What are the treatment options for a patient with a runny nose, considering potential underlying causes and medical history?

Management of Runny Nose

Start with intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) 200 mcg daily (2 sprays per nostril once daily) as first-line therapy for moderate to severe rhinorrhea, as this provides the most comprehensive symptom control regardless of whether the cause is allergic or nonallergic rhinitis. 1, 2

Initial Assessment and Diagnosis

The diagnosis is entirely clinical and does not require allergy testing initially 1. Focus your history on:

• Pattern of symptoms: Seasonal exacerbations suggest allergic rhinitis, while year-round symptoms with triggers like strong odors, temperature changes, or eating suggest nonallergic rhinitis 3
• Associated symptoms: Sneezing and itching strongly favor allergic rhinitis, while isolated postnasal drainage is less likely allergic 3
• Age of onset: Symptoms before age 20 suggest allergic rhinitis; later onset favors nonallergic rhinitis 3
• Medication history: Chronic use of topical decongestants (>3-5 days) causes rhinitis medicamentosa 3, 1

Physical examination should reveal pale, edematous turbinates in seasonal allergic rhinitis or erythematous, inflamed turbinates with serous secretions in perennial allergic rhinitis 4. Unilateral symptoms suggest structural problems like polyps or foreign bodies 3.

First-Line Treatment Algorithm

For Allergic Rhinitis (Sneezing, Itching, Rhinorrhea Predominant)

Intranasal corticosteroids are the most effective monotherapy and should be first-line for moderate to severe symptoms 1, 2, 4:

• Fluticasone 200 mcg daily (2 sprays per nostril once daily) 5
• Onset of action occurs within 12 hours, with maximum effect in several days 5
• After 4-7 days of response, may reduce to 100 mcg daily (1 spray per nostril once daily) 5

For mild symptoms or when sneezing/itching predominate, add or use second-generation oral antihistamines 1, 2:

• Cetirizine, fexofenadine, loratadine, or desloratadine 2, 4
• These are preferred over first-generation antihistamines due to less sedation 2
• More effective for rhinorrhea, sneezing, and itching than for nasal congestion 6, 7

For moderate to severe allergic rhinitis with inadequate response to intranasal corticosteroids alone, add intranasal antihistamine 1, 2:

• Azelastine or olopatadine provides 40% relative improvement over monotherapy 1
• This combination is superior to either agent alone 1, 2

For Nonallergic Rhinitis (Congestion and Postnasal Drainage Predominant)

First-line therapy is intranasal antihistamine (azelastine or olopatadine) as monotherapy or combined with intranasal corticosteroid 4:

• Intranasal antihistamines are effective for both allergic and nonallergic rhinitis 2
• Rapid onset of action with clinically significant effects on nasal congestion 8

For isolated rhinorrhea, add intranasal ipratropium bromide 3, 2:

• Particularly effective for rhinorrhea in nonallergic rhinitis through anticholinergic effects 2
• May be combined with antihistamines or intranasal corticosteroids 3

For Upper Airway Cough Syndrome (Postnasal Drip with Cough)

Use first-generation antihistamine plus decongestant combination as first-line treatment 3, 8:

• Dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release) twice daily 3, 8
• Alternative: Azatadine 1 mg + pseudoephedrine 120 mg (sustained-release) twice daily 3, 8
• Start with once-daily dosing at bedtime for several days before advancing to twice-daily to minimize sedation 8
• Improvement typically occurs within days to 2 weeks 8

Second-generation antihistamines (loratadine, fexofenadine, cetirizine) are ineffective for upper airway cough syndrome due to lack of anticholinergic activity 3, 8.

Critical Pitfalls to Avoid

Never use topical decongestants (oxymetazoline) for more than 3-5 days 1, 2:

• Prolonged use causes rhinitis medicamentosa (rebound congestion) 3, 2
• The nasal mucosa becomes dependent on the medication, worsening congestion when discontinued 2

Do not rely on oral antihistamines as monotherapy for nasal congestion 6, 7:

• Antihistamines have minimal effect on nasal obstruction 6
• Intranasal corticosteroids are far more effective for congestion 1, 2

Avoid first-generation antihistamines in patients with benign prostatic hyperplasia or narrow-angle glaucoma 8:

• Anticholinergic effects cause urinary retention and increased intraocular pressure 8

Direct intranasal corticosteroid spray away from the nasal septum 2:

• Improper technique causes mucosal erosions and potential septal perforation 2

Do not routinely add oral antihistamines to intranasal corticosteroids 2:

• Multiple high-quality trials show no additional benefit 2

Do not add leukotriene receptor antagonists to intranasal corticosteroids 2:

• They provide no additional benefit and are less effective than intranasal corticosteroids alone 2

When to Refer to Allergist/Immunologist

Consider referral when 3, 2:

• Prolonged manifestations of rhinitis unresponsive to treatment 3
• Complications such as otitis media, sinusitis, or nasal polyposis 3
• Comorbid asthma requiring coordinated management 3
• Systemic corticosteroids have been required 3
• Symptoms significantly impair quality of life, work/school performance, or sleep 3
• Consideration for allergen immunotherapy, which is the only treatment that modifies the natural history of allergic rhinitis and may prevent asthma development 2

Special Considerations

For patients with coexisting asthma, treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control 2. Leukotriene receptor antagonists (montelukast) may be particularly useful as they address both conditions, though they are less effective than intranasal corticosteroids 8.

In pediatric patients 4 years and older, start with fluticasone 100 mcg (1 spray per nostril once daily), reserving 200 mcg for inadequate responders 5. Monitor growth routinely via stadiometry, as intranasal corticosteroids may cause growth velocity reduction 5.

Nasal saline irrigation is beneficial as adjunctive therapy for chronic rhinorrhea and rhinosinusitis 2.