What is the best treatment approach for a patient with allergic rhinitis, considering their medical history and potential comorbidities such as asthma?

Treatment of Allergic Rhinitis

For patients with allergic rhinitis whose symptoms affect quality of life, intranasal corticosteroids should be the first-line therapy, as they are the most effective treatment available and carry a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery. 1

Initial Pharmacologic Management

Primary Therapy Selection Based on Symptom Profile

• Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are recommended as first-line therapy for patients with persistent moderate to severe allergic rhinitis whose symptoms affect their quality of life 1, 2
• These agents are the most potent and effective medications available for treating allergic rhinitis, superior to all other medication classes 3
• Oral second-generation antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) should be recommended for patients whose primary complaints are sneezing and itching 1, 2
• For mild intermittent or mild persistent allergic rhinitis, either a second-generation oral antihistamine or intranasal antihistamine (azelastine, olopatadine) may be used as initial therapy 2

Dosing and Administration of Intranasal Corticosteroids

• Adults should start with 200 mcg once daily (two 50-mcg sprays per nostril), which can alternatively be given as 100 mcg twice daily 4
• Pediatric patients (≥4 years) should start with 100 mcg once daily (one spray per nostril), with 200 mcg daily reserved for inadequate responders 4
• Symptom improvement may begin as early as 12 hours after initial treatment, but maximum benefit typically requires several days of regular use 4
• Once adequate control is achieved, the dose should be decreased to the minimum effective dose (100 mcg daily) 4

Assessment of Comorbidities

Clinicians must assess and document the presence of associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1

• This assessment is critical because allergic rhinitis and asthma represent "one airway, one disease," with common pathophysiologic mechanisms 1
• Pulmonary function testing should be considered in patients with rhinitis to assess for coexisting asthma, which may not be clinically apparent 1
• The presence of asthma influences treatment decisions and may indicate the need for more aggressive therapy or immunotherapy 1, 5

Management of Inadequate Response to Monotherapy

Combination Pharmacotherapy

• Combination therapy may be offered when patients have inadequate response to pharmacologic monotherapy 1
• Intranasal antihistamines (azelastine, olopatadine) may be added for seasonal, perennial, or episodic allergic rhinitis 1
• Oral leukotriene receptor antagonists should NOT be offered as primary therapy for allergic rhinitis 1

Allergen Testing and Immunotherapy

• Specific IgE testing (skin or blood) should be performed or referred for patients who do not respond to empiric treatment, when the diagnosis is uncertain, or when knowledge of specific causative allergens is needed to target therapy 1
• Immunotherapy (sublingual or subcutaneous) should be offered or referred for patients with inadequate response to pharmacologic therapy with or without environmental controls 1
• Immunotherapy is particularly appropriate for patients with moderate to severe symptoms inadequately controlled by conventional medications, those with unacceptable medication side effects, or those wishing to avoid long-term pharmacotherapy 5, 6
• A minimum of 3 years of immunotherapy is recommended for optimal clinical benefit and potential disease modification 5, 6
• Immunotherapy is the only treatment that can modify the natural history of allergic rhinitis, prevent new allergen sensitizations, and reduce the risk of future asthma development 1, 5

Environmental Control Measures

• Allergen avoidance may be advised for patients who have identified allergens that correlate with clinical symptoms, including removal of pets, use of air filtration systems, bed covers, and acaricides for dust mites 1
• However, the benefit-harm assessment for environmental controls shows equilibrium, as many studies demonstrate allergen reduction but limited symptom improvement 1
• Multiple avoidance techniques may be more effective than individual measures 1

Diagnostic Considerations

What NOT to Do

• Do not routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis 1
• Do not use IgG antibody testing to identify allergen triggers, as allergic rhinitis is IgE-mediated 6
• Not all positive allergy tests are clinically relevant; correlation with clinical history and exposure is essential 6

Clinical Diagnosis

• The clinical diagnosis should be made when patients present with nasal congestion, runny nose, itchy nose, or sneezing, along with findings consistent with an allergic cause including clear rhinorrhea, pale discoloration of nasal mucosa, and red watery eyes 1
• Patients with seasonal allergic rhinitis typically have edematous and pale turbinates, while those with perennial allergic rhinitis have erythematous and inflamed turbinates 2

Advanced and Adjunctive Therapies

Surgical Options

• Inferior turbinate reduction may be offered or referred for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management 1

Alternative Therapies

• Acupuncture may be offered or referred for patients interested in nonpharmacologic therapy 1
• No recommendation can be made regarding herbal therapy 1

Common Pitfalls to Avoid

• Do not assume all rhinitis is allergic; patients with nonallergic rhinitis present primarily with nasal congestion and postnasal drainage, have negative specific IgE testing, and are less responsive to nasal corticosteroids 2
• Do not exceed maximum recommended doses of intranasal corticosteroids (200 mcg/day), as there is no evidence that higher doses are more effective 4
• Avoid topical decongestants for prolonged use, as this leads to rhinitis medicamentosa 3
• Do not discontinue effective therapies without documented treatment failure or intolerable side effects 6
• Ensure asthma is well-controlled before initiating immunotherapy, as uncontrolled asthma is a contraindication 6