What is the first-line medication regimen for allergic rhinitis?

First-Line Medication for Allergic Rhinitis

Intranasal corticosteroids are the first-line medication for allergic rhinitis and should be initiated immediately as monotherapy—they are the most effective single medication class for controlling all four major nasal symptoms (congestion, rhinorrhea, sneezing, and itching). 1, 2, 3

Recommended Intranasal Corticosteroid Options

All FDA-approved intranasal corticosteroids demonstrate equivalent clinical efficacy, so selection is based on age-appropriateness and availability rather than superiority of any specific agent 2, 3:

Age-Specific First-Line Agents

• Children ≥2 years: Mometasone furoate (Nasonex) 1 spray per nostril daily (100 mcg total) or triamcinolone acetonide (Nasacort) 1 spray per nostril daily 2
• Children 4-11 years: Fluticasone propionate (Flonase) 1 spray per nostril daily (50 mcg per spray) or mometasone furoate 1 spray per nostril daily 2
• Adolescents ≥12 years and adults: Fluticasone propionate 2 sprays per nostril once daily (200 mcg total) OR mometasone furoate 2 sprays per nostril once daily (200 mcg total) 2

Critical Pediatric Caveat

Avoid beclomethasone dipropionate in children—it is the only intranasal corticosteroid associated with growth suppression at standard doses. 2, 4 A controlled trial demonstrated that children aged 6-9.5 years treated with beclomethasone 168 mcg twice daily grew 4.75 cm/year versus 6.20 cm/year in the placebo group, with approximately 50% growing below the 10th percentile 4.

When to Escalate Beyond Monotherapy

If intranasal corticosteroid monotherapy provides inadequate control after 2-4 weeks, add intranasal azelastine (not an oral antihistamine). 2, 5 The combination of fluticasone propionate plus azelastine provides >40% relative improvement in symptom scores compared to either agent alone 2, 5. The fixed-dose combination product (Dymista) delivers 137 mcg azelastine + 50 mcg fluticasone per spray, dosed as 1 spray per nostril twice daily in patients ≥12 years 1.

Medications to Avoid as First-Line Therapy

• Leukotriene receptor antagonists (montelukast): The American Academy of Otolaryngology provides a recommendation against using LTRAs as primary therapy—they are significantly less effective than intranasal corticosteroids and more expensive 1
• Oral antihistamines alone: Less effective than intranasal corticosteroids for nasal congestion, though they may be added for residual itching or sneezing 2, 6
• Oral antihistamine + intranasal corticosteroid combination as initial therapy: Multiple high-quality trials show no additional benefit for nasal symptoms when oral antihistamines are added to intranasal corticosteroids 2

Practical Administration Guidelines

Optimizing Drug Delivery

• For severe nasal congestion at initiation: Use a topical decongestant (oxymetazoline or phenylephrine) for 3-5 days maximum to open the nasal passages and improve corticosteroid delivery 2, 3
• Proper spray technique: Direct the spray away from the nasal septum using the contralateral hand (right hand for left nostril, left hand for right nostril)—this reduces epistaxis risk by four times 2
• If using nasal saline irrigations: Perform them before administering the steroid spray to avoid rinsing out the medication 2

Dosing Strategy

• Standard dosing: Once-daily dosing in the morning is sufficient for most patients 2, 3
• Severe congestion not responding to standard dosing: Temporarily increase to 2 sprays per nostril twice daily (400 mcg total) until symptoms are controlled, then reduce to maintenance dosing 2
• Continuous vs. as-needed: Prescribe for regular daily use throughout the allergen-exposure season rather than as-needed—continuous therapy is superior to intermittent use 2, 3

Onset and Duration of Treatment

• Onset of action: Symptom relief begins within 3-12 hours after the first dose, with some patients experiencing benefit as early as 3-4 hours 2, 3
• Maximal efficacy: Requires several days to weeks of continuous use 2, 3
• Minimum trial duration: Continue for at least 8-12 weeks to properly assess therapeutic benefit 2
• Long-term safety: Indefinite use is safe when clinically indicated—no HPA axis suppression, no growth effects at recommended doses (except beclomethasone), and no ocular complications 2

Safety Profile and Monitoring

Systemic Safety

• No HPA axis suppression at recommended doses in children or adults 2, 3
• No growth impairment with fluticasone propionate, mometasone furoate, or budesonide at approved doses 2, 3
• No ocular effects (cataracts or glaucoma) with long-term use 2
• Systemic bioavailability <0.5-1% for mometasone and fluticasone formulations 2

Local Side Effects

• Epistaxis (most common): Occurs in 5-10% of patients, typically presenting as blood-tinged secretions rather than severe nosebleeds 2, 7
• Nasal irritation, burning, stinging: Generally mild and transient 7
• Nasal septal perforation: Rare but serious—examine the nasal septum every 6-12 months during long-term use to detect early mucosal erosions 2

Monitoring Requirements

• Pediatric patients: Monitor growth routinely (e.g., via stadiometry) when using any intranasal corticosteroid 4
• All patients on long-term therapy: Periodic nasal septum examination every 6-12 months 2

Common Pitfalls to Avoid

1. Do not wait for allergy testing results before starting treatment—testing is reserved for patients who fail empiric therapy or when specific allergen identification is needed for immunotherapy 2

2. Do not prescribe oral antihistamine + intranasal corticosteroid as initial combination therapy—intranasal corticosteroid monotherapy is equally effective and more cost-efficient 2

3. Do not use topical decongestants beyond 3-5 days—they cause rebound congestion (rhinitis medicamentosa), whereas intranasal corticosteroids are safe for indefinite daily use 2

4. Do not assume all intranasal steroids are interchangeable in children—beclomethasone should be avoided due to growth suppression risk 2, 4

5. Counsel patients that this is maintenance therapy, not rescue therapy—symptoms improve over days to weeks, and treatment should not be discontinued when symptoms resolve 2