Can saline spray be used as a standalone treatment for mild to moderate chronic allergic rhinitis?

Saline Spray as Standalone Treatment for Chronic Allergic Rhinitis

Saline spray should NOT be used as standalone treatment for chronic allergic rhinitis; first-line therapy should be intranasal corticosteroids for persistent moderate-to-severe disease, or second-generation oral/intranasal antihistamines for mild disease, with saline reserved as adjunctive therapy only. 1

Treatment Algorithm Based on Disease Severity

For Mild Intermittent or Mild Persistent Allergic Rhinitis

• First-line options include second-generation H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) 1
• Saline may be considered as monotherapy only in this mild disease subset, where one small study showed it can be "an effective alternative in mild-to-moderate allergic rhinitis, particularly with respect to nasal and eye symptoms" 2
• However, this evidence is limited to a single small trial (n=15) from 2005 2

For Persistent Moderate-to-Severe Allergic Rhinitis

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be used initially, either alone or combined with intranasal antihistamines 1
• Saline has no role as standalone therapy in this population 1, 2

Evidence Supporting Limited Standalone Use

Potential Benefits in Mild Disease

• A Cochrane review found saline irrigation may reduce patient-reported disease severity compared with no treatment, with a large effect size (SMD -1.32 at up to 4 weeks; SMD -1.44 at 4 weeks to 3 months) 3
• However, the Cochrane authors rated this evidence as low quality due to small study sizes and heterogeneous outcome measures 3
• One 2005 trial showed hypertonic Dead Sea saline was less effective than intranasal corticosteroids but showed some benefit for nasal and eye symptoms in mild-to-moderate disease 2

Saline Inferior to Standard Therapies

• When directly compared to intranasal steroids, it is uncertain whether saline provides equivalent benefit, with very limited comparative data 3
• A 2024 study demonstrated that even a barrier-forming nasal spray (AM-301) was compared against saline as the control group, suggesting saline is considered a minimal intervention rather than active treatment 4

Role as Adjunctive Therapy

Saline is better positioned as adjunctive therapy rather than monotherapy:

• When added to intranasal steroids or oral antihistamines, the evidence for additional benefit is uncertain (very low quality) 3
• Consensus guidelines recommend saline nasal irrigation as adjunctive treatment for various rhinitis conditions 5
• The mechanism involves cleansing and clearing aeroallergens from the nasal cavity, improving mucociliary clearance 2, 4

Safety Profile

• Saline irrigation appears safe with no reported serious adverse events 3
• Multiple studies reported no epistaxis or local discomfort in saline groups 3
• Minor adverse effects can be avoided with technique modification and salinity adjustment 5

Critical Limitations and Caveats

• No studies reported outcomes beyond 3 months, limiting conclusions about chronic disease management 3
• The overall quality of evidence is low to very low, with small studies using varied outcome measures 3
• Studies used different saline volumes (very low to high) and tonicity (hypertonic vs isotonic), making specific recommendations about optimal formulation impossible 3
• The 2024 JAMA review, the highest quality and most recent guideline-level evidence, does not include saline as a recommended first-line monotherapy option 1

Clinical Bottom Line

For chronic allergic rhinitis, saline spray lacks sufficient evidence to recommend as standalone treatment. Begin with evidence-based pharmacotherapy (antihistamines for mild disease, intranasal corticosteroids for moderate-to-severe disease) and consider saline as a safe, low-cost adjunct for symptom management and nasal hygiene 1, 3.