What is the recommended management for allergic rhinitis?

Management of Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for moderate to severe allergic rhinitis and should be initiated immediately for comprehensive symptom control. 1, 2

Initial Treatment Strategy

For Moderate to Severe Allergic Rhinitis

• Start with intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) at 200 mcg daily (2 sprays per nostril once daily) as first-line monotherapy, as they provide superior relief for all nasal symptoms including congestion, rhinorrhea, sneezing, and itching compared to any other single medication class. 1, 3, 2
• Intranasal corticosteroids are particularly critical for nasal congestion, which oral antihistamines do not adequately address. 3
• Maximum efficacy requires several days of consistent daily use, so patients should be counseled to continue treatment even if immediate relief is not apparent. 3
• For seasonal allergic rhinitis, start medication before the pollen season begins for optimal prophylaxis. 3

For Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) or intranasal antihistamines (azelastine, olopatadine) are appropriate first-line options. 1, 4
• Second-generation antihistamines are preferred over first-generation agents due to significantly less sedation and performance impairment. 1, 2
• Intranasal antihistamines have equal or superior efficacy to oral second-generation antihistamines for seasonal allergic rhinitis and uniquely provide clinically significant relief of nasal congestion. 1

Combination Therapy for Inadequate Response

• For moderate to severe seasonal allergic rhinitis not adequately controlled with intranasal corticosteroids alone, add an intranasal antihistamine (such as azelastine), as this combination provides greater efficacy than either agent alone. 1, 2
• Adding oral antihistamines to intranasal corticosteroids is not routinely recommended, as multiple high-quality trials show no additional benefit. 2
• If nasal itching, sneezing, or eye symptoms remain problematic despite intranasal corticosteroids, adding a second-generation oral antihistamine (cetirizine 10 mg daily) is reasonable. 3

Additional Pharmacologic Options

Leukotriene Receptor Antagonists

• Oral montelukast alone or in combination with antihistamines has proven useful in treating allergic rhinitis, but is generally less efficacious than intranasal corticosteroids. 1, 2
• Leukotriene receptor antagonists should not be added to intranasal corticosteroids, as they provide no additional benefit. 2

Intranasal Anticholinergics

• Ipratropium bromide nasal spray is particularly effective for rhinorrhea but has no effect on other nasal symptoms. 1
• The combination of ipratropium bromide with an intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea. 1

Decongestants

• Oral decongestants (pseudoephedrine, phenylephrine) can reduce nasal congestion but should be used with extreme caution or avoided entirely in patients with hypertension, cardiac arrhythmia, glaucoma, hyperthyroidism, or coronary heart disease. 1, 3
• Topical nasal decongestants must be strictly limited to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 1, 3, 2

Adjunctive Therapies

• Nasal saline irrigation is beneficial as adjunctive treatment for chronic rhinorrhea and rhinosinusitis, facilitating clearance of nasal secretions and allergens. 1, 3
• Intranasal cromolyn sodium is effective for prevention and treatment with minimal side effects, but is less effective than corticosteroids. 1

Short-Term Corticosteroid Use

• A short course of oral corticosteroids may be appropriate for intractable nasal symptoms or severe nasal polyposis. 5
• The chronic use of oral or parenteral corticosteroids is inappropriate and contraindicated in allergic rhinitis due to potential long-term side effects. 5, 1

Allergen Immunotherapy

• Allergen immunotherapy should be considered for patients with demonstrable specific IgE antibodies to clinically relevant allergens when symptoms remain inadequately controlled despite optimal pharmacotherapy. 5, 1
• Immunotherapy is the only disease-modifying treatment available for allergic rhinitis and has been associated with significant improvement in symptom scores, medication use, and quality of life measures. 5, 6
• Effective immunotherapy may prevent development of new allergen sensitizations and reduce the future risk of asthma. 3, 2
• The decision to begin immunotherapy depends on the degree to which symptoms can be reduced by avoidance and medication, the amount and type of medication required, adverse effects of medications, and the impact on quality of life. 5

Environmental Control Measures

• Avoidance of allergens and irritants is fundamental to successful management and should be implemented even in early treatment. 5, 1, 2
• The most common allergic triggers include pollens, fungi, dust mites, furry animals, and insect emanations. 5
• Highly pollen-allergic individuals should limit outdoor exposure when high pollen counts are present, keep windows and doors closed during pollen season, and avoid using attic fans. 5
• For dust mite allergies, implement a combination of humidity control, dust mite covers for bedding, HEPA vacuuming of carpeting, and acaricides. 1
• For animal allergies, complete avoidance is the most effective management strategy. 1, 3
• Avoid tobacco smoke, formaldehyde, and other irritants that can trigger symptoms. 1

Critical Pitfalls to Avoid

• Never use first-generation antihistamines due to significant sedation, performance impairment, anticholinergic effects, and increased accident risk. 1, 3, 2
• First-generation antihistamines are particularly contraindicated in patients with benign prostatic hyperplasia due to urinary retention risk. 3
• Ensure patients direct intranasal corticosteroid spray away from the nasal septum to prevent mucosal erosions and potential septal perforation. 3, 2
• Do not rely on oral antihistamines as monotherapy for patients with significant nasal congestion, as they have minimal effect on this symptom. 3
• Avoid inadequate treatment of nonallergic rhinitis with oral antihistamines, which are not effective for this condition. 1

Assessment for Comorbid Conditions

• Pulmonary function tests should be considered in patients with rhinitis to assess for coexisting asthma, as patients with persistent allergic rhinitis should be evaluated for asthma and vice versa. 5
• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma. 3, 2
• Intranasal corticosteroids reduce nasal airway resistance and may benefit patients with obstructive sleep apnea and rhinitis. 5

When to Refer to Specialist

• Refer to an allergist/immunologist for prolonged manifestations not responding to standard therapy. 1, 2
• Refer when complications develop, including nasal polyps, otitis media, or sinusitis. 1, 2
• Refer when systemic corticosteroids have been required. 1, 2
• Refer for consideration of allergen immunotherapy when symptoms remain inadequately controlled despite optimal pharmacotherapy or when medication side effects are problematic. 1, 3