What is the recommended management for allergic rhinitis?

Management of Allergic Rhinitis

Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis and should be initiated as first-line treatment for moderate to severe symptoms, with second-generation antihistamines reserved for mild intermittent disease. 1

Initial Treatment Strategy Based on Severity

Mild Intermittent Allergic Rhinitis

• Start with a second-generation oral antihistamine (cetirizine, fexofenadine, loratadine, or desloratadine) as these agents effectively control sneezing, itching, and rhinorrhea without the sedation and anticholinergic effects of first-generation agents 1, 2
• Alternatively, use an intranasal antihistamine (azelastine or olopatadine) which provides rapid symptom relief and is effective for both allergic and nonallergic rhinitis 1, 2

Moderate to Severe or Persistent Allergic Rhinitis

• Initiate intranasal corticosteroid immediately at standard dosing (e.g., fluticasone, mometasone, budesonide, or triamcinolone at 200 mcg daily for adults—2 sprays per nostril once daily) 1, 3
• Intranasal corticosteroids control all major symptoms including nasal congestion, which oral antihistamines do not adequately address 1, 2
• For optimal efficacy, combine intranasal corticosteroid with intranasal antihistamine, as this combination provides greater symptom reduction than either agent alone 1, 3

Environmental Control Measures

• Implement allergen avoidance strategies targeting specific allergens identified through skin testing or specific IgE antibody testing 3
• Address nonallergen irritants including tobacco smoke, strong odors, and temperature/humidity extremes 3
• Nasal saline irrigation mechanically removes allergens and secretions from nasal passages and is beneficial as monotherapy or adjunctive treatment 1, 3

Critical Medication Considerations and Pitfalls

What to Avoid

• Never use topical decongestants for more than 3-10 days as prolonged use causes rhinitis medicamentosa (rebound congestion), worsening the underlying condition 1, 3
• Avoid first-generation antihistamines due to sedation, performance impairment, and anticholinergic effects including urinary retention in patients with benign prostatic hyperplasia 1
• Do not prescribe recurrent parenteral corticosteroids—this is contraindicated due to greater potential for long-term systemic adverse effects 3
• Oral decongestants should be used with extreme caution in patients with coronary heart disease and hypertension, as they can cause palpitations, elevated blood pressure, insomnia, and irritability 1

Proper Technique

• Direct intranasal corticosteroid spray away from the nasal septum to prevent mucosal erosions and potential septal perforation 1
• Monitor for local side effects including nasal irritation, bleeding, and rarely Candida infection with long-term intranasal corticosteroid use 1

Additional Pharmacologic Options

Leukotriene Receptor Antagonists

• Montelukast is less effective than intranasal corticosteroids but may be used in patients who cannot tolerate or refuse intranasal medications 1, 3
• Useful as adjunctive therapy in patients with coexisting asthma 3

Intranasal Cromolyn

• Effective for prevention and treatment with minimal side effects, but less effective than intranasal corticosteroids in most patients 3
• Should be started as early as possible in an allergy season for prophylaxis 1

Intranasal Anticholinergics

• Ipratropium bromide is particularly effective for rhinorrhea in both allergic and nonallergic rhinitis 1
• May be combined with antihistamines or intranasal corticosteroids for increased efficacy 1

Short-Course Oral Corticosteroids

• Reserve for very severe or intractable nasal symptoms or significant nasal polyposis only 3
• Use 5-7 day courses when necessary 3

Allergen Immunotherapy: The Only Disease-Modifying Treatment

Consider allergen immunotherapy (subcutaneous or sublingual) for patients with inadequate response to optimal pharmacotherapy, as this is the only treatment that modifies the natural history of allergic rhinitis. 3, 4

Indications for Immunotherapy

• Patients with demonstrable specific IgE antibodies to clinically relevant allergens whose symptoms correlate with allergen exposure 3
• Inadequate symptom control despite environmental controls and pharmacotherapy 3
• Significant medication side effects or desire to reduce medication burden 3
• Patient preference for disease-modifying therapy 3

Benefits Beyond Symptom Control

• May prevent development of new allergen sensitizations 3
• Reduces risk for future development of asthma in patients with allergic rhinitis 3
• Clinical benefits can persist for years after discontinuation of treatment 1

Important Contraindications

• Do not initiate immunotherapy in patients with negative specific IgE tests or positive tests that do not correlate with clinical symptoms and exposure history 3
• The presence of specific IgE antibodies alone does not indicate clinical sensitivity—correlation with symptoms and exposure is essential 3

Management of Comorbid Conditions

Allergic Rhinitis with Asthma

• Treatment of allergic rhinitis may improve asthma control in patients with coexisting conditions 3
• Patients with allergic rhinitis are at increased risk for developing asthma 3

Pregnancy Considerations

• Second-generation antihistamines are safe based on accumulated human observational data 3
• Avoid oral decongestants during the first trimester when organogenesis occurs 3
• Topical decongestants used short-term may have better safety profile than oral agents 3
• Intranasal cromolyn and montelukast are safe treatment options during pregnancy 3

When to Refer to Allergist/Immunologist

Consultation should be considered for patients with inadequately controlled symptoms despite optimal therapy, reduced quality of life, adverse medication reactions, or when allergen immunotherapy is being considered. 3

Specific Referral Indications

• Symptoms inadequately controlled with first-line pharmacotherapy 3, 1
• Desire to identify specific allergens and receive environmental control advice 3
• Comorbid conditions such as asthma, recurrent sinusitis, or nasal polyps 3
• Consideration of allergen immunotherapy 3
• Allergist/immunologist care improves patient outcomes, though consultation services are often underutilized 3

Individualized Step-Up and Step-Down Approach

Management should be based on:

• Spectrum, duration, and severity of symptoms 3
• Physical examination findings including turbinate appearance and presence of nasal polyps 3
• Age of the patient and comorbidities 3
• Patient preferences and medication tolerability 3
• Response to previous medications and compliance patterns 3

Effective management requires physician/patient/family partnership, environmental trigger avoidance, and appropriate use of prescribed interventions. 3

Patient Education as Foundation

Education is a key element in promoting adherence and optimizing treatment outcomes, including proper medication technique, realistic expectations, and understanding of the chronic nature of allergic rhinitis. 3