What medication is recommended for a patient with a runny nose, considering potential allergic or infectious causes and patient factors like age, pregnancy, or underlying conditions such as hypertension?

Treatment of Runny Nose (Rhinorrhea)

For a patient presenting with runny nose, intranasal corticosteroids are the most effective first-line treatment for moderate to severe symptoms, while intranasal antihistamines are preferred for mild symptoms or when rapid relief is needed. 1, 2

Determining the Cause

The approach depends on whether the runny nose is allergic or infectious:

• Allergic rhinitis typically presents with rhinorrhea (90% of cases), sneezing, nasal itching, and eye symptoms, often with pale/edematous turbinates on exam 3
• Viral rhinitis (common cold) lasts up to 10 days and includes systemic symptoms like fever and malaise 4
• Nonallergic rhinitis presents primarily with nasal congestion and postnasal drainage without itching or eye symptoms 3

First-Line Treatment Algorithm

For Allergic Rhinitis (Mild Intermittent)

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are effective for rhinorrhea, sneezing, and itching but have minimal effect on congestion 1, 3
• Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses 1
• Cetirizine may cause sedation at recommended doses 1

For Allergic Rhinitis (Moderate to Severe or Persistent)

• Intranasal corticosteroids (fluticasone 200 mcg daily, mometasone, budesonide, triamcinolone) should be initiated as first-line monotherapy 2, 3
• Adults should start with 2 sprays per nostril once daily (200 mcg total) 5
• Symptom improvement may begin within 12 hours, but maximum benefit requires several days of treatment 5
• These are more effective than oral antihistamines for all symptoms including rhinorrhea 1, 2

For Nonallergic Rhinitis

• Intranasal antihistamines (azelastine, olopatadine) are first-line therapy, either alone or combined with intranasal corticosteroids 2, 3
• Azelastine: 1-2 sprays per nostril twice daily for adults 6
• These provide rapid onset of action and are particularly useful for episodic symptoms 1

For Viral Upper Respiratory Infection (Common Cold)

• Intranasal anticholinergics (ipratropium bromide) are particularly effective for rhinorrhea but have no effect on other nasal symptoms 1
• Combining ipratropium with an intranasal corticosteroid is more effective than either alone without increased adverse events 1
• Oral decongestants (pseudoephedrine 60 mg every 4-6 hours) can provide symptomatic relief 7

Special Population Considerations

Hypertension or Cardiac Disease

• Avoid oral decongestants (pseudoephedrine, phenylephrine) entirely or use with extreme caution, as they can cause palpitations, elevated blood pressure, insomnia, and irritability 1, 2
• Intranasal corticosteroids are safe at recommended doses without clinically significant systemic effects 2

Pregnancy

• Caution is recommended for decongestants during the first trimester due to reports of fetal heart rate changes 1
• Intranasal corticosteroids are generally preferred as they have minimal systemic absorption 1

Children

• Avoid OTC cough and cold medications in children under 6 years due to lack of efficacy and potential toxicity 1
• For children ≥6 years with allergic rhinitis: start with intranasal corticosteroids 100 mcg daily (1 spray per nostril) 5
• Intranasal antihistamines approved for age ≥6 years: azelastine 1 spray per nostril twice daily 1, 6

Benign Prostatic Hyperplasia

• First-generation antihistamines are contraindicated due to anticholinergic effects causing urinary retention 2
• Second-generation antihistamines are safe alternatives 2

Combination Therapy

When monotherapy fails:

• Adding intranasal antihistamine to intranasal corticosteroid provides greater symptom reduction than either agent alone for moderate to severe allergic rhinitis 2, 8
• The combination azelastine/fluticasone (Dymista) is FDA-approved: 1 spray per nostril twice daily for patients ≥12 years 1
• Do NOT routinely add oral antihistamines to intranasal corticosteroids, as multiple trials show no additional benefit 2

What NOT to Do

• Do NOT use oral leukotriene receptor antagonists (montelukast) as primary therapy for allergic rhinitis, as they are less effective than intranasal corticosteroids and more expensive 1, 2
• Do NOT use topical decongestants (oxymetazoline) for more than 3 days due to risk of rhinitis medicamentosa (rebound congestion) 1, 2, 8
• Do NOT use first-generation antihistamines due to sedation, performance impairment, and anticholinergic effects 2, 8
• Do NOT administer recurrent parenteral corticosteroids, as this is contraindicated due to greater potential for long-term side effects 1

Critical Administration Technique

• Direct intranasal corticosteroid spray away from the nasal septum (aim laterally) to prevent mucosal erosions and potential septal perforation 2, 8
• Prime the delivery system before initial use: 4 sprays for azelastine until fine mist appears 6

Long-Term Management

• For patients with inadequately controlled symptoms despite optimal pharmacotherapy, consider referral to an allergist for allergen immunotherapy, which is the only treatment that modifies the natural history of allergic rhinitis and may prevent asthma development 1, 2
• Immunotherapy requires demonstrable specific IgE antibodies to clinically relevant allergens 1
• Nasal saline irrigation is beneficial as sole or adjunctive treatment for chronic rhinorrhea 1, 2