What is the recommended treatment for rhinitis, including allergic and viral forms?

Rhinitis Treatment

First-Line Treatment for Allergic Rhinitis

Intranasal corticosteroids (fluticasone, mometasone, budesonide, or triamcinolone) are the most effective monotherapy and should be initiated immediately as first-line treatment for moderate-to-severe allergic rhinitis, outperforming all other drug classes in controlling nasal congestion, rhinorrhea, sneezing, and nasal itching. 1, 2

• Start with 2 sprays per nostril once daily (approximately 200 mcg) in adults and children ≥12 years; onset of relief occurs within 3–12 hours, with maximal benefit achieved after several days of regular use 1
• Direct the spray toward the lateral nasal wall using the contralateral hand to reduce epistaxis risk by approximately four-fold and prevent septal perforation 1, 2
• Intranasal corticosteroids can be initiated without waiting for allergy test results if symptoms impair quality of life 1
• These agents are safe for long-term use with no HPA-axis suppression, no clinically relevant growth impact in children, and no ocular adverse effects at recommended doses 1

Treatment Algorithm by Severity

Mild Intermittent or Mild Persistent Allergic Rhinitis

• Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) OR intranasal antihistamines (azelastine, olopatadine) may be used as initial therapy 2, 3
• Second-generation agents are strongly preferred over first-generation antihistamines due to lack of sedation, performance impairment, and anticholinergic effects 1, 2

Moderate-to-Severe Allergic Rhinitis

• Combination therapy with intranasal corticosteroid PLUS intranasal antihistamine provides >40% greater symptom improvement compared with either agent alone 1, 2
• Azelastine provides rapid (≈3 hours) and clinically meaningful reduction in nasal congestion, an effect not seen with oral antihistamines 1
• Oral antihistamines should NOT be routinely added to intranasal corticosteroids, as multiple high-quality trials show no additional benefit 4

Adjunctive Therapies

For Predominant Rhinorrhea

• Ipratropium bromide nasal spray specifically reduces watery rhinorrhea without affecting congestion, sneezing, or itching 1, 2
• When combined with an intranasal corticosteroid, ipratropium provides superior control of rhinorrhea without increasing adverse events 1

Nasal Saline Irrigation

• Isotonic or hypertonic saline irrigation is beneficial as sole or adjunctive therapy for chronic rhinorrhea and rhinosinusitis 5, 1, 2
• Perform saline irrigation BEFORE intranasal corticosteroid application to enhance drug delivery 1
• Saline has minimal side effects (occasional burning, irritation, nausea) and good patient acceptance 5

Short-Term Decongestant Use

• Topical decongestants (oxymetazoline) must be strictly limited to 3–5 days maximum to avoid rhinitis medicamentosa (rebound congestion) 1, 2, 4
• May be used for a short course at the start of corticosteroid therapy in patients with severe congestion to improve steroid deposition 1

Treatments to Avoid or Use with Caution

• Leukotriene receptor antagonists (montelukast) are NOT recommended as primary therapy for allergic rhinitis; they are markedly less effective than intranasal corticosteroids 1, 2
• Oral corticosteroids are contraindicated for chronic rhinitis due to greater potential for long-term adverse effects; reserve only for rare patients with severe intractable symptoms unresponsive to all other treatments 5, 2
• First-generation antihistamines should be avoided entirely due to sedation, performance impairment, and anticholinergic effects 1, 2
• Prolonged use of intranasal decongestants beyond 3–5 days causes medication-induced rhinitis that worsens the underlying condition 5, 2

Allergen Immunotherapy

• Allergen immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with benefits persisting years after discontinuation 5, 2
• Consider immunotherapy for patients with demonstrable specific IgE antibodies to clinically relevant allergens when symptoms remain inadequately controlled despite optimal pharmacotherapy 5, 2
• Immunotherapy may prevent development of new allergen sensitizations and reduce the risk of future asthma development 5, 2
• Treatment of allergic rhinitis with intranasal corticosteroids may improve asthma control in patients with coexisting asthma 2

Nonallergic Rhinitis

• Intranasal antihistamines are effective as monotherapy or in combination with intranasal corticosteroids for nonallergic rhinitis 2, 3
• Patients with nonallergic rhinitis present primarily with nasal congestion and postnasal drainage, frequently with sinus pressure and eustachian tube dysfunction, and are less responsive to nasal corticosteroids than allergic rhinitis patients 3

Viral Rhinitis (Common Cold)

• Viral rhinitis is self-limited with short duration morbidity and no mortality; existing pharmacological treatments are largely palliative, targeting symptom relief rather than viral eradication 6
• The most appropriate and least expensive prophylactic measures are good hygiene and contact avoidance 6
• Saline nasal irrigation may provide symptomatic relief for acute upper respiratory tract infections 7

Patient Education and Monitoring

• Educate patients that intranasal corticosteroids are maintenance medications, not rescue agents, and require regular daily use for optimal benefit 1
• During long-term therapy, inspect the nasal septum every 6–12 months to detect mucosal erosion that could precede rare septal perforation 1
• Local adverse effects of intranasal corticosteroids include epistaxis (5–10% of users), nasal irritation, headache, or sore throat 1

Referral Indications

• Refer to an allergist/immunologist for prolonged manifestations, complications (otitis media, sinusitis, nasal polyposis), comorbid conditions (asthma, chronic sinusitis), inadequately controlled symptoms despite optimal therapy, or when immunotherapy is being considered 5, 2