What is the recommended treatment for a patient with allergic rhinitis, considering age, overall health, and potential allergies or sensitivities?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis in patients 12 years and older, as they are the most effective medication for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Treatment Algorithm Based on Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Start with either a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, loratadine) or an intranasal antihistamine (azelastine, olopatadine) as first-line therapy. 3
• Oral antihistamines are particularly effective for sneezing and itching symptoms but less effective for nasal congestion. 1
• Second-generation antihistamines are preferred over first-generation agents due to minimal sedation at recommended doses. 1

Moderate to Severe or Persistent Allergic Rhinitis

• Begin with an intranasal corticosteroid (fluticasone, mometasone, triamcinolone, budesonide) as monotherapy. 1, 2, 3
• Intranasal corticosteroids are superior to oral antihistamines for controlling all four major symptoms and are more effective than leukotriene receptor antagonists. 1
• For patients 12 years and older, typical dosing is 2 sprays per nostril once daily (e.g., fluticasone 200 mcg total daily). 2, 4

Inadequate Response to Monotherapy

• Add an intranasal antihistamine to the intranasal corticosteroid for moderate-to-severe symptoms not controlled by steroid alone. 2, 1
• The combination of fluticasone propionate and azelastine shows >40% relative improvement compared to either agent alone. 1
• Do not add an oral antihistamine to an intranasal corticosteroid, as this provides no additional benefit. 1

Age-Specific Considerations

Children Ages 2-5 Years

• Triamcinolone acetonide: 1 spray per nostril daily (approved for ages ≥2 years). 4
• Mometasone furoate: 1 spray per nostril daily (approved for ages ≥2 years). 4

Children Ages 6-11 Years

• Fluticasone propionate: 1 spray per nostril daily (50 mcg per spray). 4
• Azelastine 0.1% or 0.15%: 1 spray per nostril twice daily. 2
• Limit continuous use to 2 months per year before consulting a physician due to potential growth effects. 4, 5

Adults and Children ≥12 Years

• Fluticasone propionate: 2 sprays per nostril once daily (200 mcg total). 4
• Mometasone furoate: 2 sprays per nostril once daily (200 mcg total). 4
• Azelastine: 1-2 sprays per nostril twice daily or 2 sprays once daily. 2
• Can use continuously for up to 6 months before checking with a physician. 5

Special Population Considerations

Elderly Patients with Cardiovascular or Renal Disease

• Fexofenadine is the preferred oral antihistamine due to no sedation even at higher doses, no significant cardiovascular concerns, and minimal renal effects. 6
• Avoid first-generation antihistamines entirely due to increased risk of falls, fractures, psychomotor impairment, and anticholinergic effects. 6
• Avoid oral decongestants (pseudoephedrine, phenylephrine) in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1

Pregnancy

• Consider FDA risk categories and review human cohort studies before selecting medications. 2
• The first trimester is the most critical period for concern about potential congenital malformations. 2

Proper Administration Technique for Intranasal Corticosteroids

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

• Prime the bottle before first use and shake before each spray. 4
• Have the patient blow their nose prior to using the spray. 4
• Keep the head upright during administration. 4
• Use the contralateral hand technique (hold spray in opposite hand from nostril being treated) to direct spray away from the nasal septum, reducing epistaxis risk by four times. 4
• Do not close the opposite nostril during administration. 4
• If using nasal saline irrigations, perform them before administering the steroid spray. 4

Duration of Treatment

Short-Term Use

• Patients must continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this period. 4
• Minimum treatment duration of 8-12 weeks is recommended to properly assess therapeutic benefit. 4

Long-Term Use

• Intranasal corticosteroids are safe for indefinite use when clinically indicated, with no effect on hypothalamic-pituitary-adrenal axis function at recommended doses. 4
• For seasonal allergic rhinitis, continue throughout the allergen exposure period. 4
• For perennial allergic rhinitis, continuous daily therapy is more effective than intermittent use. 4
• Periodically examine the nasal septum (every 6-12 months) to detect mucosal erosions that may precede septal perforation. 4

Adjunctive Therapies

Nasal Saline Irrigation

• Beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea. 2, 1

Intranasal Ipratropium Bromide

• Effectively reduces rhinorrhea but has no effect on other nasal symptoms. 1
• Combining with intranasal corticosteroids is more effective than either alone for rhinorrhea. 1

Leukotriene Receptor Antagonists

• Not recommended as primary therapy, as they are significantly less effective than intranasal corticosteroids. 1
• May be used as adjunctive therapy (montelukast 10 mg once daily). 1

Refractory Disease Management

Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual), which is the only disease-modifying treatment available. 2, 1

• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 2, 1
• A short 5-7 day course of oral corticosteroids may be appropriate only for very severe or intractable symptoms. 2, 1
• Recurrent or single-dose parenteral corticosteroids are contraindicated due to greater potential for long-term side effects including adrenal suppression. 2, 4

Common Pitfalls to Avoid

• Do not discontinue intranasal corticosteroids when symptoms improve; they are maintenance therapy, not rescue therapy. 4
• Do not use topical decongestants for more than 3 days due to risk of rhinitis medicamentosa (rebound congestion). 4
• Do not share nasal spray bottles between patients, as this can spread germs. 5
• Do not spray fluticasone in eyes or mouth; it is meant only for nasal use. 5
• Most common side effect is epistaxis (4-8% short-term, up to 20% over one year), typically presenting as blood-tinged secretions. 4
• Bitter taste occurs in 2.1-13.5% of patients using intranasal antihistamines. 1
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating. 1

Drug Interactions

Avoid or use caution when combining fluticasone with:

• HIV protease inhibitors (such as ritonavir) - may increase fluticasone levels. 5
• Ketoconazole pills - may increase fluticasone levels. 5
• Other glucocorticoid medications for asthma, skin conditions, or eye conditions - discuss with physician before combining. 5

Associated Conditions to Assess

Always evaluate for comorbid conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1

• Treatment of allergic rhinitis may improve asthma control in patients with coexisting conditions. 2
• Consider consultation with an allergist/immunologist for inadequately controlled symptoms, reduced quality of life, adverse medication reactions, or when immunotherapy is being considered. 2