What treatment options are available for a patient with allergies and throat irritation, possibly with a history of asthma or other respiratory conditions?

Treatment of Allergies with Throat Irritation

For patients with allergies causing throat irritation, intranasal corticosteroids should be the first-line treatment, as they are the most effective therapy for allergic rhinitis and can reduce postnasal drainage that causes throat symptoms. 1

Initial Assessment and Diagnosis

When evaluating throat irritation in the context of allergies, you must assess for coexisting conditions that commonly occur together:

• Screen for asthma in all patients with allergic rhinitis, as over 50% of asthmatic patients have allergic rhinitis, and treating the rhinitis improves asthma control 1, 2, 3
• Document presence of associated conditions including atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1, 2, 3
• Throat irritation in allergic rhinitis typically results from postnasal drainage causing pharyngeal symptoms 4

First-Line Pharmacologic Treatment

Intranasal Corticosteroids (Primary Recommendation)

Intranasal corticosteroids are recommended as first-line therapy for patients whose symptoms affect quality of life, including those with throat irritation from postnasal drainage 1, 4

• These agents are more effective than oral antihistamines for moderate to severe allergic rhinitis 5
• Available options include fluticasone, triamcinolone, budesonide, and mometasone 1, 4
• Should be used continuously throughout allergen exposure periods rather than intermittently for optimal prevention of symptom recurrence 2
• In patients with coexisting asthma, intranasal corticosteroids reduce bronchial hyperreactivity and improve asthma control 1, 2

Oral Second-Generation Antihistamines (Alternative for Mild Symptoms)

Oral second-generation antihistamines should be recommended for patients whose primary complaints are sneezing and itching, though they are less effective for nasal congestion and postnasal drainage 1, 4

• Preferred agents include cetirizine, fexofenadine, desloratadine, and loratadine 6, 4, 7
• Never use first-generation antihistamines (diphenhydramine, chlorpheniramine, brompheniramine) as they produce sedation, impairment, and worsen sleep architecture 6, 7
• Second-generation agents are nonsedating and nonimpairing even at higher than recommended doses 6, 7

Intranasal Antihistamines (Alternative Option)

Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative, with rapid onset and increased effectiveness over oral antihistamines for nasal congestion 1, 8, 4

• Dosing for azelastine: 1-2 sprays per nostril twice daily for patients age 12 and older 8
• Common side effects include poor taste and epistaxis 1, 8

Management of Inadequate Response

Combination Therapy

When monotherapy fails, combination pharmacologic therapy should be offered, particularly combining intranasal corticosteroid with intranasal antihistamine 1, 2, 3

• This combination provides greater efficacy than either agent alone for moderate to severe symptoms 1, 2
• The combination of intranasal corticosteroid plus oral antihistamine has mixed evidence, with some studies showing comparable efficacy to intranasal corticosteroid alone 5

Immunotherapy (Disease-Modifying Treatment)

Immunotherapy (subcutaneous or sublingual) should be offered or referred for patients with inadequate response to pharmacologic therapy, as it is the only treatment that can alter the natural history of allergic rhinitis 1, 2, 3

• Minimum of 3 years of treatment is recommended for optimal clinical benefit 3
• Can prevent development of new allergen sensitivities and reduce risk of future asthma development 2, 3
• Particularly important for patients with coexisting asthma, as combined treatment of rhinitis and asthma improves asthma outcomes 1

Critical Pitfalls to Avoid

• Do not use oral leukotriene receptor antagonists (montelukast) as primary therapy, as they are less efficacious than intranasal corticosteroids 1, 2, 9
• Avoid prolonged use of intranasal decongestants beyond 3-10 days, as this leads to rhinitis medicamentosa (rebound congestion) 1, 2
• Do not use oral corticosteroids for routine treatment due to significant long-term adverse effects; reserve only for severe intractable symptoms unresponsive to all other treatments 2, 10
• Never recommend first-generation antihistamines due to sedation, impairment, and worsened sleep architecture 6, 7

Environmental Control Measures

Allergen avoidance may be advised for patients with identified allergens correlating with clinical symptoms 1, 2, 3:

• For pollen allergies: keep windows closed during high pollen seasons, avoid outdoor activities when pollen counts are elevated 2
• For dust mite allergies: consider allergen-impermeable bed covers, air filtration systems, and removal of carpeting 2
• For pet allergies: remove pets from the home when feasible, or at minimum exclude them from bedrooms 2