoms inadequately controlled with first-line pharmacotherapy, suspected complications (otitis media, sinusitis, nasal polyposis), comorbid asthma or chronic sinusitis, or when immunotherapy is being considered. 1, 2