What is the appropriate initial management for a patient with allergic rhinitis?

Initial Management of Allergic Rhinitis

Intranasal corticosteroids are the first-line therapy for most patients with allergic rhinitis, as they are the single most effective medication for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itching. 1

First-Line Pharmacotherapy

Intranasal Corticosteroids (Primary Treatment)

• Start intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) at 200 mcg once daily (2 sprays per nostril) for patients with moderate to severe or persistent symptoms. 1, 2
• Maximum efficacy requires several days of consistent daily use, so counsel patients to continue therapy even if immediate relief is not apparent. 2
• Direct sprays away from the nasal septum to prevent irritation, bleeding, and potential septal perforation. 2, 3
• For seasonal allergic rhinitis, start medication before the pollen season begins for optimal prophylaxis. 2

Alternative for Mild Intermittent Symptoms

• For patients with mild intermittent symptoms (less than 4 consecutive days/week or less than 4 consecutive weeks/year), second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) are appropriate alternatives. 2, 4
• Intranasal antihistamines work within hours and are equal or superior to oral antihistamines for seasonal allergic rhinitis, with the unique advantage of reducing nasal congestion. 1, 2

Environmental Control Measures (Concurrent with Pharmacotherapy)

Allergen avoidance is the most effective management strategy and must be implemented alongside pharmacotherapy. 1

Specific Avoidance Strategies

• During peak pollen periods, keep windows and doors closed, remain in air-conditioned environments, and avoid outdoor activities when pollen counts are high. 5, 1
• For dust mite allergy: use humidity control, dust mite covers, HEPA vacuuming, and acaricides. 1
• For animal allergies, complete avoidance is the most effective strategy. 2
• Avoid non-allergen irritants including tobacco smoke, strong odors, and temperature/humidity extremes. 2

Escalation for Inadequate Response

Add-On Therapy

• If symptoms remain inadequately controlled on intranasal corticosteroids alone, add intranasal antihistamine to the intranasal corticosteroid, as this combination is the most effective pharmacologic approach. 1
• For persistent rhinorrhea despite intranasal corticosteroids, add ipratropium intranasal spray (0.03%), which specifically targets rhinorrhea but has no effect on other nasal symptoms. 2, 6
• For severe nasal congestion, topical oxymetazoline may be added to intranasal corticosteroid for maximum 3-5 days only to avoid rebound congestion (rhinitis medicamentosa). 1, 2, 3

Adjunctive Non-Pharmacologic Therapy

• Nasal saline irrigation is recommended as adjunctive therapy to relieve congestion and facilitate clearance of nasal secretions and allergens. 2, 3

Critical Pitfalls to Avoid

• Never use topical nasal decongestants (oxymetazoline, phenylephrine) for more than 3-5 days, as this causes rebound congestion (rhinitis medicamentosa) that worsens the underlying condition. 1, 2, 3
• Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine) due to sedation, impaired work performance, increased accident risk, and anticholinergic effects, especially in older adults. 2
• Do not prescribe antibiotics for allergic rhinitis, as they are ineffective for allergic conditions and contribute to antimicrobial resistance. 2
• Oral decongestants (pseudoephedrine) should only be used after screening for contraindications including hypertension, anxiety, or cardiac conditions. 2

Monitoring and Referral Criteria

Assessment Parameters

• Periodically assess quality of life including time lost from work or activities, sleep quality, smell and taste function, fatigue level, and general well-being. 5, 1
• Evaluate all patients with allergic rhinitis for asthma, as rhinitis increases asthma risk and treatment of rhinitis improves asthma control. 5, 1, 2

When to Refer to Allergist

• Refer patients whose symptoms persist for 2-4 weeks despite optimal intranasal corticosteroid therapy and interfere with occupational performance or quality of life. 1, 3
• Consider allergen immunotherapy (subcutaneous or sublingual) for patients with inadequate response to pharmacotherapy with or without environmental controls, as it is the only disease-modifying treatment that can prevent new allergen sensitizations and reduce future asthma risk. 1, 2
• Development of complications including sinusitis, otitis media, or new asthma-type symptoms warrants specialist evaluation. 5, 1

Special Populations

• In children under 3 years, avoid decongestants and antihistamines due to risk of adverse effects outweighing benefits. 2
• In older adults, exercise extreme caution with first-generation antihistamines due to increased sensitivity to psychomotor impairment and anticholinergic effects. 2