What is the first‑line therapy for allergic rhinitis?

First-Line Therapy for Allergic Rhinitis

Intranasal corticosteroids are the first-line therapy for allergic rhinitis and should be prescribed as monotherapy for initial treatment. 1, 2

Why Intranasal Corticosteroids Are Superior

Intranasal corticosteroids outperform all other medication classes—including oral antihistamines, leukotriene receptor antagonists, and intranasal antihistamines—for controlling the four cardinal symptoms of allergic rhinitis: nasal congestion, rhinorrhea, sneezing, and itching. 1, 2 The 2017 Joint Task Force on Practice Parameters issued a strong recommendation based on high-quality evidence that intranasal corticosteroids are more effective than leukotriene receptor antagonists for initial treatment. 1

Specific Agent Selection

All approved intranasal corticosteroids (fluticasone propionate, mometasone furoate, budesonide, triamcinolone acetonide) demonstrate equivalent clinical efficacy. 2, 3 The choice depends primarily on:

• Age appropriateness: Triamcinolone acetonide and mometasone furoate are approved for children ≥2 years; fluticasone propionate requires age ≥4 years 2, 4
• Dosing convenience: Once-daily formulations improve adherence 3
• Patient preference: Delivery device and sensory characteristics affect compliance 5

Onset and Duration of Therapy

Symptom relief begins within 3–12 hours after the first dose, though maximal benefit requires days to weeks of continuous use. 2, 6 For seasonal allergic rhinitis, initiate therapy before symptom onset and continue throughout the allergen exposure period. 2 Unlike topical decongestants (which must be limited to ≤3 days), intranasal corticosteroids do not cause rebound congestion and are safe for long-term daily use. 2, 6

What NOT to Do as First-Line Therapy

Do Not Routinely Add Oral Antihistamines

Adding an oral antihistamine to an intranasal corticosteroid provides no additional benefit for initial treatment. 1, 2 Both the 2017 Joint Task Force and the 2015 American Academy of Otolaryngology–Head and Neck Surgery concluded—based on moderate-quality evidence—that combination therapy with intranasal corticosteroid plus oral antihistamine is no more effective than intranasal corticosteroid monotherapy. 1 This represents a strong recommendation against routine combination as first-line therapy. 1, 2

Do Not Use Leukotriene Receptor Antagonists as Primary Therapy

Leukotriene receptor antagonists (montelukast) are inferior to intranasal corticosteroids and should not be used as first-line treatment. 1, 2 The American Academy of Otolaryngology–Head and Neck Surgery issued a recommendation against using oral leukotriene receptor antagonists as primary therapy, except in patients with concurrent asthma who may benefit from this class. 1

When to Use Oral Antihistamines Instead

Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine) are appropriate first-line therapy only for patients with:

• Mild or intermittent symptoms where sneezing and itching predominate 1, 2
• Intolerance to intranasal corticosteroids 2, 4

The 2015 American Academy of Otolaryngology–Head and Neck Surgery guideline recommends oral second-generation antihistamines specifically for patients whose primary complaints are sneezing and itching, but these agents are less effective for nasal congestion. 1, 6

Important Caveat About Antihistamines

First-generation antihistamines (diphenhydramine, chlorpheniramine) should be avoided in children and adults due to sedation, anticholinergic effects, and increased accident risk. 2 Among second-generation agents, cetirizine and intranasal azelastine may cause sedation at recommended doses, unlike fexofenadine, loratadine, and desloratadine. 2, 6

Escalation for Inadequate Response

If intranasal corticosteroid monotherapy fails to control moderate-to-severe symptoms after 2–3 weeks:

Add Intranasal Antihistamine (NOT Oral)

Adding an intranasal antihistamine (azelastine or olopatadine) to an intranasal corticosteroid provides clinically meaningful benefit, unlike adding an oral antihistamine. 1, 2 The 2017 Joint Task Force found strong-quality evidence that this combination yields >40% relative improvement compared to either agent alone, though the recommendation was graded as weak due to concerns about cost, adverse effects (dysgeusia, somnolence), and potential study bias. 1

Consider Intranasal Ipratropium for Predominant Rhinorrhea

For patients whose main complaint is watery nasal discharge, intranasal ipratropium bromide effectively reduces rhinorrhea without affecting other symptoms. 2, 6 When combined with an intranasal corticosteroid, the duo is more effective than either agent alone without increased adverse events. 2, 6

Common Pitfalls to Avoid

• Do not prescribe intranasal corticosteroid + oral antihistamine as initial therapy—monotherapy is equally effective and more cost-effective. 1, 2
• Do not use topical nasal decongestants for >3 days—they cause rebound congestion (rhinitis medicamentosa). 2, 6
• Do not use oral decongestants in young children or patients with cardiovascular disease, hypertension, glaucoma, or bladder obstruction. 2, 6
• Teach proper spray technique—direct the spray away from the nasal septum using the contralateral hand to reduce epistaxis risk by fourfold. 2, 4
• Counsel patients about delayed onset—maximal efficacy requires days to weeks of regular use, not as-needed dosing. 2, 4

Safety Profile of Intranasal Corticosteroids

At recommended doses, intranasal corticosteroids cause no clinically significant systemic effects: no hypothalamic-pituitary-adrenal axis suppression, no growth suppression in children (except beclomethasone dipropionate, which should be avoided), no bone density loss, and no ocular complications. 2, 4, 3 The most common adverse event is mild epistaxis (blood-tinged secretions) in 5–10% of patients, which can be minimized with proper technique. 2, 4, 3