What is the recommended year‑round treatment regimen for persistent allergic rhinitis (seasonal allergies)?

Year-Round Treatment for Persistent Allergic Rhinitis

For persistent allergic rhinitis requiring year-round treatment, start with an intranasal corticosteroid (fluticasone, mometasone, or budesonide) as daily monotherapy, and add an intranasal antihistamine (azelastine) only if symptoms remain inadequately controlled after 2–4 weeks. 1, 2

First-Line Treatment: Intranasal Corticosteroids

Why Intranasal Corticosteroids Are Superior

• Intranasal corticosteroids are the single most effective medication class for controlling all four major symptoms of allergic rhinitis (nasal congestion, rhinorrhea, sneezing, and itching), outperforming oral antihistamines and leukotriene receptor antagonists. 1, 2
• They address the underlying persistent inflammation that exists even between symptomatic episodes—a state termed "minimal persistent inflammation"—which contributes to hyperreactivity and increased susceptibility to symptom flares. 3
• Symptom relief begins within 3–12 hours after the first dose, though maximal benefit requires several days to weeks of continuous daily use. 2, 4

Specific Agent Selection

• All approved intranasal corticosteroids (fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide) demonstrate equivalent clinical efficacy, so selection can be based on availability, cost, and patient preference. 2, 4
• For adults and children ≥12 years: start with 2 sprays per nostril once daily (200 mcg total). 2
• For children ages 4–11 years: use 1 spray per nostril once daily (100 mcg total). 2, 5
• For children ages 2–3 years: mometasone furoate is the preferred agent as it is FDA-approved for this age group at 1 spray per nostril daily. 2

Long-Term Safety for Year-Round Use

• Intranasal corticosteroids are safe for continuous, indefinite use when clinically indicated, with no hypothalamic-pituitary-adrenal axis suppression at recommended doses in children or adults. 2, 6, 7
• Studies demonstrate no effect on linear growth in children when fluticasone propionate, mometasone furoate, or budesonide are used at recommended doses. 2, 5
• No increased risk of cataracts, glaucoma, or bone density loss has been documented with long-term intranasal corticosteroid use. 2
• Nasal biopsies from patients treated continuously for 1–5 years show no evidence of mucosal atrophy. 2

Administration Technique to Minimize Side Effects

• Direct the spray away from the nasal septum by using the contralateral hand (right hand for left nostril, left hand for right nostril)—this reduces epistaxis risk by fourfold. 2
• The most common adverse event is epistaxis (blood-tinged nasal secretions), occurring in 5–10% of patients, but this is typically mild and can be minimized with proper technique. 2, 7
• Periodically examine the nasal septum every 6–12 months during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication). 2

When to Escalate: Adding Intranasal Antihistamine

Combination Therapy for Inadequate Response

• If symptoms remain moderate-to-severe after 2–4 weeks of intranasal corticosteroid monotherapy, add an intranasal antihistamine (azelastine) rather than an oral antihistamine. 1, 8
• The combination of fluticasone propionate (200 mcg) plus azelastine (548 mcg) as a single combination spray provides >40% greater symptom reduction compared to either agent alone, with clinically meaningful improvements in total nasal symptom scores. 1, 8
• Combination therapy is more effective than adding an oral antihistamine to an intranasal corticosteroid. 1, 8

Safety Profile of Combination Therapy

• Adverse events with combination therapy are low: dysgeusia (altered taste) in 2.1–13.5%, epistaxis similar to placebo, and somnolence in 0.4–1.1%. 1
• Quality-of-life improvements with combination therapy did not consistently exceed the minimal clinically important difference compared to monotherapy, though nasal symptom control was superior. 1

What NOT to Do

Avoid Oral Antihistamines as Add-On Therapy

• Do not routinely add oral antihistamines to intranasal corticosteroids for initial treatment—eight randomized trials show no additional clinical benefit. 8
• Oral antihistamines are less effective than intranasal corticosteroids for nasal congestion and do not address the underlying persistent inflammation. 2, 3

Avoid Leukotriene Receptor Antagonists

• Do not use leukotriene receptor antagonists (montelukast) as primary or add-on therapy for allergic rhinitis—they are significantly less effective than intranasal corticosteroids. 1, 2, 8
• Montelukast is FDA-approved for seasonal and perennial allergic rhinitis but should not be considered first-line therapy. 9

Avoid Topical Decongestants for Chronic Use

• Limit topical decongestants to ≤3 days maximum due to rebound congestion (rhinitis medicamentosa). 2
• A short 3–5 day course of topical decongestant may be used when initiating intranasal corticosteroid therapy if severe congestion is present, to improve drug delivery. 2

Treatment Duration and Monitoring

Continuous Daily Use Throughout Allergen Exposure

• Prescribe intranasal corticosteroids for continuous daily use throughout the year rather than as-needed dosing, as continuous therapy is more effective for persistent allergic rhinitis. 2, 4, 6
• Patients with perennial allergic rhinitis require daily therapy due to unavoidable, ongoing allergen exposure (dust mites, pet dander, mold). 2
• Do not discontinue therapy when symptoms improve—intranasal corticosteroids are maintenance therapy, not rescue therapy. 2

When to Reassess

• If no improvement occurs after 2–4 weeks of intranasal corticosteroid monotherapy, escalate to combination therapy with intranasal antihistamine. 8
• If symptoms remain inadequately controlled after 3 months of combination therapy, consider alternative diagnoses (nonallergic rhinitis, chronic rhinosinusitis) or refer for allergy testing and possible immunotherapy. 2

Special Considerations

Severe Congestion at Initiation

• For patients with severe nasal congestion that impairs drug delivery, consider a short 3–5 day course of topical decongestant while starting the intranasal corticosteroid. 2
• Alternatively, temporarily increase the intranasal corticosteroid dose to 2 sprays per nostril twice daily (400 mcg total) until congestion is controlled, then reduce to maintenance dosing. 2

Pediatric Patients

• Intranasal corticosteroids can be used long-term in children at the lowest effective dose without concern for growth suppression when using fluticasone, mometasone, or budesonide. 2, 5
• Teach proper administration technique using visual aids or demonstrations, as studies show significantly higher competency in children taught using animated cartoons. 2

Pregnancy and Breastfeeding

• Intranasal corticosteroids may be used during pregnancy and breastfeeding, though patients should consult their physician. 9