Treatment of Allergic Rhinitis
Intranasal corticosteroids are the first-line treatment for allergic rhinitis and should be prescribed as monotherapy for initial management in patients 12 years and older. 1, 2
Initial Treatment Approach
First-Line Monotherapy
Prescribe an intranasal corticosteroid alone rather than combining it with an oral antihistamine for initial treatment. 1 The evidence does not support adding oral antihistamines to intranasal corticosteroids, as combination therapy provides no additional benefit over intranasal corticosteroids alone. 2
Intranasal corticosteroids are superior to all other medication classes, including oral antihistamines and leukotriene receptor antagonists, for controlling all four major nasal symptoms: congestion, rhinorrhea, sneezing, and itching. 1, 2
Specific intranasal corticosteroid options include fluticasone propionate, mometasone furoate, budesonide, and triamcinolone acetonide. 1, 3 All are equally efficacious, with differences limited to potency, dosing regimens, and patient preference. 3
When to Consider Intranasal Corticosteroids Without Prior Trials
Intranasal corticosteroids may be initiated immediately without requiring a previous trial of antihistamines or oral decongestants. 1 This is particularly important for patients with moderate-to-severe symptoms affecting quality of life, work performance, or school attendance. 2
Symptom relief begins within 12 hours, though maximal efficacy requires days to weeks of regular use. 2 Patients must understand this is maintenance therapy, not rescue therapy. 2
Stepwise Escalation for Inadequate Response
Second-Line: Add Intranasal Antihistamine
For moderate-to-severe allergic rhinitis with inadequate response to intranasal corticosteroid monotherapy, add an intranasal antihistamine (azelastine or olopatadine). 2 This combination provides greater than 40% relative improvement compared to either agent alone. 2
The combination of fluticasone propionate and azelastine represents the most effective pharmacologic option for seasonal allergic rhinitis. 2 This combination is more effective than adding an oral antihistamine. 2
Intranasal antihistamines alone are equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis, but remain less effective than intranasal corticosteroids. 1
Alternative Second-Line Options for Specific Symptoms
For predominant rhinorrhea: Add intranasal ipratropium bromide, which effectively reduces rhinorrhea but has minimal effect on other nasal symptoms. 1 The combination of ipratropium with intranasal corticosteroids is more effective than either drug alone without increased adverse effects. 1
For mild intermittent symptoms: Oral second-generation antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) may be used for patients whose primary complaints are sneezing and itching. 2, 4 However, these are less effective than intranasal corticosteroids for nasal congestion. 2
Third-Line: Consider Leukotriene Receptor Antagonists
- Oral leukotriene receptor antagonists (montelukast 10 mg once daily) may be added as adjunctive therapy, though they are generally less effective than intranasal corticosteroids. 1, 2 These should not be used as primary therapy. 2
Management of Severe or Refractory Disease
Short-Term Oral Corticosteroids
A short 5-7 day course of oral corticosteroids (prednisone) may be appropriate only for very severe or intractable rhinitis that significantly impacts quality of life. 1, 5 This should be reserved for patients unresponsive to all other treatment modalities. 5
Single administration of parenteral corticosteroids is discouraged, and recurrent administration is contraindicated due to greater potential for long-term side effects including adrenal suppression, muscle atrophy, and fat necrosis. 1, 5
Allergen Immunotherapy
Refer patients with inadequate response to pharmacologic therapy for allergen immunotherapy (subcutaneous or sublingual). 1, 2 This is the only disease-modifying intervention available for allergic rhinitis. 6
Allergen immunotherapy should be considered when symptoms cannot be adequately controlled by avoidance and medication, or when the amount and adverse effects of medications become problematic. 1
Immunotherapy may prevent development of new allergen sensitizations and reduce the risk for future development of asthma. 1, 2
Adjunctive Measures
Environmental Control
- Implement empiric avoidance of suspected inciting allergens, irritants, and medications even in early treatment. 1 For severe seasonal allergic rhinitis, advise patients to stay inside air-conditioned buildings with windows and doors closed whenever possible. 1
Nasal Saline
- Topical saline is beneficial as sole modality or adjunctive treatment for chronic rhinorrhea and rhinosinusitis. 1, 2 Hypertonic solutions exert decongestant activity and help remove secretions, allergens, and mediators. 7
Important Caveats and Common Pitfalls
Proper Administration Technique
- Direct the spray away from the nasal septum using the contralateral hand technique to reduce epistaxis risk by four times. 2 Improper technique increases local side effects and reduces efficacy. 2
Decongestant Use
Oral and topical decongestants should be used with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 1
Topical decongestants should be limited to 3 days maximum due to rebound congestion (rhinitis medicamentosa). 2 Intranasal corticosteroids do not cause rhinitis medicamentosa and are safe for long-term use. 2
Monitoring During Long-Term Use
Periodically examine the nasal septum (every 6-12 months) to detect mucosal erosions that may precede septal perforation, a rare complication. 2 Proper spray technique minimizes this risk. 2
Common adverse effects include epistaxis (typically blood-tinged secretions in 5-10% of patients), nasal irritation, headache, and pharyngitis. 2, 3 These are generally mild and transient. 1
Intranasal corticosteroids at recommended doses cause no clinically significant systemic effects, HPA axis suppression, or growth suppression in children. 2, 3