What are the guideline-recommended management steps for allergic rhinitis?

Management of Allergic Rhinitis

Intranasal corticosteroids are the first-line treatment for all patients with moderate to severe allergic rhinitis whose symptoms affect quality of life, as they are superior to all other medication classes in controlling nasal congestion, rhinorrhea, sneezing, and itching. 1, 2

Initial Diagnosis and Assessment

Clinical diagnosis should be made based on history and physical examination when patients present with one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing, along with findings consistent with an allergic cause including clear rhinorrhea, pale discoloration of nasal mucosa, and red watery eyes. 1

• Do NOT routinely perform sinonasal imaging in patients presenting with symptoms consistent with allergic rhinitis. 1
• Always assess and document associated comorbidities including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as these significantly impact management and outcomes. 1, 3
• Perform or refer for specific IgE testing (skin or blood) when patients fail empiric treatment, when diagnosis is uncertain, or when knowledge of specific allergens is needed to target therapy. 1

First-Line Pharmacotherapy

Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) should be initiated immediately for moderate to severe symptoms without requiring a prior trial of antihistamines. 2, 3

• Proper technique is critical: Direct sprays away from the nasal septum to prevent irritation, bleeding, and potential septal perforation. 2, 4
• Maximum efficacy requires several days of consistent daily use, so counsel patients on adherence and realistic expectations. 2
• For seasonal allergic rhinitis, start medication before the pollen season begins for optimal prophylaxis. 2
• Intranasal corticosteroids are superior to oral antihistamines, leukotriene receptor antagonists, and all other medication classes for comprehensive symptom control. 2, 4

Alternative First-Line for Mild Intermittent Symptoms

Oral second-generation antihistamines (cetirizine, loratadine, fexofenadine) should be recommended for patients with mild intermittent allergic rhinitis whose primary complaints are sneezing and itching. 1, 2

• Avoid first-generation antihistamines (diphenhydramine) due to sedation, impaired work performance, and increased accident risk. 2, 4

Second-Line Treatment for Inadequate Response

If intranasal corticosteroid monotherapy fails to control moderate to severe symptoms, add an intranasal antihistamine (azelastine or olopatadine), as this combination provides greater symptom reduction than either agent alone. 4, 3

• Do NOT add oral antihistamines to intranasal corticosteroids, as multiple high-quality trials demonstrate no additional benefit that outweighs the cost. 2, 3
• Do NOT use oral leukotriene receptor antagonists (montelukast) as primary therapy, and do not add them to intranasal corticosteroids as they provide no additional benefit. 1, 3

Adjunctive Therapies

Intranasal ipratropium bromide (0.03%) effectively reduces rhinorrhea but has no effect on other nasal symptoms; combining it with intranasal corticosteroids is more effective than either alone for patients with persistent watery discharge. 4, 3

Nasal saline irrigation is beneficial as sole or adjunctive therapy for chronic rhinorrhea and helps clear secretions, allergens, and inflammatory mediators. 2, 3

Oral decongestants (pseudoephedrine) may be offered for severe nasal congestion, but screen first for contraindications including hypertension, anxiety, cardiac arrhythmia, angina, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism. 2, 3

Critical Pitfall to Avoid

Topical nasal decongestants (oxymetazoline/Afrin) must be limited to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa). 2, 4

Environmental Control Measures

Advise avoidance of known allergens and environmental controls (removal of pets, air filtration systems, bed covers, acaricides) in patients who have identified allergens that correlate with clinical symptoms. 1

• For seasonal allergic rhinitis, advise staying in air-conditioned environments with windows and doors closed during high pollen counts. 4
• Implement allergen avoidance strategies early, even during initial pharmacologic treatment. 3

Third-Line Treatment for Refractory Disease

Offer or refer for allergen immunotherapy (sublingual or subcutaneous) for patients with inadequate response to pharmacologic therapy with or without environmental controls. 1, 3

• Immunotherapy is the only disease-modifying treatment that can alter the natural history of allergic rhinitis. 2, 3
• Immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 2, 3

Severe or Intractable Symptoms

A short 5-7 day course of oral prednisone (0.5-1 mg/kg/day, maximum 60 mg) may be considered only for very severe or intractable symptoms that significantly impact quality of life after all other pharmacologic options have failed. 4

• Never use depot (long-acting injectable) corticosteroids for allergic rhinitis due to heightened risk for systemic adverse effects including adrenal suppression and tissue atrophy. 4

Surgical Considerations

Offer or refer for inferior turbinate reduction in patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. 1

Acupuncture may be offered for patients interested in non-pharmacologic therapy. 1