What is the recommended treatment for a patient with rhinitis?

Treatment for Rhinitis

Intranasal corticosteroids are the first-line treatment for moderate to severe or persistent rhinitis, while second-generation oral antihistamines or intranasal antihistamines are appropriate for mild intermittent symptoms. 1, 2, 3

Initial Treatment Algorithm

For Mild Intermittent Rhinitis

• Start with a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, desloratadine) or an intranasal antihistamine (azelastine, olopatadine) for patients with mild intermittent symptoms, which effectively control sneezing, itching, and rhinorrhea 1, 2, 4
• Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation and performance impairment 2
• Note that cetirizine and intranasal azelastine may cause sedation at recommended doses, while other second-generation antihistamines are generally non-sedating 3

For Moderate to Severe or Persistent Rhinitis

• Intranasal corticosteroid monotherapy (fluticasone, triamcinolone, budesonide, mometasone) is the most effective first-line treatment, relieving all nasal symptoms including congestion, rhinorrhea, sneezing, and itching, while preventing late-phase allergic responses 1, 2, 3
• Intranasal corticosteroids are superior to leukotriene receptor antagonists and should be chosen over them for patients age 12 and older 3
• Do not routinely combine intranasal corticosteroids with oral antihistamines initially, as multiple high-quality trials show no additional benefit 2, 3
• Relief may begin the first day, but it takes several days to reach full effectiveness, so daily use is essential 5

Escalation for Inadequate Response

Adding Intranasal Antihistamine

• Combine intranasal corticosteroid with intranasal antihistamine for patients with moderate to severe disease not responding to monotherapy, as this combination provides greater symptom reduction than either agent alone 2, 3

Managing Persistent Rhinorrhea

• Add intranasal ipratropium bromide (anticholinergic) to the intranasal corticosteroid regimen for patients with persistent rhinorrhea despite above measures, as it is particularly effective for rhinorrhea in both allergic and nonallergic rhinitis 2, 6

Severe Nasal Obstruction

• For patients with severe nasal obstruction, add topical oxymetazoline for a maximum of 3 days to avoid rhinitis medicamentosa (rebound congestion) 1, 2
• Topical decongestants should never exceed 3-10 days of use to prevent rebound effect 7, 2

What NOT to Add

• Do not add leukotriene receptor antagonists to intranasal corticosteroids, as they provide no additional benefit and are less effective than intranasal corticosteroids alone 2
• Leukotriene receptor antagonants may be considered only when treatment can benefit combined upper and lower airway disease (coexisting asthma), particularly in steroid-phobic families 7

Adjunctive Therapies

Allergen Avoidance and Environmental Control

• Implement allergen avoidance strategies even during early treatment, including staying indoors in air-conditioned environments with closed windows and doors during high pollen periods 1, 2

Nasal Saline Irrigation

• Nasal saline irrigation is beneficial as sole or adjunctive therapy for chronic rhinorrhea and rhinosinusitis, with minimal side effects (burning, irritation, nausea), low cost, and good patient acceptance 7, 1, 2
• Both isotonic and hypertonic saline solutions provide modest benefit for reducing symptoms and improving quality of life 7

Refractory Disease Management

Allergen Immunotherapy

• Refer patients for allergen immunotherapy when pharmacotherapy fails, as it is the only disease-modifying treatment available that can alter the natural history of allergic rhinitis 7, 2, 3
• Immunotherapy should be considered for patients with demonstrable evidence of specific IgE antibodies to clinically relevant allergens, and its use depends on the degree to which symptoms can be reduced by avoidance and medication 7
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk, with clinical benefits that may persist years after discontinuation 7, 2, 3

Special Populations and Considerations

Children Age 4 to 11

• Use 1 spray in each nostril once daily (lower dose than adults) for up to 2 months per year before checking with a doctor 5
• Long-term use of intranasal corticosteroids may cause slower growth rate in some children, so use for the shortest duration necessary to achieve symptom relief 5

Adults and Children Age 12 and Older

• Use up to 2 sprays in each nostril once daily for up to 6 months before checking with a doctor 5

Patients with Coexisting Asthma

• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma 2, 3
• Document presence of comorbidities (asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, otitis media), as improved rhinitis control may improve these associated conditions 3

Nonallergic Rhinitis

• First-line therapy consists of intranasal antihistamine as monotherapy or in combination with an intranasal corticosteroid, as oral antihistamines are less effective for nonallergic rhinitis 4, 6

Critical Pitfalls to Avoid

Medication Errors

• Never use first-generation antihistamines due to sedation and performance impairment 2
• Never use prolonged intranasal decongestants (>3 days) leading to rhinitis medicamentosa 2
• Never administer recurrent parenteral corticosteroids for chronic rhinitis except for rare patients with severe intractable symptoms unresponsive to other treatments 7, 2
• Never spray intranasal corticosteroids directly at the nasal septum, as this can lead to mucosal erosions and potential septal perforations; direct spray away from septum 2

Inappropriate Use

• Intranasal corticosteroids do not cause rebound effect unlike topical decongestants 5
• Intranasal corticosteroids do not cause drowsiness 5
• Use pseudoephedrine/phenylephrine with caution in older adults, young children, and patients with cardiac arrhythmia, hypertension, glaucoma, or bladder neck obstruction 3
• Avoid oral decongestants in children under 6 years due to significant risks including tachyarrhythmias, insomnia, hyperactivity, and even death 1

When to Stop and Reassess

• If symptoms are not better after one week of intranasal corticosteroid use, stop and see a doctor, as this may indicate infection 5
• Stop intranasal corticosteroids and see a doctor immediately for severe or frequent nosebleeds, constant whistling sound, severe facial pain, or thick nasal discharge suggesting sinus infection 5

Assessment and Referral Criteria

Follow-up Evaluation

• Evaluate multiple parameters including nasal symptoms, physical signs, quality of life, and comorbid conditions to assess treatment response 1

When to Refer to Allergist/Immunologist

• Prolonged manifestations despite treatment 1, 2
• Complications such as otitis media, sinusitis, or nasal polyposis 2
• Comorbid asthma or chronic sinusitis 1, 2
• Significant quality of life impairment 1
• When allergen immunotherapy is a consideration 7, 2