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 anticholinergics (ipratropium bromide) reserved as the most effective option specifically for rhinorrhea-predominant disease. 1

Symptom-Based Treatment Algorithm

For Predominant Nasal Congestion

• Start with intranasal corticosteroids as monotherapy (fluticasone, mometasone, budesonide, or beclomethasone at standard doses—typically 200 mcg daily for adults, 2 sprays per nostril once daily). 1, 2
• These are the most effective agents for reducing congestion in vasomotor rhinitis and should be initiated immediately without prior trials of other medications. 1
• Direct sprays away from the nasal septum to minimize local side effects including mucosal erosions and potential septal perforation. 1

For Predominant Rhinorrhea (Watery Discharge)

• Intranasal ipratropium bromide 0.03% (42 µg per nostril, 2–3 times daily) is the treatment of choice, as it blocks cholinergic-mediated glandular hypersecretion. 1
• Ipratropium markedly reduces rhinorrhea but has no effect on nasal congestion or sneezing, making it ideal when rhinorrhea is the dominant symptom. 1
• For gustatory rhinitis (food-triggered rhinorrhea), administer ipratropium before meals for maximum benefit. 1
• Adverse effects are minimal; the most common is mild nasal dryness with prolonged use. 1

For Mixed Symptoms (Congestion + Rhinorrhea)

• Combine intranasal corticosteroid with ipratropium bromide for superior control compared to either agent alone, without increasing adverse effects. 1
• Alternatively, combine intranasal corticosteroid with intranasal antihistamine (azelastine) for greater overall symptom relief than monotherapy. 1
• Azelastine dosing: 137 µg (2 sprays) per nostril twice daily for patients ≥12 years. 1, 3

Intranasal Antihistamines as Alternative First-Line

• Azelastine nasal spray is FDA-approved for non-allergic rhinitis and effective for vasomotor rhinitis, particularly when patients cannot tolerate or refuse corticosteroids. 1, 3
• Provides clinically significant reduction in nasal congestion, though less effective than intranasal corticosteroids for overall symptom control. 1
• Common side effects include bitter taste and somnolence in approximately 10% of users; systemic absorption can cause sedation. 1
• Has rapid onset of action, making it suitable for as-needed use. 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
• Oral decongestants (pseudoephedrine) reduce nasal congestion but must be used with extreme caution or avoided entirely in patients with hypertension, cardiac arrhythmias, insomnia, prostatic enlargement, or glaucoma due to risks of palpitations, elevated blood pressure, and urinary retention. 1, 2

Specific Non-Allergic Rhinitis Subtypes

Rhinitis Medicamentosa (Rebound Congestion)

• Discontinue nasal decongestant sprays immediately and institute intranasal corticosteroids. 1
• Topical decongestants must be limited to ≤3 days to prevent this condition. 1, 2

Non-Allergic Rhinitis with Eosinophilia (NARES)

• Intranasal corticosteroids are the treatment of choice for this inflammatory phenotype despite negative allergy testing. 1

Vasomotor Rhinitis

• Intranasal corticosteroids and intranasal antihistamines are both effective. 1
• Identify and avoid triggering irritants including perfumes, tobacco smoke, temperature extremes, strong odors, bleach, solvents, automotive fumes, and chlorine. 2

Critical Pitfalls to Avoid

• Never use oral antihistamines (cetirizine, loratadine, fexofenadine) for non-allergic rhinitis—they are ineffective and should be avoided entirely. 1, 2
• Never use topical decongestants for >3 days to prevent rhinitis medicamentosa. 1, 2
• Avoid systemic corticosteroids except for very rare, severe, refractory cases; short courses (5–7 days) may be justified only in exceptional circumstances, but repeated or chronic use is contraindicated. 1
• Ensure patients understand proper intranasal spray technique: keep head tilted downward (not back), aim spray away from septum, and breathe gently to avoid drawing medication into throat. 1, 3
• Perform periodic nasal septum examination in patients on long-term intranasal corticosteroids to detect mucosal erosions early. 1

When to Refer

• Refer to allergist/immunologist for prolonged symptoms unresponsive to standard therapy after 4–8 weeks of optimal treatment. 1
• Refer when complications develop including nasal polyps, chronic sinusitis, or otitis media. 1
• Refer if systemic corticosteroids have been required, as this indicates severe refractory disease. 1