What is the next step in managing a patient with persistent allergic rhinitis (hay fever) who has not improved with intranasal mometasone (Nasonex) and oral/intranasal antihistamines and now wants a steroid approach?

Next Steps for Persistent Allergic Rhinitis Unresponsive to Nasonex and Antihistamines

Add an intranasal antihistamine (azelastine or olopatadine) to the existing Nasonex regimen rather than switching to oral steroids, as this combination provides superior symptom control (37.9% vs 29.1% reduction) compared to intranasal corticosteroid monotherapy and avoids systemic steroid risks. 1, 2

Why the Current Regimen May Be Failing

Before escalating therapy, verify that the patient is using Nasonex correctly:

• Proper spray technique: The spray must be directed away from the nasal septum to maximize mucosal contact and minimize local irritation 3, 2
• Adequate duration: Maximum therapeutic effect requires up to 2 weeks of consistent daily use, though some benefit appears within 12 hours 4, 5
• Sufficient dosing: Adults should receive 200 mcg daily (two 50-mcg sprays per nostril once daily), which can be given as 100 mcg twice daily if once-daily dosing is inadequate 4

First-Line Escalation: Add Intranasal Antihistamine

The combination of intranasal corticosteroid plus intranasal antihistamine is the evidence-based next step for moderate-to-severe allergic rhinitis that fails monotherapy. 1, 6, 2

• This combination demonstrates significantly greater symptom reduction than either agent alone in controlled trials 1, 6
• The 2017 ARIA guidelines and Joint Task Force give this combination a strong recommendation based on high-quality evidence 3, 1
• Intranasal antihistamines (azelastine, olopatadine) provide rapid onset of action—often within hours—addressing breakthrough symptoms while the corticosteroid controls underlying inflammation 7, 8
• The combination is more effective than adding an oral antihistamine to the intranasal steroid, which provides no additional benefit in most patients 1, 6, 9

Why NOT Oral Steroids as the Next Step

A short course of oral corticosteroids (5-7 days of prednisone) should be reserved only for very severe or intractable rhinitis that significantly impairs quality of life after all other pharmacologic options have failed. 3, 6, 2

• Oral steroids carry substantially higher risk of systemic adverse effects including adrenal suppression, hyperglycemia, mood changes, and bone density loss 6, 2
• Single or repeated parenteral (injectable) corticosteroids are explicitly contraindicated due to even greater potential for long-term complications 3, 6
• The patient has not yet tried the most effective combination therapy (intranasal steroid + intranasal antihistamine), making systemic steroids premature 1, 6

Additional Second-Line Options If Combination Therapy Insufficient

If symptoms remain inadequately controlled after 2-4 weeks of intranasal corticosteroid plus intranasal antihistamine:

• Intranasal ipratropium bromide: Add this if rhinorrhea (watery discharge) is the predominant complaint; it reduces rhinorrhea without affecting other symptoms and enhances efficacy when combined with intranasal corticosteroids 3, 6, 2
• Leukotriene receptor antagonist (montelukast 10 mg daily): This is an inferior option compared to intranasal corticosteroids but can be added as adjunctive therapy; however, it should only be used if there has been inadequate response or intolerance to preferred therapies 1, 6, 8
• Nasal saline irrigation: Recommend isotonic or hypertonic saline rinses as adjunctive therapy to clear allergens, secretions, and inflammatory mediators 6, 2

When to Consider Oral Steroids (If Truly Necessary)

Only prescribe a brief oral steroid course if:

• Symptoms are very severe or intractable, markedly diminishing quality of life 3, 6, 2
• The patient has failed optimal doses of intranasal corticosteroid plus intranasal antihistamine for at least 2-4 weeks 6, 2
• Additional adjunctive therapies (ipratropium, montelukast, saline irrigation) have been tried 6, 2

If oral steroids are necessary:

• Prescribe prednisone 0.5-1 mg/kg/day (maximum 60 mg) for 5-7 days only 3, 6
• Do not use depot injectable corticosteroids 3, 8
• Counsel the patient that this is a temporary bridge, not a long-term solution 6, 2

Referral for Allergen Immunotherapy

Refer to an allergist for consideration of subcutaneous or sublingual allergen immunotherapy if symptoms remain inadequately controlled despite optimal pharmacotherapy. 1, 6, 2

• Immunotherapy is the only disease-modifying treatment for allergic rhinitis and may prevent development of new allergen sensitizations and reduce future asthma risk 6, 2
• This is appropriate for patients requiring excessive medication use or experiencing unacceptable side effects from pharmacotherapy 1, 6

Environmental Control Measures

Reinforce allergen avoidance strategies:

• For seasonal allergic rhinitis: Stay in air-conditioned environments with windows and doors closed during high pollen counts 3, 2
• Identify and avoid specific allergen triggers (pollens, dust mites, pet dander, molds) through history or allergy testing 6, 2

Common Pitfalls to Avoid

• Do not add an oral antihistamine to the intranasal corticosteroid—this provides no additional benefit in controlled trials and increases cost and pill burden 1, 6, 9
• Do not use topical nasal decongestants for more than 3 days due to risk of rhinitis medicamentosa (rebound congestion) 3, 6, 2
• Do not use oral decongestants without caution in patients with cardiovascular disease, hypertension, hyperthyroidism, or urinary retention 6, 2
• Verify adherence and technique before concluding treatment failure—many patients use intranasal sprays incorrectly or inconsistently 2, 4