What is the management of allergic rhinitis symptoms in adults?

Management of Allergic Rhinitis in Adults

Clinical Diagnosis

Diagnose allergic rhinitis clinically when patients present with one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing, along with physical findings consistent with an allergic cause including clear rhinorrhea, pale nasal mucosa, and red watery eyes. 1

• The presence of nasal itching and eye symptoms strongly suggests allergic rhinitis rather than other conditions like rhinosinusitis 2
• Allergic rhinitis is characterized by sneezing, nasal itching, congestion, and rhinorrhea, often associated with conjunctivitis 3
• Document associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1

First-Line Pharmacotherapy

Intranasal corticosteroids are the most effective monotherapy and should be first-line treatment for adults with allergic rhinitis whose symptoms affect quality of life. 1, 4

Intranasal Corticosteroids (Preferred Initial Treatment)

• Fluticasone propionate, triamcinolone, budesonide, or mometasone are recommended as first-line agents 2, 5
• Start adults with 200 mcg daily (two 50-mcg sprays per nostril once daily) or 100 mcg twice daily 6
• Maximum effect may take several days of consistent use; symptom improvement can begin as early as 12 hours 6
• Patients must direct sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations 2, 4
• After 4-7 days of response, maintenance dosing can be reduced to 100 mcg daily (one spray per nostril once daily) 6
• Intranasal corticosteroids control all symptoms including sneezing, rhinorrhea, itching, and nasal congestion 7, 6

Alternative First-Line for Mild Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are recommended for patients with primary complaints of sneezing and itching 1, 4
• These agents are preferred over first-generation antihistamines due to less sedation and performance impairment 4
• Oral antihistamines are effective for rhinorrhea, sneezing, and itching but have limited effect on nasal congestion 4
• Continuous treatment is more effective than intermittent use for seasonal or perennial allergic rhinitis 1

Treatment Algorithm by Severity

Mild Intermittent Symptoms (< 4 days/week or < 4 weeks/year)

• Start with second-generation oral antihistamine OR intranasal antihistamine (azelastine, olopatadine) 5
• For seasonal allergic rhinitis, start medication before the season begins for optimal prophylaxis 2

Moderate to Severe or Persistent Symptoms (> 4 days/week and > 4 weeks/year)

• Begin with intranasal corticosteroid as monotherapy 5
• If inadequate response after several days, add intranasal antihistamine to the intranasal corticosteroid 4
• This combination provides greater symptom reduction than either agent alone 4

Severe Nasal Obstruction

• Consider adding topical oxymetazolone for maximum 3 days to avoid rhinitis medicamentosa (rebound congestion) 4
• Topical nasal decongestants must be limited to 3-5 days maximum 2

Adjunctive Therapies

For Persistent Rhinorrhea

• Intranasal anticholinergics (ipratropium bromide 0.03%) are specifically effective for rhinorrhea 7, 4
• May be used in combination with antihistamines or intranasal corticosteroids for increased efficacy 4
• Minimal effect on other symptoms but targets rhinorrhea without systemic effects 7

Non-Pharmacological Measures

• Nasal saline irrigation provides adjunctive relief for congestion and facilitates clearance of nasal secretions 2, 4
• Identify specific allergens through skin or blood IgE testing when diagnosis is uncertain or response to empiric treatment is inadequate 1
• Implement targeted allergen avoidance strategies based on testing results 2
• Address non-allergen irritants including tobacco smoke, strong odors, and temperature/humidity extremes 2

What NOT to Do

Avoid these common pitfalls:

• Do not routinely add oral antihistamines to intranasal corticosteroids - multiple trials show no additional benefit 4
• Do not add leukotriene receptor antagonants (montelukast) to intranasal corticosteroids - they provide no additional benefit and are less effective than intranasal corticosteroids alone 4
• Avoid first-generation antihistamines due to sedation, impaired work performance, and increased accident risk 2
• Never use antibiotics for allergic rhinitis - they are ineffective and contribute to antimicrobial resistance 2
• Avoid prolonged use of topical decongestants beyond 3-5 days to prevent rhinitis medicamentosa 2, 4
• Do not routinely prescribe oral corticosteroids except for rare patients with severe intractable symptoms unresponsive to other treatments 4

Advanced Treatment Options

Allergen Immunotherapy

Offer or refer for immunotherapy (sublingual or subcutaneous) when patients have inadequate response to pharmacologic therapy with or without environmental controls. 1

• Requires documented specific IgE antibodies to clinically relevant allergens 2, 4
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis 4
• Benefits can persist years after discontinuation and may prevent development of new allergen sensitizations and asthma 4

Special Considerations

Coexisting Asthma

• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma 4
• Assess all patients with allergic rhinitis for asthma 1

Referral Indications

• Inadequate symptom control despite optimal pharmacotherapy 2
• Complications such as otitis media, sinusitis, or nasal polyposis 4
• When immunotherapy is being considered 4
• Uncertain diagnosis or atypical presentation 2