What is the recommended treatment for a typical adult patient with a history of allergies and no significant medical comorbidities, presenting with moderate to severe allergic rhinitis, using intranasal corticosteroids?

Intranasal Corticosteroids for Moderate to Severe Allergic Rhinitis

Intranasal corticosteroids should be prescribed as first-line monotherapy for your patient with moderate to severe allergic rhinitis, as they are the most effective medication class for controlling all four major symptoms (congestion, rhinorrhea, sneezing, and itching) and should be initiated without requiring a prior trial of antihistamines or other agents. 1

Why Intranasal Corticosteroids Are Superior

• Intranasal corticosteroids are more effective than oral antihistamines for relieving nasal congestion, discharge, sneezing, and itching in both seasonal and persistent allergic rhinitis, with high-quality evidence supporting their superiority. 1

• They outperform leukotriene receptor antagonants (like montelukast) with strong recommendation based on low-quality evidence for seasonal allergic rhinitis. 1, 2

• Intranasal corticosteroids are more effective than the combination of an oral antihistamine plus leukotriene antagonist in most studies of seasonal allergic rhinitis. 1

• They are significantly more effective than intranasal antihistamines (strong recommendation, high-quality evidence) and should be chosen over intranasal antihistamines as initial therapy. 1

Specific Prescribing Recommendations

For Adults (≥12 years):

• Fluticasone propionate: 2 sprays per nostril once daily (200 mcg total) 3, 4
• Mometasone furoate: 2 sprays per nostril once daily (200 mcg total) 3
• Triamcinolone acetonide: Available over-the-counter, 2 sprays per nostril once daily 3

Duration of Treatment:

• Continue daily use throughout the entire allergen exposure period, not just when symptoms are present. 4
• For year-round allergies, continuous daily use up to 6 months is appropriate before checking with a physician for ongoing management. 4
• Minimum 2 weeks of consistent use is required before full therapeutic benefit becomes evident. 3

Critical Administration Technique

Proper technique is essential to maximize efficacy and minimize side effects:

• Use the contralateral hand technique (right hand for left nostril, left hand for right nostril) to naturally angle the spray away from the nasal septum, which reduces epistaxis risk by four times. 3
• Prime the bottle before first use and shake before each administration. 3
• Keep head upright during spraying (not tilted back). 3
• Have the patient blow their nose before administration. 3

Safety Profile and Monitoring

Intranasal corticosteroids at recommended doses are remarkably safe:

• No clinically significant systemic side effects occur at recommended doses, including no effect on the hypothalamic-pituitary-adrenal axis. 1, 3
• No effect on growth in children when fluticasone propionate, mometasone furoate, or budesonide are used at recommended doses. 3
• Long-term use (up to 52 weeks studied) is safe with no evidence of nasal mucosal atrophy. 3

Common local side effects (5-10% of patients):

• Epistaxis (nosebleeds) - most common adverse event 3, 5
• Nasal irritation, burning, or dryness 1, 5
• Headache 3, 5
• Pharyngitis 3

Monitoring requirements:

• Periodically examine the nasal septum to ensure no mucosal erosions are present, as these may precede septal perforation (a rare complication). 1, 3

What NOT to Do

• Never administer intramuscular corticosteroids for allergic rhinitis - this is strongly contraindicated due to serious potential side effects that far outweigh benefits. 1
• Do not prescribe oral antihistamines as initial monotherapy when the patient has moderate to severe symptoms, as intranasal corticosteroids are significantly more effective. 1
• Avoid topical nasal decongestants (oxymetazoline, phenylephrine) beyond 3-5 days due to rhinitis medicamentosa risk. 1

When to Add Combination Therapy

If symptoms remain inadequately controlled after 2-3 weeks of intranasal corticosteroid monotherapy:

• Add an intranasal antihistamine (azelastine) to the intranasal corticosteroid, as the combination of fluticasone propionate plus azelastine shows >40% relative improvement compared to either agent alone. 3
• Adding an oral antihistamine to intranasal corticosteroid generally has not demonstrated greater benefit in controlled trials, though some patients with prominent itching may benefit. 1

Special Considerations for Severe Symptoms

For very severe or intractable rhinitis:

• A short 5-7 day course of oral corticosteroids may be appropriate as adjunctive therapy, but recurrent administration is contraindicated. 1
• This should be reserved for patients not responding to optimal intranasal therapy. 1

Drug Interactions to Screen For

Before prescribing, ask about:

• HIV protease inhibitors (ritonavir) - may increase fluticasone levels; discuss with pharmacist before prescribing. 4
• Ketoconazole (oral) - may increase fluticasone levels; discuss with pharmacist before prescribing. 4
• Other corticosteroid medications (inhaled, topical, ophthalmic) - document concurrent use but generally safe to use together. 4

Patient Education Points

• Emphasize that this is maintenance therapy, not rescue therapy - symptoms will not improve immediately like with decongestants. 3
• Full benefit requires 2 weeks of consistent daily use, with maximal efficacy reached over days to weeks. 3
• Continue using daily throughout allergen exposure, even when feeling better, to maintain symptom control. 4
• Do not share the bottle with others, as this spreads germs. 4
• Never spray in eyes or mouth - this medication works only in the nose. 4

When to Refer

Refer to an allergist/immunologist if:

• No good response after 2-3 weeks of optimal intranasal corticosteroid therapy 1
• Symptoms persist despite combination therapy with intranasal corticosteroid plus intranasal antihistamine 3
• Consider allergen immunotherapy for long-term disease modification in patients requiring continuous pharmacotherapy 3