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

Treatment of Allergic Rhinitis

Intranasal corticosteroids should be prescribed as first-line monotherapy for allergic rhinitis affecting quality of life, as they are the most effective pharmacologic option for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching. 1, 2

Initial Treatment Algorithm

For All Patients Age 12 and Older

• Start with intranasal corticosteroid monotherapy (fluticasone, mometasone, budesonide, or triamcinolone) as the single most effective first-line treatment 1, 2
• Intranasal corticosteroids work by blocking multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes) at the source, not just histamine alone 3
• These agents are superior to leukotriene receptor antagonists (montelukast) and should be chosen over them 1, 2
• Do not routinely combine with oral antihistamines initially—adding oral antihistamines to intranasal corticosteroids provides no additional benefit 2

For Mild Symptoms with Predominant Sneezing/Itching

• Second-generation oral antihistamines (loratadine, cetirizine, fexofenadine, desloratadine) may be used as an alternative first-line option when sneezing and itching are the primary complaints 1, 2, 4
• Intranasal antihistamines (azelastine, olopatadine) are another option for seasonal, perennial, or episodic allergic rhinitis 1, 2

Escalation for Inadequate Response

Moderate to Severe Disease Not Responding to Monotherapy

• Combine intranasal corticosteroid with intranasal antihistamine (not oral antihistamine) for greater symptom reduction than either agent alone 1, 2
• This combination is the only evidence-based escalation strategy for initial treatment of moderate-to-severe seasonal allergic rhinitis 1

Persistent Rhinorrhea Despite Above Measures

• Add intranasal ipratropium bromide (anticholinergic) to the intranasal corticosteroid regimen 1, 2
• Ipratropium effectively reduces rhinorrhea but has minimal effect on congestion or other symptoms 1
• The combination of intranasal anticholinergic with intranasal corticosteroid is more effective than either alone 1, 2

Refractory Disease Management

When Pharmacotherapy Fails

• Refer for allergen immunotherapy (subcutaneous or sublingual)—this is the only disease-modifying treatment available 1, 2, 5
• Immunotherapy may prevent new allergen sensitizations and reduce future asthma risk 2
• Consider inferior turbinate reduction surgery only after medical management has failed in patients with nasal airway obstruction and enlarged turbinates 1

Very Severe or Intractable Symptoms

• A short 5-7 day course of oral corticosteroids (prednisone) may be appropriate only for very severe symptoms significantly impacting quality of life 1, 2
• Never use single-dose or recurrent parenteral corticosteroids—these are contraindicated due to greater potential for long-term adverse effects 1

Adjunctive Measures

Environmental Controls

• Implement allergen avoidance strategies even during early treatment 1
• For severe seasonal allergic rhinitis, advise staying indoors in air-conditioned buildings with windows and doors closed during high pollen periods 1
• Nasal saline irrigation is beneficial as sole or adjunctive therapy for chronic rhinorrhea 2

What NOT to Do

• Do not prescribe leukotriene receptor antagonists (montelukast) as primary therapy—they are less effective than intranasal corticosteroids 1, 2
• Do not routinely order sinonasal imaging for patients presenting with allergic rhinitis symptoms 1, 2
• Avoid prolonged use of topical nasal decongestants beyond 3 days—this can cause rhinitis medicamentosa 1, 6

Special Populations

Children Age 4-11 Years

• Use lower dosing: 1 spray per nostril once daily (versus up to 2 sprays for age 12+) 3
• Limit use to shortest duration necessary due to potential growth rate effects with long-term intranasal corticosteroid use 1, 3
• Consult physician if treatment needed beyond 2 months per year 3

Adults Age 12 and Older

• May use up to 2 sprays per nostril once daily 3
• Consult physician if daily use extends beyond 6 months 3

Critical Assessment Points

Always Evaluate for Comorbidities

• Document presence of asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1, 2
• Improved rhinitis control may improve these associated conditions, particularly asthma 1

Common Pitfalls to Avoid

• Expecting immediate relief: Intranasal corticosteroids may take several days to reach maximum effect—counsel patients to use regularly and not discontinue prematurely 3
• Improper spray technique: Incorrect use may result in inadequate dosing and suboptimal relief 3
• Stopping treatment when symptoms improve: Continue daily use as long as exposed to triggering allergens 3
• Sedation concerns: Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating 2
• Oral decongestant risks: Use pseudoephedrine/phenylephrine with caution in older adults, young children, and patients with cardiac arrhythmia, hypertension, glaucoma, or bladder neck obstruction 2
• Most common adverse effect: Dysgeusia (altered taste) occurs in 2.1-13.5% of patients using intranasal corticosteroids and antihistamines 2