Guidelines for Allergy Management
Allergic Rhinitis
Diagnosis
Diagnose allergic rhinitis through clinical presentation of nasal congestion, rhinorrhea, postnasal drainage, sneezing, and itching of eyes/nose/throat, confirmed with specific IgE testing for aeroallergens. 1
- Rhinorrhea occurs in 90% of patients and nasal congestion in 94% 1
- Physical examination reveals edematous, pale turbinates in seasonal allergic rhinitis and erythematous, inflamed turbinates with serous secretions in perennial disease 1
- Negative specific IgE testing excludes allergic rhinitis and suggests nonallergic rhinitis 1
Classification
Classify allergic rhinitis as intermittent (symptoms <4 consecutive days/week or <4 consecutive weeks/year) versus persistent (symptoms >4 consecutive days/week and >4 consecutive weeks/year) to guide treatment duration. 1
Treatment Algorithm
Mild Intermittent or Mild Persistent Disease
Start with second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) as first-line therapy. 1, 2, 3
- Second-generation antihistamines are strongly preferred over first-generation agents due to minimal sedation and performance impairment 4, 2
- For intermittent symptoms, use antihistamines as-needed due to rapid onset of action 4
- For persistent symptoms, continuous daily antihistamine treatment is recommended over intermittent use 4
Moderate to Severe Persistent Disease
Initiate intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as first-line monotherapy. 1, 5, 3
- Intranasal corticosteroids are the treatment of choice for moderate to severe disease 5
- ARIA 2024-2025 guidelines recommend intranasal corticosteroids over intranasal antihistamines alone for persistent disease 3
Inadequate Response to Monotherapy
Escalate to combination therapy with intranasal corticosteroid plus intranasal antihistamine, which is more effective than either agent alone. 5, 2, 3
- This combination provides second-line treatment for poorly controlled symptoms 5
- ARIA 2024-2025 strongly recommends fixed-dose INAH+INCS combinations over monotherapy 3
- For patients with coexisting asthma, prolonged antihistamine therapy improves rhinitis-specific quality of life and reduces comorbidities 4
Refractory Disease
Refer for allergen immunotherapy (subcutaneous or sublingual tablet) when pharmacologic therapy fails to adequately control symptoms. 4, 2
- Immunotherapy is highly effective when specific allergen drives symptoms 5
- Both subcutaneous and sublingual tablet immunotherapy receive strong recommendations 2
Monitoring and Pitfalls
- Periodically reassess patients on long-term therapy for symptom control, adherence, side effects, and need for adjustment 4
- Never use intranasal decongestants continuously beyond 3-7 days due to rhinitis medicamentosa risk 4
- Avoid oral decongestant monotherapy and routine oral corticosteroids 2
- Instruct patients on allergen avoidance measures 1, 2
Chronic Urticaria
Use second-generation antihistamines as first-line treatment for chronic urticaria, avoiding first-generation agents except when sedation is specifically desired. 6
- Second-generation antihistamines have superior side effect profiles with less impact on quality of life and learning 6
- Consider individual drug differences within the second-generation class for each patient's circumstances 6
Allergic Asthma
Treat coexisting allergic rhinitis aggressively in asthma patients, as rhinitis treatment provides significant benefits for pulmonary function and asthma symptoms. 5, 7
- Allergic rhinitis is a risk factor for asthma development and frequently coexists with asthma 5, 7
- Nasal inflammation and obstruction directly affect pulmonary function 7
- Treatment with antihistamines, nasal corticosteroids, immunotherapy, and allergen avoidance positively impacts lung function and asthma symptomatology 7