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

Treatment of Seasonal Allergic Rhinitis

Start with intranasal corticosteroid monotherapy (such as fluticasone propionate) as first-line treatment for patients with seasonal allergic rhinitis whose symptoms affect their quality of life. 1

First-Line Therapy: Intranasal Corticosteroids

• Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of allergic rhinitis: nasal congestion, rhinorrhea, sneezing, and nasal itching. 1, 2

• The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation for intranasal steroids in patients whose symptoms affect quality of life. 1

• Fluticasone propionate is available over-the-counter and works by blocking multiple inflammatory mediators (histamine, prostaglandins, cytokines, tryptases, chemokines, and leukotrienes), not just histamine alone like oral antihistamines. 3

Dosing for Intranasal Corticosteroids

• Adults and children ≥12 years: Start with 2 sprays per nostril once daily (fluticasone propionate 100 mcg per nostril). 3

• Children 4-11 years: Use 1 spray per nostril once daily. 3

• Maximum effect may take several days, so patients must use it regularly throughout the allergy season, not just as needed. 3

Duration Limits and Follow-up

• Adults ≥12 years: Check with a doctor if daily use exceeds 6 months. 3

• Children 4-11 years: Check with a doctor if use exceeds 2 months per year due to potential effects on growth rate. 3

Second-Line Therapy: Oral Antihistamines

Use second-generation oral antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) when patients have primary complaints of sneezing and itching, or when they prefer oral medication. 1, 4

• The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation for oral second-generation/less sedating antihistamines for patients with sneezing and itching as primary complaints. 1

• Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation (0.4-3% vs higher rates with first-generation). 5, 6

Specific Oral Antihistamine Dosing

• Cetirizine: 10 mg once daily for adults and children ≥6 years; 5 mg once daily for children 2-5 years. 6

• Loratadine: 10 mg once daily for adults and children ≥6 years. 4

• Cetirizine may cause slightly more sedation than loratadine or fexofenadine, so consider morning dosing or alternative agents if sedation is a concern. 6

What NOT to Do

• Do NOT routinely start with combination therapy (intranasal corticosteroid + oral antihistamine) as initial treatment. The Joint Task Force on Practice Parameters provides a strong recommendation for intranasal corticosteroid monotherapy over combination therapy for initial treatment in patients ≥12 years. 1

• Do NOT offer oral leukotriene receptor antagonists (montelukast) as primary therapy. The American Academy of Otolaryngology-Head and Neck Surgery provides a recommendation against this approach, as intranasal corticosteroids are significantly more effective. 1

• Do NOT use oral corticosteroids for routine management. Reserve these only for severe, intractable cases unresponsive to other treatments. 2, 5

• Do NOT perform routine sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1

When to Escalate or Add Therapy

Consider combination therapy only when patients have inadequate response to intranasal corticosteroid monotherapy after 4-7 days of regular use. 1, 2

• Add an intranasal antihistamine (azelastine, olopatadine) to the intranasal corticosteroid if symptoms persist. 1, 2

• The American Academy of Otolaryngology-Head and Neck Surgery provides an option (not a strong recommendation) for combination pharmacologic therapy in patients with inadequate response to monotherapy. 1

When to Consider Allergy Testing and Immunotherapy

• Perform or refer for specific IgE testing (skin or blood) when patients do not respond to empiric treatment, when diagnosis is uncertain, or when knowledge of specific causative allergen is needed to target therapy. 1

• Offer or refer for immunotherapy (sublingual or subcutaneous) when patients have inadequate response to pharmacologic therapy with or without environmental controls. 1, 2

• Immunotherapy is the only disease-modifying treatment and may prevent development of new allergen sensitizations. 6, 7

Common Pitfalls to Avoid

• Don't assume combination therapy is always superior to monotherapy—evidence shows intranasal corticosteroid alone is often sufficient and avoids unnecessary medication exposure and cost. 1, 2

• Don't forget to counsel patients that intranasal corticosteroids take several days to reach maximum effect—they must use it daily throughout the allergy season, not just when symptoms are severe. 3

• Don't share nasal spray bottles between patients—this spreads germs since the nozzle is inserted into the nose. 3

• Don't use intranasal corticosteroids for colds or asthma—they are specifically for allergic rhinitis symptoms. 3

Drug Interactions to Check

Before prescribing intranasal corticosteroids, ask patients if they are taking:

• HIV medications (such as ritonavir): Consult with doctor or pharmacist before use. 3

• Ketoconazole pills (antifungal): Consult with doctor or pharmacist before use. 3

• Other steroid medications for asthma, skin conditions, or eye conditions: Consult with doctor or pharmacist before use. 3

Assessment of Comorbidities

Document the presence of associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1

• These comorbidities are common in allergic rhinitis patients and may require additional management strategies. 1, 4