What is the best treatment approach for a patient with allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for patients with allergic rhinitis whose symptoms affect quality of life, as they are the most effective medication class for controlling all major symptoms. 1

Initial Pharmacologic Management

For Moderate to Severe Symptoms

• Start with intranasal corticosteroids (fluticasone, triamcinolone, budesonide, or mometasone) as monotherapy, which provides superior efficacy compared to all other pharmacological treatments including oral antihistamines and leukotriene receptor antagonists. 2, 3, 4
• Patients should be counseled to direct sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations. 2, 3
• Maximum efficacy may take several days of consistent use, though symptom improvement can begin within 12 hours. 5
• Adults may use 200 mcg once daily (two 50-mcg sprays per nostril) or 100 mcg twice daily; pediatric patients 4 years and older should start with 100 mcg once daily. 5

For Mild Intermittent Symptoms

• Oral second-generation antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are appropriate for patients with primary complaints of sneezing and itching. 1, 4
• Intranasal antihistamines (azelastine, olopatadine) are equal or superior to oral antihistamines and have the unique advantage of reducing nasal congestion. 2, 3, 4
• First-generation antihistamines should be avoided due to sedation, impaired work performance, and increased accident risk. 3

Combination Therapy for Inadequate Response

• For moderate to severe recurrent allergic rhinitis not controlled with intranasal corticosteroids alone, add an intranasal antihistamine, as this combination provides greater symptom reduction than either agent alone. 2
• Do not routinely add oral antihistamines to intranasal corticosteroids, as multiple high-quality trials show no additional benefit. 2
• Ipratropium intranasal can be added specifically for persistent rhinorrhea despite intranasal corticosteroid treatment. 2, 3

Medications to Avoid

• Do not offer oral leukotriene receptor antagonists as primary therapy, as they are less effective than intranasal corticosteroids and provide no additional benefit when added to them. 1, 2
• Avoid prolonged use of intranasal decongestants beyond 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 2, 3
• Do not administer oral corticosteroids for chronic rhinitis except for rare patients with severe intractable symptoms unresponsive to all other treatments. 2

Allergen Immunotherapy

• Offer or refer for immunotherapy (sublingual or subcutaneous) for patients with inadequate response to pharmacologic therapy with or without environmental controls. 1
• Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis and may prevent development of new allergen sensitizations and reduce future risk of asthma. 2, 3
• Specific IgE testing (skin or blood) should be performed before initiating immunotherapy to identify clinically relevant allergens. 1

Adjunctive Non-Pharmacologic 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
• Nasal saline irrigation is beneficial as adjunctive therapy to relieve congestion and facilitate clearance of nasal secretions. 2, 3

Assessment of Comorbidities

• Assess and document the presence of associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as treatment of allergic rhinitis may improve control of coexisting asthma. 1, 2

Surgical Considerations

• Offer or refer for inferior turbinate reduction only in patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. 1

Common Pitfalls to Avoid

• Do not routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1
• Avoid using first-generation antihistamines, recurrent administration of parenteral corticosteroids, and inadequate treatment of nonallergic rhinitis with oral antihistamines. 2
• Ensure proper diagnosis, as antihistamines have limited efficacy in nonallergic rhinitis syndromes. 6