Which intranasal medication is first‑line for an adult with allergic rhinitis and what is the appropriate dosing?

First-Line Intranasal Medication for Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for adults with allergic rhinitis and should be started immediately without requiring a trial of antihistamines or other medications. 1, 2

Recommended Agent and Dosing

For adults (≥12 years), prescribe fluticasone propionate 200 mcg once daily (2 sprays per nostril once daily, 50 mcg per spray) or mometasone furoate 200 mcg once daily (2 sprays per nostril once daily, 50 mcg per spray). 1

• All approved intranasal corticosteroids (fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide) provide equivalent clinical efficacy; differences relate only to potency, dosing schedule, and patient preference 1, 3
• Symptom relief begins within 3–12 hours after the first dose, though maximal benefit requires several days to weeks of continuous use 1

Dosing Adjustments for Severe Congestion

For patients with severe nasal congestion unresponsive to standard once-daily dosing, temporarily increase to 2 sprays per nostril twice daily (400 mcg total) until symptoms are controlled, then reduce back to maintenance dosing. 1

• When initiating therapy in patients with severe congestion, consider adding a topical decongestant for 3–5 days maximum to improve drug delivery, then discontinue to avoid rebound congestion 1
• Topical decongestants must never exceed 5 days of use due to risk of rhinitis medicamentosa 4, 1

Proper Administration Technique

Instruct patients to use the contralateral hand technique (right hand for left nostril, left hand for right nostril) and aim the spray away from the nasal septum to reduce epistaxis risk by four times. 1

• Prime the bottle with 4 sprays before first use 5
• Have the patient blow their nose before administration 1
• Keep the head upright during spraying 1
• Breathe in gently during administration without closing the opposite nostril 1
• If using nasal saline irrigation, perform it before the steroid spray to avoid rinsing out the medication 1

Safety Profile and Monitoring

Intranasal corticosteroids at recommended doses cause no clinically significant systemic effects, including no HPA axis suppression, no growth effects in children, and no bone density or ocular complications. 1, 3

• The most common adverse event is mild epistaxis (blood-tinged nasal secretions), occurring in 5–10% of patients 1, 3
• Other common side effects include nasal irritation, headache, and pharyngitis, all generally mild 1
• Nasal septal perforation is rare but can occur with long-term use; examine the nasal septum every 6–12 months during continuous therapy to detect mucosal erosions 1

Duration of Treatment

Continue intranasal corticosteroids indefinitely for as long as symptoms persist; they are safe for long-term daily use and do not cause rhinitis medicamentosa. 1

• For seasonal allergic rhinitis, initiate before symptom onset and continue throughout the allergen exposure period 1
• For perennial allergic rhinitis, continuous year-round therapy is appropriate due to unavoidable ongoing allergen exposure 1
• Minimum treatment duration should be 8–12 weeks to properly assess therapeutic benefit 1

When Monotherapy Fails

For moderate-to-severe allergic rhinitis with inadequate response to intranasal corticosteroid alone, add intranasal azelastine (1–2 sprays per nostril twice daily), as this combination provides >40% greater symptom reduction than either agent alone. 1, 2, 5

• Do not add oral antihistamines to intranasal corticosteroids, as this provides no additional benefit 2
• For predominant rhinorrhea, add intranasal ipratropium bromide (2 sprays per nostril 2–3 times daily), which specifically targets watery discharge 1, 6

Contraindications and Cautions

Do not use intramuscular or parenteral corticosteroids for allergic rhinitis, as they carry serious risks including prolonged adrenal suppression, muscle atrophy, and fat necrosis. 4, 1

• Intranasal corticosteroids are contraindicated only in patients with hypersensitivity to the medication or its components 1
• Avoid formulations containing propylene glycol in patients experiencing significant nasal burning or irritation 1
• For refractory disease unresponsive to optimal pharmacotherapy, refer for allergen immunotherapy (subcutaneous or sublingual), the only disease-modifying treatment 1, 2, 6

Common Pitfalls to Avoid

• Never delay starting intranasal corticosteroids while waiting for allergy testing results—testing is reserved for patients who fail empiric treatment 1
• Never start with oral antihistamines or leukotriene antagonists as first-line therapy—intranasal corticosteroids are significantly more effective for all four major nasal symptoms (congestion, rhinorrhea, sneezing, itching) 4, 1, 7
• Never prescribe a short course of oral corticosteroids as routine therapy—reserve this only for very severe, intractable symptoms as a 5–7 day course after all other options have failed 4, 1