What is the recommended management for a patient with allergic rhinitis?

Management of Allergic Rhinitis

First-Line Treatment

Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) should be prescribed as first-line therapy for all patients with allergic rhinitis whose symptoms affect their quality of life, as they are the most effective monotherapy available. 1, 2

• Intranasal corticosteroids control all nasal symptoms including congestion, rhinorrhea, sneezing, and itching more effectively than any other single agent 1, 3, 4
• These agents work on both early and late-phase allergic responses, with studies showing near-complete prevention of late-phase symptoms 5
• Dosing is once daily, with timing individualized to patient preference for allergic rhinitis (unlike asthma, which requires evening dosing) 6
• Common adverse effects are limited to local nasal symptoms: dryness, burning, stinging, and epistaxis in 5-10% of patients 5
• Critical technique: Direct the spray away from the nasal septum to prevent mucosal erosions and potential septal perforation 2

Alternative First-Line Options for Mild Symptoms

For patients with mild intermittent symptoms (less than 4 consecutive days/week or less than 4 consecutive weeks/year) where primary complaints are sneezing and itching:

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are appropriate as initial therapy 1, 2, 3
• These are strongly preferred over first-generation antihistamines due to significantly less sedation and performance impairment 2
• Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis 1, 2, 3
• Note: Cetirizine and intranasal azelastine may cause sedation even at recommended doses 7

Treatment Escalation for Moderate to Severe Disease

For patients aged 12 years or older with moderate to severe symptoms not adequately controlled by intranasal corticosteroid monotherapy, add an intranasal antihistamine to the intranasal corticosteroid. 1, 2, 7

• This combination provides greater symptom reduction than either agent alone, based on high-quality evidence 1, 2
• Do NOT add an oral antihistamine to an intranasal corticosteroid—this provides no additional benefit 7

What NOT to Use

• Oral leukotriene receptor antagonists (montelukast) should NOT be offered as primary therapy 1, 2
• Intranasal corticosteroids are superior to montelukast for allergic rhinitis treatment 1, 7
• Montelukast may be considered only as adjunctive therapy in refractory cases, but remains less effective than intranasal corticosteroids 7, 6

Adjunctive Therapies

Nasal Saline Irrigation

• Beneficial as monotherapy or adjunctive treatment for chronic rhinorrhea and rhinosinusitis 2, 7

Intranasal Ipratropium Bromide

• Effectively reduces rhinorrhea but has no effect on other nasal symptoms 7
• Combining with intranasal corticosteroids is more effective than either alone for rhinorrhea 7

Oral Decongestants

• Use with extreme caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 7
• May cause insomnia, irritability, and palpitations 8

Critical Pitfall: Intranasal Decongestants

Never use intranasal decongestants (oxymetazoline, phenylephrine) for more than 10 days—this causes rhinitis medicamentosa (rebound congestion). 2

Immunotherapy for Refractory Disease

Offer or refer for allergen immunotherapy (subcutaneous or sublingual) when patients have inadequate response to pharmacologic therapy with or without environmental controls. 1, 2

• Immunotherapy is the only disease-modifying treatment that can alter the natural history of allergic rhinitis 2, 7
• May prevent development of new allergen sensitizations and reduce future asthma risk 1, 2, 7
• Requires demonstrable evidence of specific IgE antibodies to clinically relevant allergens 1

When to Perform Allergy Testing

Perform or refer for specific IgE testing (skin or blood) when: 1, 2

• Patients do not respond to empiric treatment
• Diagnosis is uncertain
• Knowledge of specific causative allergens is needed to target therapy or immunotherapy

Do NOT routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis 1, 2, 7

Environmental Control Measures

Advise avoidance of known allergens or environmental controls (removal of pets, air filtration systems, bed covers, acaricides) for patients with identified allergens that correlate with clinical symptoms 1, 2, 8

• Avoidance is the most effective management for animal sensitivity 8
• However, evidence does not support mite-proof mattress/pillow covers, air filtration systems alone, or delayed exposure to pets in childhood 9

Assessment of Comorbidities

Always assess and document the presence of associated conditions: 1, 2, 7

• Asthma (present in increased frequency with allergic rhinitis; treating allergic rhinitis may improve asthma control) 1, 2
• Atopic dermatitis 2, 7
• Sleep-disordered breathing 2, 7
• Conjunctivitis 2, 7
• Rhinosinusitis 2, 7
• Otitis media 2, 7

Systemic Corticosteroids: Use Sparingly

• A short 5-7 day course of oral corticosteroids may be appropriate only for very severe or intractable nasal symptoms that significantly impact quality of life 1, 7
• Single-dose parenteral corticosteroids are discouraged 1
• Recurrent administration of parenteral corticosteroids is contraindicated due to greater potential for long-term adverse effects 1, 2

When to Refer to Allergist/Immunologist

Consider referral for patients who: 1, 2

• Have inadequately controlled symptoms despite treatment
• Have reduced quality of life or ability to function
• Experience adverse reactions to medications
• Desire identification of specific allergens for environmental control
• Have comorbid conditions such as asthma or recurrent sinusitis
• Are being considered for allergen immunotherapy
• Have required systemic corticosteroids 2