Treatment of Allergic Rhinitis
Intranasal corticosteroids are the first-line treatment for allergic rhinitis, as they are the most effective medication class for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2, 3
Treatment Algorithm Based on Severity
Mild Intermittent or Mild Persistent Allergic Rhinitis
- Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) or an intranasal antihistamine (azelastine, olopatadine) as first-line options. 4
- Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation and fewer anticholinergic effects. 1, 3
- These agents effectively control sneezing, itching, and rhinorrhea but have limited effect on nasal congestion. 4
Moderate to Severe or Persistent Allergic Rhinitis
- Begin treatment with an intranasal corticosteroid (fluticasone, triamcinolone, budesonide, mometasone) as monotherapy. 1, 2, 3, 4
- Intranasal corticosteroids are superior to leukotriene receptor antagonists (montelukast) for allergic rhinitis treatment. 2
- These medications control all nasal symptoms including congestion, which antihistamines cannot adequately address. 5
- Clinical efficacy can be demonstrated within 24 hours after the first dose. 6
Escalation for Inadequate Response to Monotherapy
Combination Therapy
- For moderate to severe allergic rhinitis not responding to intranasal corticosteroid monotherapy, add an intranasal antihistamine (not an oral antihistamine) to the intranasal corticosteroid. 2, 3
- This combination provides greater symptom reduction than either agent alone. 2, 7
- Do not add oral antihistamines to intranasal corticosteroids—multiple high-quality trials show no additional benefit. 2, 3
- Do not add leukotriene receptor antagonists to intranasal corticosteroids—they provide no additional benefit and are less effective than intranasal corticosteroids alone. 3
Adjunctive Therapies
- 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 Management
- Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual), which is the only disease-modifying treatment. 2, 3
- Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk in patients with allergic rhinitis. 2, 3
- Benefits can be maintained for years after discontinuation of treatment. 3
Specific Dosing Considerations
Adults and Children ≥12 Years
- Fluticasone propionate: 1-2 sprays per nostril once daily (FDA-approved for ages ≥4 years). 1, 8
- Triamcinolone acetonide: 1-2 sprays per nostril once daily. 1
- Mometasone furoate: 1-2 sprays per nostril once daily. 1
- Duration: May use up to 6 months of daily use before checking with a doctor. 8
Children Ages 4-11 Years
- Use lower doses: 1 spray per nostril once daily. 1, 8
- Triamcinolone acetonide is FDA-approved for children ≥2 years. 1
- Mometasone furoate is approved for children as young as 2 years. 1
- Duration limit: Check with a doctor if use exceeds 2 months per year due to potential effects on growth rate. 1, 8
Critical Pitfalls to Avoid
Medications to Avoid
- Never use first-generation antihistamines due to sedative and anticholinergic effects. 1, 3
- Avoid topical decongestants for more than 3 days to prevent rhinitis medicamentosa (rebound congestion). 1, 3
- Do not use oral decongestants in young children as they can cause irritability, insomnia, and loss of appetite. 1
- Systemic corticosteroids should be reserved only for severe, intractable symptoms unresponsive to other treatments and used only for short courses. 1, 2
Proper Technique
- Direct the intranasal corticosteroid 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. 8
Environmental Control
- Allergen avoidance is fundamental to successful management and should be implemented even in early treatment. 1, 2, 3
- Identify and educate patients about avoiding specific triggers. 1
Special Considerations
Drug Interactions
- Avoid concurrent use with ritonavir (HIV medication) or ketoconazole pills, as they may cause excessive fluticasone levels. 8
- Exercise caution when using other glucocorticosteroid medications concurrently for asthma, skin conditions, or eye conditions. 8