What is the recommended treatment for non‑allergic (vasomotor) rhinitis?

Treatment of Non-Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for non-allergic rhinitis, effectively relieving both congestion and rhinorrhea, with intranasal antihistamines (azelastine) and intranasal anticholinergics (ipratropium) serving as equally effective first-line alternatives depending on the predominant symptom pattern. 1

Primary Treatment Options

First-Line Agents

• Intranasal corticosteroids (fluticasone propionate, beclomethasone, mometasone) are the most effective monotherapy for non-allergic rhinitis and should be initiated immediately at standard dosing (e.g., 2 sprays per nostril once daily for adults). 1, 2

• Intranasal azelastine (137 µg per nostril twice daily for patients ≥12 years) is highly effective for vasomotor rhinitis despite the non-allergic nature of the condition, with rapid onset of action (within 3 hours) and potent anti-inflammatory effects beyond simple histamine blockade. 1, 3, 4

• Intranasal ipratropium bromide 0.03% (42 µg per nostril 2–3 times daily) is the most effective agent specifically for rhinorrhea-predominant non-allergic rhinitis because it blocks cholinergic-mediated glandular hypersecretion. 1

Symptom-Based Treatment Algorithm

Predominant Congestion

• Start with intranasal corticosteroids as monotherapy. 1
• If inadequate response after 2–4 weeks, add intranasal azelastine for combination therapy, which provides greater relief than either agent alone. 1

Predominant Rhinorrhea

• Start with ipratropium bromide monotherapy, as it markedly reduces rhinorrhea but has no effect on congestion or sneezing. 1
• If response is inadequate after 2–4 weeks, add an intranasal corticosteroid; this combination yields superior control without increasing adverse events. 1

Mixed Symptoms (Congestion + Rhinorrhea)

• Initiate combination therapy with intranasal corticosteroid plus intranasal antihistamine (azelastine) from the outset, as this provides greater efficacy than monotherapy. 1
• Alternatively, combine intranasal corticosteroid with ipratropium for patients with prominent rhinorrhea. 1

Subtype-Specific Management

Vasomotor Rhinitis

• Intranasal corticosteroids and intranasal azelastine are both effective. 1, 3
• Counsel patients to avoid triggering irritants (temperature extremes, strong odors, tobacco smoke, caustic chemicals). 1

Gustatory Rhinitis

• Ipratropium bromide applied before meals is particularly effective for meal-triggered rhinorrhea. 1

Rhinitis Medicamentosa

• Immediately discontinue nasal decongestant sprays and institute intranasal corticosteroids. 1
• Topical decongestants must be limited to <3 days to prevent this rebound phenomenon. 1

Non-Allergic Rhinitis with Eosinophilia (NARES)

• Intranasal corticosteroids are the treatment of choice for this inflammatory phenotype. 1

Adjunctive Therapies

• Nasal saline irrigation provides symptomatic relief for chronic rhinorrhea without adverse effects and can be used alone or as adjunct therapy. 1, 2

• Oral decongestants (pseudoephedrine) help reduce congestion but must be used with extreme caution or avoided entirely in patients with hypertension, arrhythmias, insomnia, benign prostatic hyperplasia, or glaucoma. 1

Critical Pitfalls to Avoid

Ineffective Therapies

• Never prescribe nonsedating oral antihistamines (cetirizine, loratadine, fexofenadine) for non-allergic rhinitis, as they have not been shown to be effective in this condition. 1

Medication Misuse

• Topical decongestants must be limited to <3 days to prevent rhinitis medicamentosa; educate patients explicitly about this risk. 1
• Avoid systemic corticosteroids except for very severe refractory cases requiring short 5–7 day courses; repeated or chronic parenteral corticosteroid use is contraindicated due to long-term side-effect risk. 1

Proper Intranasal Corticosteroid Technique

• Instruct patients to direct sprays away from the nasal septum to minimize local side effects including mucosal erosions and potential septal perforation. 1, 2
• Perform periodic nasal examination to ensure no mucosal erosions develop with long-term use. 1
• Common local adverse effects include nasal dryness, irritation, bleeding, and rarely Candida infection. 1

When to Refer

Refer to an allergist/immunologist or otolaryngologist for: 1, 2

• Prolonged manifestations not responding to standard first-line therapy after 4–8 weeks
• Development of complications such as nasal polyps
• Requirement for systemic corticosteroids
• Significantly impaired quality of life despite optimal pharmacotherapy

Combination Therapy Evidence

The combination of fluticasone propionate and azelastine has been shown to increase treatment efficacy by more than 40% compared with either product alone, making it a promising option for achieving better symptom reduction in refractory cases. 5, 6