What is the first-line treatment for rhinitis, specifically allergic rhinitis?

First-Line Treatment for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for moderate to severe allergic rhinitis, as they are the most effective monotherapy for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itching. 1, 2, 3

Treatment Algorithm Based on Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) are appropriate first-line options for mild disease 3
• Intranasal antihistamines provide more rapid symptom relief than intranasal corticosteroids and are equal to or superior to oral antihistamines for seasonal allergic rhinitis, with significant effects on nasal congestion 1
• When immediate symptom relief is the priority, intranasal antihistamines should be selected as they provide rapid onset of action while effectively controlling nasal symptoms 1

Moderate to Severe Persistent Allergic Rhinitis

• Intranasal corticosteroids should be initiated as monotherapy for patients with moderate to severe symptoms, as they are superior to oral antihistamines and leukotriene receptor antagonists for nasal symptom reduction 2, 4, 3
• Available intranasal corticosteroids include fluticasone, triamcinolone, budesonide, mometasone, and beclomethasone, all of which demonstrate comparable efficacy 5, 3
• The main limitation is that intranasal corticosteroids may take several days to reach maximum effect, unlike intranasal antihistamines which work immediately 1

Escalation for Inadequate Response to Monotherapy

• Combination therapy with intranasal corticosteroid plus intranasal antihistamine should be considered for moderate to severe seasonal allergic rhinitis that does not respond adequately to monotherapy alone 2, 4
• This combination shows greater symptom reduction than either agent alone and is supported by high-quality evidence 2
• Do not add an oral antihistamine to an intranasal corticosteroid, as this provides no additional benefit 2

Alternative and Adjunctive Therapies

• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy or in patients who cannot tolerate intranasal corticosteroids, though they are less effective than intranasal corticosteroids 2, 6
• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea 2
• 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

Management of Ocular Symptoms

• Topical ophthalmic agents (azelastine, epinastine, ketotifen, or olopatadine) are more effective than oral antihistamines for ocular symptoms and should be used when eye symptoms are prominent 4
• Cold compresses and refrigerated artificial tears can provide symptomatic relief for ocular symptoms 4
• Oral antihistamines can worsen dry eye syndrome and should be avoided in patients with significant ocular dryness 4

Critical Pitfalls to Avoid

• Never use first-generation antihistamines due to significant sedation, performance impairment, and anticholinergic effects 1, 4
• Cetirizine and intranasal azelastine may cause sedation at recommended doses, which should be considered when selecting treatment 1, 2
• Avoid ocular corticosteroids except for severe symptoms, as they carry vision-threatening risks including cataract formation, elevated intraocular pressure, and secondary infections 4
• Oral decongestants should be used with extreme caution in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 1, 2

Special Population Considerations

• For older adults, fexofenadine is particularly advantageous due to its non-sedating properties and should be strongly preferred over other antihistamines 1
• For children, second-generation antihistamines are well-tolerated, but first-generation antihistamines should be avoided in children under 6 years 1

Refractory Disease Management

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

Associated Conditions to Assess

• Always assess for asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media in patients with allergic rhinitis, as treatment of rhinitis can improve asthma outcomes and reduce asthma-related hospitalizations 7, 2