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

Management of Non-Allergic (Vasomotor) Rhinitis

Intranasal corticosteroids are the first-line treatment for non-allergic rhinitis, effectively controlling both nasal congestion and rhinorrhea. 1

Primary Pharmacologic Options

For Congestion-Predominant Symptoms

• Start with intranasal corticosteroids as the most effective monotherapy for vasomotor rhinitis, addressing both congestion and inflammation. 2, 1
• These agents are effective for multiple forms of non-allergic rhinitis including vasomotor rhinitis and NARES (non-allergic rhinitis with eosinophilia). 2
• Direct sprays away from the nasal septum to minimize local side effects such as irritation and bleeding. 1
• Perform periodic nasal septum examination during long-term use to monitor for mucosal erosions. 1

For Rhinorrhea-Predominant Symptoms

• Intranasal ipratropium bromide (0.03%, 42 µg per nostril 2-3 times daily) is the most effective agent when rhinorrhea is the dominant symptom, as it blocks cholinergic-mediated glandular hypersecretion. 1
• Ipratropium is particularly effective for preventing rhinorrhea in gustatory rhinitis when used before meals. 2, 1
• This anticholinergic agent reduces rhinorrhea but has no effect on nasal congestion or sneezing. 2, 1
• Adverse effects are minimal, with mild nasal dryness being the most common complaint. 1

For Mixed Symptoms

• Combine intranasal corticosteroids with intranasal antihistamines (azelastine) for greater symptomatic relief than either agent alone. 2, 1
• The combination of ipratropium bromide and intranasal corticosteroids is more effective for rhinorrhea than either drug alone, without increasing adverse effects. 2, 1

Intranasal Antihistamines as Alternative First-Line

• Azelastine nasal spray (137 µg per nostril twice daily for patients ≥12 years) is effective for vasomotor rhinitis and approved by the FDA specifically for non-allergic rhinitis. 2, 3, 4
• Intranasal antihistamines have a rapid onset of action, making them appropriate for as-needed use. 2, 5
• They provide clinically significant reduction in nasal congestion, superior to oral antihistamines but less effective than intranasal corticosteroids overall. 2, 1
• Common side effects include bitter taste and somnolence (approximately 11.5%). 2, 3

Adjunctive Therapies

• Oral decongestants (pseudoephedrine) reduce nasal congestion but use with caution in patients with hypertension, arrhythmias, insomnia, prostate hypertrophy, or glaucoma. 2, 1, 6
• Side effects include insomnia, irritability, palpitations, and hypertension. 2
• Nasal saline irrigation provides symptomatic relief and can be used alone or as adjunct therapy without notable adverse effects. 1, 7

Critical Pitfalls to Avoid

• Do NOT use oral antihistamines as they are generally ineffective for non-allergic rhinitis and should be avoided. 2, 1
• Limit topical decongestants to less than 3 days to prevent rhinitis medicamentosa (rebound congestion). 2, 1
• For patients with rhinitis medicamentosa, discontinue nasal decongestant sprays immediately and institute intranasal corticosteroids. 1
• Avoid repeated or chronic systemic corticosteroids; reserve short courses (5-7 days) only for very severe, refractory symptoms. 2, 1

Treatment Algorithm by Symptom Pattern

Step 1: Identify predominant symptom

• Congestion → intranasal corticosteroids 1
• Rhinorrhea → ipratropium bromide 1
• Mixed → combination therapy 1

Step 2: If inadequate response after 2-4 weeks

• Add second agent (intranasal corticosteroid + ipratropium OR intranasal corticosteroid + azelastine) 1

Step 3: Optimize environmental control

• Avoid triggers including temperature extremes, strong odors, tobacco smoke, and other irritants 1, 7

When to Refer

• Refer to specialist for prolonged manifestations not responding to standard therapy after appropriate trial of first-line agents. 1
• Consider referral when complications such as nasal polyps develop. 1
• Refer if systemic corticosteroids have been required beyond a single short course. 1