How should allergic rhinitis be treated in adults, adolescents, and children, including pharmacologic and non‑pharmacologic measures?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for allergic rhinitis in all age groups, superior to all other medication classes for controlling nasal congestion, rhinorrhea, sneezing, and itching. 1, 2, 3

First-Line Pharmacotherapy: Intranasal Corticosteroids

Start intranasal corticosteroids immediately upon clinical diagnosis when symptoms affect quality of life—no allergy testing is required before initiating treatment. 1, 2

Age-Specific Intranasal Corticosteroid Selection

• Children 2-5 years: Triamcinolone acetonide (Nasacort) 1 spray per nostril daily, or mometasone furoate (Nasonex) 1 spray per nostril daily 1
• Children 6-11 years: Fluticasone propionate (Flonase) 1 spray per nostril daily (50 μg per spray), mometasone furoate 1 spray per nostril daily, or triamcinolone acetonide 1 spray per nostril daily 1
• Adolescents ≥12 years and adults: Fluticasone propionate 2 sprays per nostril once daily (200 mcg total), mometasone furoate 2 sprays per nostril once daily (200 mcg total), or triamcinolone acetonide 2 sprays per nostril once daily 1

Proper Administration Technique (Critical for Efficacy and Safety)

• Use the contralateral hand technique: Hold the spray in the opposite hand relative to the nostril being treated to direct spray away from the nasal septum—this reduces epistaxis risk by four times 1
• Prime the bottle before first use and shake before each administration 1
• Have the patient blow their nose before using the spray 1
• Keep the head upright during administration 1
• Instruct the patient to breathe in gently during spraying 1
• Do not close the opposite nostril during administration 1
• If using nasal saline irrigations, perform them before administering the steroid spray to avoid rinsing out the medication 1

Onset and Duration Expectations

• Symptom relief begins within 12 hours, with some patients experiencing benefit as early as 3-4 hours, though maximal efficacy requires days to weeks of regular use 1, 2
• Counsel patients to continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this period 1
• For seasonal allergic rhinitis with predictable patterns, initiate treatment before symptom onset and continue throughout the allergen exposure period 1

Treatment Duration and Long-Term Safety

• Intranasal corticosteroids are safe for indefinite long-term use when clinically indicated—they do not cause rhinitis medicamentosa (rebound congestion) unlike topical decongestants 1, 2
• No hypothalamic-pituitary-adrenal axis suppression occurs at recommended doses in children or adults 1, 2
• No growth suppression in children at recommended doses (fluticasone propionate, mometasone furoate, and budesonide have been studied up to twice the recommended doses without growth effects) 1
• No ocular effects (cataracts or glaucoma) with long-term use 1
• Periodically examine the nasal septum every 6-12 months during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication) 1, 2

Common Side Effects and Management

• Epistaxis (nasal bleeding) is the most common adverse event, occurring in 4-8% of patients in short-term studies and up to 20% with year-long use, typically presenting as blood-tinged nasal secretions rather than severe nosebleeds 1, 4
• Nasal irritation, burning, headache, and pharyngitis occur in 5-10% of patients 1, 4
• These local side effects can be minimized with proper spray technique (directing spray away from septum) 1

Second-Line and Adjunctive Therapies

When to Add or Switch Medications

For moderate-to-severe allergic rhinitis with inadequate response to intranasal corticosteroid monotherapy after 2-3 weeks, add an intranasal antihistamine (azelastine or olopatadine)—this combination provides >40% relative improvement compared to either agent alone. 1, 2, 5

Oral Second-Generation Antihistamines

• Use oral antihistamines (loratadine, cetirizine, fexofenadine) for patients whose primary complaints are sneezing and itching, though they are less effective than intranasal corticosteroids for nasal congestion 1, 2, 3
• Do NOT add an oral antihistamine to an intranasal corticosteroid—this combination provides no additional benefit over intranasal corticosteroid monotherapy 2, 3
• Cetirizine and intranasal azelastine may cause sedation at recommended doses; other second-generation antihistamines are generally non-sedating 2

Intranasal Antihistamines

• Intranasal antihistamines (azelastine, olopatadine) may be used as monotherapy for mild allergic rhinitis or in combination with intranasal corticosteroids for moderate-to-severe disease 1, 2, 5
• The fixed combination of azelastine plus fluticasone propionate in a single device (Dymista) is highly effective for moderate-to-severe seasonal allergic rhinitis 1, 2, 6

Intranasal Ipratropium Bromide

• For patients with predominant watery rhinorrhea, intranasal ipratropium bromide effectively reduces nasal discharge but has no effect on other nasal symptoms 2
• Combining ipratropium bromide with an intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea without increased adverse events 2

Leukotriene Receptor Antagonists

• Leukotriene receptor antagonists (montelukast 10 mg daily) are NOT recommended as primary therapy—they are significantly less effective than intranasal corticosteroids 1, 2, 3
• Montelukast may be used as adjunctive therapy in patients with concomitant asthma 2

Nasal Saline Irrigation

• Nasal saline irrigation (isotonic or hypertonic) is beneficial as sole therapy or adjunctive treatment for chronic rhinorrhea, helping to clear secretions, allergens, and inflammatory mediators 2, 7
• Hypertonic solutions exert a decongestant activity 7

Management of Severe or Refractory Disease

Short-Course Oral Corticosteroids

• A brief 5-7 day course of oral prednisone may be considered only for very severe or intractable symptoms that significantly impact quality of life and have failed all other pharmacologic options 1, 2
• Single or repeated parenteral (injectable) corticosteroids are contraindicated due to greater potential for prolonged adrenal suppression, muscle atrophy, and fat necrosis 1, 2

Allergen Immunotherapy

• Refer patients with inadequate response to optimal pharmacotherapy for allergen immunotherapy (subcutaneous or sublingual)—this is the only disease-modifying treatment for allergic rhinitis 2, 5
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk 2

Non-Pharmacologic Measures

Environmental Control and Allergen Avoidance

• Empiric avoidance of suspected allergens, irritants, and trigger medications should be instituted early 2
• For severe seasonal disease, advise staying in air-conditioned environments with windows and doors closed 2
• Environmental control measures for indoor allergens (dust mites, pet dander, mold) are effective management strategies 2

Important Contraindications and Cautions

Intranasal Corticosteroids

• Contraindicated in patients with hypersensitivity to the medication or its components 1
• Avoid in patients with recent nasal surgery or nasal trauma until healing has occurred 1

Oral and Topical Decongestants

• Topical decongestants (oxymetazoline, phenylephrine) should be limited to 3 days maximum due to rebound congestion risk (rhinitis medicamentosa) 1, 2
• Use oral decongestants (pseudoephedrine, phenylephrine) with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 2

Common Pitfalls to Avoid

• Do not wait for allergy testing results before initiating intranasal corticosteroids—testing is reserved for patients who fail empiric treatment or when specific allergen identification is needed 1
• Do not start with oral antihistamines or leukotriene antagonists as first-line therapy—intranasal corticosteroids are significantly more effective for all four major nasal symptoms 1, 2, 3
• Do not assume combination therapy is always superior to monotherapy—intranasal corticosteroid alone is often sufficient 2, 3
• Patients must understand that intranasal corticosteroids are maintenance therapy, not rescue therapy—they should not be discontinued when symptoms improve 1
• Teach proper administration technique using visual aids or demonstrations—studies show significantly higher competency in children taught using animated cartoons 1
• Do not routinely order sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis 2

Associated Conditions to Assess

Always assess for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, allergic conjunctivitis, rhinosinusitis, and otitis media in patients with allergic rhinitis 2