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 both allergic and nonallergic rhinitis, providing superior symptom control compared to oral antihistamines. 1

Determining the Cause

The approach differs based on whether rhinorrhea is allergic or infectious:

• Allergic rhinitis typically presents with rhinorrhea (90% of cases), nasal congestion (94%), sneezing, and itching of eyes, nose, and throat, often with pale/edematous turbinates on exam 2
• Viral rhinitis (common cold) lasts up to 10 days and may include fever, malaise, and general symptoms of infection 3
• Nonallergic rhinitis presents primarily with nasal congestion and postnasal drainage, with negative allergy testing 2

First-Line Treatment Algorithm

For Allergic Rhinitis

Mild intermittent symptoms (< 4 days/week or < 4 weeks/year):

• Start with a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, or desloratadine) OR an intranasal antihistamine (azelastine or olopatadine) 2
• Second-generation antihistamines are preferred over first-generation due to significantly less sedation and performance impairment 4, 1

Moderate to severe or persistent symptoms (> 4 days/week and > 4 consecutive weeks):

• Initiate intranasal corticosteroid immediately (fluticasone 200 mcg daily as 2 sprays per nostril once daily, or mometasone, budesonide, or triamcinolone) 1, 2
• Intranasal corticosteroids are more effective than oral antihistamines for all nasal symptoms, particularly nasal congestion 4
• Maximum effect may take several days, but symptom improvement can begin within 12 hours 5

For Nonallergic Rhinitis

• Start with intranasal antihistamine (azelastine 0.15% solution, 1-2 sprays per nostril twice daily for age ≥12 years) as monotherapy or combined with intranasal corticosteroid 2
• Intranasal antihistamines are effective for both allergic and nonallergic rhinitis 4, 1

For Viral Rhinitis (Common Cold)

• Nasal saline irrigation is beneficial as sole therapy or adjunctive treatment for rhinorrhea 4, 1
• Oral decongestants (pseudoephedrine 60 mg every 4-6 hours) may provide relief but should be limited to short-term use 6
• Avoid OTC cough and cold medications in children under 6 years due to lack of efficacy and potential toxicity 4

When Initial Treatment Fails

If intranasal corticosteroid alone is inadequate:

• Add intranasal antihistamine (azelastine or olopatadine) to the intranasal corticosteroid—this combination provides greater symptom reduction than either agent alone 1, 7
• Do NOT routinely add oral antihistamines to intranasal corticosteroids, as multiple high-quality trials show no additional benefit 1

For severe rhinorrhea specifically:

• Add intranasal anticholinergic (ipratropium bromide nasal spray) to intranasal corticosteroid—this combination is more effective than either drug alone for rhinorrhea without increased adverse events 4, 1
• Ipratropium effectively reduces rhinorrhea but has no effect on other nasal symptoms 4

Special Population Considerations

Pregnancy:

• Intranasal corticosteroids at recommended doses do not cause clinically significant systemic effects and are generally safe 1
• Use caution with oral decongestants in first trimester due to reported fetal heart rate changes 4

Hypertension/Cardiac Disease:

• Avoid or use extreme caution with oral decongestants (pseudoephedrine, phenylephrine), as they can cause palpitations, elevated blood pressure, insomnia, and irritability 4, 1
• Intranasal corticosteroids are safe alternatives 1

Benign Prostatic Hyperplasia:

• First-generation antihistamines are contraindicated due to anticholinergic effects causing urinary retention 1
• Second-generation antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are safe alternatives 1

Children (age 4-11 years):

• Fluticasone: Start with 100 mcg (1 spray per nostril once daily); may increase to 200 mcg if inadequate response 5
• Azelastine 0.15%: 1 spray per nostril twice daily for ages 6-11 years 4

Children under 6 years:

• Avoid OTC cough and cold medications due to lack of proven efficacy and potential toxicity 4

Critical Pitfalls to Avoid

• Never use topical nasal decongestants (oxymetazoline, phenylephrine) for more than 3 days—rhinitis medicamentosa (rebound congestion) can develop as early as day 3-4 of use 4, 1, 7
• Do NOT use oral leukotriene receptor antagonists (montelukast) as primary therapy—they are less effective than intranasal corticosteroids and should not be first-line treatment 4, 1
• Direct intranasal corticosteroid spray away from the nasal septum to prevent mucosal erosions and potential septal perforation 1, 7
• Avoid first-generation antihistamines due to sedation, performance impairment, and anticholinergic effects 1, 7
• Do not administer recurrent parenteral corticosteroids—this is contraindicated due to greater potential for long-term side effects 4

Dosing Specifics for Common Medications

Intranasal Corticosteroids:

• Fluticasone propionate: Adults 200 mcg/day (2 sprays per nostril once daily or 1 spray twice daily); Children ≥4 years: 100 mcg/day 5
• Mometasone furoate: Adults 200 mcg/day (2 sprays per nostril once daily); Children 2-11 years: 100 mcg/day 4

Intranasal Antihistamines:

• Azelastine 0.15%: Age ≥12 years: 1-2 sprays per nostril twice daily or 2 sprays daily; Age 6-11 years: 1 spray twice daily 4
• Olopatadine 0.6%: Age ≥12 years: 2 sprays twice daily; Age 6-11 years: 1 spray twice daily 4

Oral Antihistamines:

• Cetirizine: Age ≥6 years: 10 mg/day; Age 2-5 years: 5 mg/day 4
• Fexofenadine: Age ≥12 years: 60 mg twice daily or 180 mg/day 4

Long-Term Management

• After 4-7 days of good control with intranasal corticosteroid 200 mcg/day, may reduce to maintenance dose of 100 mcg/day (1 spray per nostril once daily) 5
• Consider referral to allergist/immunologist for allergen immunotherapy if symptoms remain inadequately controlled despite optimal pharmacotherapy—this is the only treatment that modifies the natural history of allergic rhinitis and may prevent asthma development 1