In a patient with allergic rhinitis whose most bothersome symptom on the Sinonasal Outcome Test‑22 (SNOT‑22) is nasal obstruction, what is the recommended first‑line therapy?

Nasal Obstruction as the Dominant Symptom in Allergic Rhinitis

For a patient with allergic rhinitis whose dominant symptom on SNOT-22 is nasal obstruction, intranasal corticosteroids are the recommended first-line therapy.

Rationale for Intranasal Corticosteroids

Nasal obstruction is fundamentally different from other allergic rhinitis symptoms because it is driven by type 2 inflammation rather than direct histamine release 1. This mechanistic distinction is critical:

• Nasal congestion results from vasodilation, eosinophilic infiltration of the nasal mucosa, and increased mucus production—all manifestations of inflammatory processes 1
• Intranasal corticosteroids directly target this underlying inflammation, providing superior relief for nasal obstruction compared to antihistamines 1
• These agents effectively control symptoms in both the early and late phases of allergic response, with studies demonstrating almost complete prevention of late-phase symptoms 2

Treatment Algorithm Based on Symptom Profile

When nasal obstruction dominates the clinical picture:

• Start with an intranasal corticosteroid (fluticasone, triamcinolone, budesonide, or mometasone) as monotherapy 3
• This recommendation applies specifically to patients with persistent moderate-to-severe allergic rhinitis where nasal congestion is the primary complaint 3
• Adequate drug concentrations at receptor sites in the nasal mucosa achieve symptom control while minimizing systemic adverse effects 2

When to Consider Combination Therapy

If monotherapy with intranasal corticosteroids provides insufficient relief:

• Add an intranasal antihistamine (azelastine or olopatadine) to the corticosteroid regimen 4, 3
• Combination therapy with intranasal antihistamine spray plus nasal steroid provides greater symptomatic relief than monotherapy 4
• This approach is particularly effective when patients have both nasal obstruction and histamine-mediated symptoms (itching, sneezing, rhinorrhea) 1

Important Clinical Caveats

Avoid the common pitfall of prescribing oral or intranasal antihistamines as monotherapy when nasal obstruction is the dominant symptom. Antihistamines are particularly indicated for histamine-dependent symptoms (itching, sneezing, rhinorrhea) but are less effective for inflammation-driven nasal congestion 1. Patients with primarily nasal obstruction will experience suboptimal outcomes with antihistamine monotherapy.

Safety Profile

Intranasal corticosteroids have an excellent safety profile:

• Adverse reactions are typically limited to local nasal effects: dryness, burning, stinging, and epistaxis occurring in 5-10% of patients regardless of formulation 2
• Systemic adverse effects are negligible due to topical administration 5
• These agents have been safely used since the early 1980s with consolidated evidence confirming both efficacy and safety 5

Adjunctive Measures

While pharmacotherapy is primary, patients should also:

• Implement allergen avoidance strategies specific to their sensitization profile 3
• Consider nasal lavage with hypertonic solutions, which removes allergens and mediators while providing decongestant activity 1