First-Line Management of Allergic Rhinitis
Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be initiated immediately for patients with moderate to severe symptoms, as they control all major nasal symptoms including congestion, rhinorrhea, sneezing, and itching better than any other single medication. 1, 2
Initial Treatment Approach
Start with intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) at 200 mcg daily (2 sprays per nostril once daily) as monotherapy for moderate to severe allergic rhinitis. 3, 1, 2
Intranasal corticosteroids are superior to oral antihistamines, leukotriene receptor antagonists, and all other pharmacological treatments for comprehensive symptom control. 1, 2
For mild intermittent symptoms only, second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) may be used as first-line treatment, particularly when sneezing, itching, and rhinorrhea are the primary complaints. 3, 1, 2
Critical Administration Instructions
Patients must direct the intranasal spray away from the nasal septum toward the lateral nasal wall to prevent mucosal erosions and potential septal perforation. 1, 2
Maximum efficacy requires several days of consistent daily use; counsel patients to continue treatment even if immediate relief is not apparent. 2
For seasonal allergic rhinitis, start intranasal corticosteroids before the pollen season begins for optimal prophylaxis. 2
Combination Therapy for Inadequate Response
Add intranasal antihistamine (azelastine) to intranasal corticosteroid for moderate to severe symptoms not adequately controlled by corticosteroid alone, as this combination provides greater and more rapid symptom reduction than either agent alone. 1, 4
Adding oral antihistamines to intranasal corticosteroids provides no additional benefit and should be avoided. 1
Adding leukotriene receptor antagonists to intranasal corticosteroids provides no additional benefit and is not recommended. 1
For persistent rhinorrhea despite intranasal corticosteroid, add ipratropium bromide nasal spray, as the combination is more effective than either agent alone. 3, 1
Environmental Control Measures
Implement allergen avoidance strategies for known or suspected triggers even during early treatment, though avoidance alone without pharmacotherapy is insufficient. 3, 1
Complete avoidance is the most effective strategy for animal allergies. 3, 5
Nasal saline irrigation is beneficial as adjunctive therapy to relieve congestion and facilitate clearance of nasal secretions. 3, 1, 2
Critical Medications to Avoid
Never use first-generation antihistamines (diphenhydramine, chlorpheniramine) due to significant sedation, performance impairment, and anticholinergic effects including urinary retention. 3, 1, 2
Limit topical nasal decongestants (oxymetazoline, phenylephrine) to a maximum of 3-5 days to prevent rhinitis medicamentosa (rebound congestion). 1, 2
Avoid oral decongestants (pseudoephedrine) in patients with hypertension, coronary heart disease, cardiac arrhythmias, anxiety, or bladder neck obstruction. 3, 2
Never use oral corticosteroids for chronic management due to significant systemic side effects; reserve only for rare cases of severe intractable symptoms unresponsive to all other treatments. 3, 1
Referral for Immunotherapy
Refer to an allergist/immunologist for allergen immunotherapy (subcutaneous or sublingual) when symptoms remain inadequately controlled despite optimal pharmacotherapy with or without environmental controls. 3, 1, 5
Immunotherapy requires demonstrable specific IgE antibodies to clinically relevant allergens via skin testing or serum-specific IgE testing. 3, 5
Immunotherapy is the only disease-modifying treatment that alters the natural history of allergic rhinitis, may prevent development of new allergen sensitizations, and can reduce future asthma risk. 3, 1, 4