What medications can be used to treat a patient with symptoms of rhinorrhea (runny nose) and tearing (runny eyes), possibly due to an allergic reaction or viral infection?

Treatment for Runny Nose and Runny Eyes

For symptoms of runny nose (rhinorrhea) and runny eyes (tearing), start with intranasal corticosteroids as first-line therapy for persistent symptoms, or use second-generation oral antihistamines (loratadine, cetirizine, fexofenadine) or intranasal antihistamines (azelastine, olopatadine) for mild intermittent symptoms. 1, 2

First-Line Treatment Selection

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

• Second-generation oral antihistamines such as loratadine, cetirizine, fexofenadine, or desloratadine are FDA-approved to temporarily relieve runny nose, itchy watery eyes, sneezing, and itching of nose or throat 3, 2
• Intranasal antihistamines (azelastine, olopatadine) provide rapid relief and are equally effective as oral antihistamines 1, 2
• Both oral and intranasal antihistamines effectively treat the ocular symptoms (runny eyes) associated with rhinitis 1

For Persistent Moderate-to-Severe Symptoms (> 4 days/week and > 4 weeks/year):

• Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are the most effective medication class for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1, 4, 2
• Intranasal corticosteroids are more effective than antihistamines alone and should be used regularly for maximum effectiveness 1, 5
• These medications also effectively relieve ocular symptoms (runny eyes) with similar efficacy to oral and intranasal antihistamines 1

Adjunctive Therapies

Non-Pharmacologic Measures:

• Saline nasal irrigation provides significant symptomatic relief by improving mucosal clearance, enhancing ciliary activity, and removing allergens and inflammatory mediators 1, 6
• Cold compresses and refrigerated artificial tears for eye symptoms provide additional comfort 1
• Allergen avoidance: wearing sunglasses as a barrier to airborne allergens, staying indoors with air conditioning during high pollen seasons, hypoallergenic bedding, and frequent clothes washing 1

For Isolated Rhinorrhea:

• Intranasal anticholinergics (ipratropium bromide 0.03%) specifically reduce rhinorrhea without affecting other nasal symptoms 1, 6, 7
• This is particularly useful when runny nose is the predominant symptom 6

Combination Therapy for Inadequate Response

• If intranasal corticosteroids alone are insufficient, combine intranasal corticosteroid with intranasal antihistamine, which is more effective than either agent alone 5
• Avoid chronic use of topical decongestants (> 3 days) due to risk of rebound vasodilation and rhinitis medicamentosa 1

Important Caveats

Avoid These Medications:

• First-generation antihistamines (diphenhydramine) may worsen dry eye syndrome and impair the tear film's protective barrier, potentially worsening allergic conjunctivitis despite treating rhinorrhea 1, 8
• Oral antihistamines can induce or worsen dry eye and should be used cautiously if eye symptoms are prominent 1
• Topical antibiotics or corticosteroids for the eyes should be avoided without proper diagnosis, as indiscriminate use can cause toxicity or prolong viral infections 1

Proper Administration:

• Direct intranasal sprays away from the nasal septum to minimize risk of nasal irritation, bleeding, or septal perforation 1
• Store topical eye medications in the refrigerator for additional cooling comfort upon instillation 1
• Use concomitant preservative-free artificial tears to dilute allergens and inflammatory mediators on the ocular surface 1

When to Escalate Care

• If symptoms persist despite 2-4 weeks of appropriate therapy, consider allergy testing to identify specific allergens 5
• For severe refractory cases, allergen-specific immunotherapy (subcutaneous or sublingual) should be considered 1, 5, 4
• A brief course (1-2 weeks) of topical corticosteroids with low side effect profile can be added for severe ocular symptoms not controlled by other measures 1