What is the recommended management of allergic rhinitis in adults and children?

Management of Allergic Rhinitis in Adults and Children

First-Line Pharmacotherapy

Intranasal corticosteroids are the most effective first-line treatment for moderate-to-severe allergic rhinitis in both adults and children, and should be initiated immediately as they address all major nasal symptoms including congestion, rhinorrhea, sneezing, and itching by reducing IgE-mediated inflammation. 1, 2, 3

• For children ≥4 years and adults: Start mometasone furoate, fluticasone propionate, or budesonide once daily (1 spray per nostril). 2, 3
• Critical technique: Use the contralateral hand (right hand for left nostril) and direct spray away from the nasal septum to reduce epistaxis risk by 4-fold. 4
• Continuous daily dosing is more effective than intermittent use for perennial symptoms due to ongoing allergen exposure. 1, 2
• These agents are safe for long-term continuous use with no clinically significant systemic effects, HPA axis suppression, or growth suppression in children at recommended doses. 4

Add a second-generation oral antihistamine (cetirizine, loratadine, desloratadine, or fexofenadine) for patients with prominent sneezing, itching, and rhinorrhea, particularly in seasonal/pollen-induced rhinitis. 1, 2, 3

• Second-generation agents avoid the sedation, anticholinergic effects, and cognitive impairment of first-generation antihistamines. 3
• For children: cetirizine 5-10 mg daily depending on age. 2

Combination Therapy for Inadequate Response

For patients with persistent moderate-to-severe symptoms despite intranasal corticosteroids alone, add intranasal antihistamine (azelastine or olopatadine) to provide greater efficacy than either agent alone. 3, 5, 6

• Azelastine dosing: Adults and children ≥12 years: 1-2 sprays per nostril twice daily; children 5-11 years: 1 spray per nostril twice daily. 7
• Warn patients about potential sedation from systemic absorption of intranasal antihistamines. 3
• Fixed-combination intranasal antihistamine plus corticosteroid sprays show superior efficacy but are indicated for adolescents only. 8

Allergen Immunotherapy

Allergen immunotherapy should be strongly considered for patients with demonstrable specific IgE antibodies to clinically relevant allergens who have inadequate response to optimal pharmacotherapy, as it is the only disease-modifying treatment that alters the natural history of allergic rhinitis. 1, 3

Indications for immunotherapy:

• Poor response to or intolerable side effects from pharmacotherapy after 3-6 months of optimal treatment. 1, 2, 3
• Patient desire to avoid long-term pharmacotherapy. 1, 3
• Significant impact on quality of life despite medications. 3
• Presence of comorbid asthma (when stable). 1

Evidence for efficacy:

• Subcutaneous immunotherapy (SCIT): Effective in both adults and children for pollen, dust mite, animal dander, mold, and cockroach allergens. 1, 2
• Sublingual immunotherapy (SLIT): Recommended for adults with pollen-induced (moderate-quality evidence) or dust mite-induced rhinitis (low-quality evidence). 1
• For children: SLIT is conditionally recommended for pollen-induced rhinitis (moderate-quality evidence), but should only be used in rigorously designed clinical trials for dust mite-induced rhinitis (very low-quality evidence). 1, 2

Disease-modifying benefits:

• Clinical benefits persist years after discontinuation of treatment. 1
• May prevent development of new allergen sensitivities. 1, 2, 3
• Reduces risk of future asthma development in patients with allergic rhinitis. 1, 2
• Treatment duration typically 3-5 years for sustained benefit. 2

Safety considerations:

• Fatality rate: 1 per 2.5 million injections (average 3.4 deaths per year). 1
• Local adverse effects with SLIT are relatively frequent (~35%). 1
• Contraindications include severe uncontrolled asthma and significant cardiovascular disease. 1

Environmental Control Measures

Identify specific allergens through skin prick testing or serum-specific IgE testing, then implement targeted avoidance strategies. 1, 2

• For dust mites: Use allergen-impermeable mattress and pillow covers, wash bedding weekly in hot water (>130°F), reduce indoor humidity to <50%. 2
• For animal allergens: Remove pets from the home or at minimum keep them out of the bedroom; use HEPA air filters. 2
• For mold: Control indoor humidity, repair water leaks, improve ventilation in bathrooms and kitchens. 2
• Avoid irritant triggers including tobacco smoke, strong odors, and temperature extremes. 1

Classification and Treatment Algorithm

Classify patients by symptom frequency and severity to guide treatment intensity: 1, 2

• Intermittent: <4 days/week or <4 weeks/year
• Persistent: >4 days/week and >4 weeks/year
• Mild vs. moderate-to-severe: Based on impact on sleep, school/work performance, and quality of life

Treatment approach by severity:

• Mild intermittent: Second-generation oral antihistamine or intranasal antihistamine as needed or prophylactically before allergen exposure. 1, 6
• Mild persistent: Second-generation oral antihistamine or intranasal antihistamine daily. 6
• Moderate-to-severe (intermittent or persistent): Intranasal corticosteroid as primary therapy, with addition of oral or intranasal antihistamine as needed. 1, 2, 3, 6

Monitoring and Follow-Up

Evaluate treatment response after 2-4 weeks of continuous therapy. 2

• For partial improvement: Increase intranasal corticosteroid dose or add intranasal antihistamine. 2
• For minimal improvement: Reassess diagnosis, verify medication adherence and proper technique, consider allergen testing if not done. 2
• After 3-6 months of optimal medical therapy with persistent symptoms: Consider allergen immunotherapy. 2

Assessment of Comorbid Conditions

Evaluate for commonly associated conditions that impact management and prognosis: 3

• Asthma: Present in many patients with allergic rhinitis; treating rhinitis with intranasal corticosteroids may improve asthma control and prevent asthma development. 2, 3, 4
• Allergic conjunctivitis: Often coexists; may require addition of topical ophthalmic antihistamines. 1
• Chronic rhinosinusitis, atopic dermatitis, sleep-disordered breathing, otitis media: Document and address as part of comprehensive management. 3

Critical Pitfalls to Avoid

Never use first-generation antihistamines (diphenhydramine, chlorpheniramine) due to sedation, anticholinergic effects, impaired work/school performance, and increased accident risk, particularly dangerous in older adults. 3, 4

Avoid intranasal decongestants (oxymetazoline, phenylephrine) beyond 3-5 days maximum, as prolonged use causes rhinitis medicamentosa (rebound congestion). 3, 4

Do not prescribe oral or parenteral corticosteroids for chronic management—they are contraindicated due to systemic adverse effects; reserve short 5-7 day courses only for very severe intractable symptoms or significant nasal polyposis. 1, 3, 4

Do not use leukotriene receptor antagonists (montelukast) as primary therapy—they are less effective than intranasal corticosteroids and provide no additional benefit when added to intranasal corticosteroids. 3

Do not recommend homeopathy, acupuncture, or butterbur—these interventions lack evidence of efficacy and carry uncertain risks. 1

Additional Therapeutic Options

Nasal saline irrigation is safe, inexpensive, and effective for symptom relief through mechanical removal of allergens, mucus, and inflammatory mediators. 1, 8

• Hypertonic saline solutions provide additional decongestant activity. 1
• Minimal side effects (burning, irritation, nausea) with good patient acceptance. 1

Intranasal anticholinergics (ipratropium bromide) can be added specifically for profuse watery rhinorrhea unresponsive to other therapies. 1