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

Treatment Algorithm for Allergic Rhinitis

First-Line Treatment: Intranasal Corticosteroids

Intranasal corticosteroids are the most effective first-line therapy for allergic rhinitis and should be initiated for all patients with moderate to severe symptoms, as they control all nasal symptoms including congestion, rhinorrhea, sneezing, and itching better than any other single agent. 1, 2, 3

• Start with fluticasone, triamcinolone, budesonide, or mometasone nasal spray 4
• These agents are superior to oral antihistamines for comprehensive symptom control, particularly nasal congestion 1, 3
• They are also more effective than leukotriene receptor antagonists (montelukast) 1
• Critical technique: Direct the spray away from the nasal septum to avoid mucosal erosions and potential septal perforations 2
• Symptom improvement typically begins within 3 hours of initial dosing 5

For Mild Intermittent Symptoms

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) may be used as monotherapy for patients whose primary complaints are sneezing and itching 1, 4
• Intranasal antihistamines (azelastine, olopatadine) are equally effective alternatives 1, 4

Second-Line: Combination Therapy for Inadequate Response

If monotherapy with intranasal corticosteroid fails to control moderate to severe symptoms, add an intranasal antihistamine—this combination provides greater symptom reduction than either agent alone. 1, 2

• Do NOT add oral antihistamines to intranasal corticosteroids—multiple high-quality trials show no additional benefit 1, 2
• Do NOT add leukotriene receptor antagonists to intranasal corticosteroids—they provide no additional benefit 2
• For severe nasal obstruction, topical oxymetazoline may be added for a maximum of 3 days to avoid rhinitis medicamentosa 2

Adjunctive Therapies

• Nasal saline irrigation is beneficial as sole or adjunctive therapy for chronic rhinorrhea 1, 2
• Intranasal ipratropium bromide (0.03%) effectively reduces rhinorrhea but has no effect on other symptoms; combining it with intranasal corticosteroids is more effective than either alone 1, 2
• Leukotriene receptor antagonists (montelukast 10 mg once daily) can be used as adjunctive therapy but are generally less effective than intranasal corticosteroids 1

Third-Line: Immunotherapy for Refractory Disease

Patients with inadequate response to pharmacologic therapy should be referred for allergen immunotherapy (subcutaneous or sublingual), which is the only disease-modifying treatment that can alter the natural history of allergic rhinitis. 1, 2

• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk 1, 2
• Clinical benefits can persist for years after discontinuation of treatment 2
• Consider referral when symptoms are inadequately controlled, quality of life is reduced, or patients experience adverse reactions to medications 2

Oral Corticosteroids: Rarely Appropriate

• A short 5-7 day course of oral prednisone may be appropriate only for very severe or intractable symptoms that significantly impact quality of life 1
• Avoid routine use of oral corticosteroids due to greater potential for long-term adverse effects 2, 3

Environmental Control Measures

• Implement allergen avoidance strategies for identified triggers 1, 2
• Begin avoidance measures early, even during initial treatment 2

Common Pitfalls to Avoid

• Never use intranasal decongestants for more than 3-10 days—prolonged use leads to rhinitis medicamentosa (rebound congestion) 2
• Avoid first-generation antihistamines due to sedation and cognitive impairment 2, 3
• Do not use oral decongestants (pseudoephedrine, phenylephrine) in patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 1
• Cetirizine and intranasal azelastine may cause sedation at recommended doses (0.4-3% incidence); other second-generation antihistamines are generally non-sedating 1, 3
• Dysgeusia (altered taste) occurs in 2.1-13.5% of patients using intranasal corticosteroids and antihistamines 1

Assessment of Comorbid Conditions

• Always evaluate for associated conditions: asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1
• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma 2
• Consider surgical referral for severe nasal septal deviation, inferior turbinate hypertrophy, adenoidal hypertrophy, or refractory sinusitis 6