What are the treatment options for allergic rhinitis?

From the Guidelines

The most effective treatment for allergic rhinitis is intranasal corticosteroids, which should be prescribed as monotherapy for initial treatment in persons aged 12 years or older, as recommended by the 2017 joint task force on practice parameters 1.

Treatment Options

The treatment of allergic rhinitis involves a combination of avoidance strategies, medications, and in some cases, immunotherapy.

• First-line medications include intranasal corticosteroids such as fluticasone (Flonase) 1-2 sprays per nostril daily or mometasone (Nasonex) 2 sprays per nostril daily, which reduce inflammation and multiple allergic symptoms.
• Second-generation oral antihistamines like cetirizine (Zyrtec) 10mg daily, loratadine (Claritin) 10mg daily, or fexofenadine (Allegra) 180mg daily can be used alone for mild symptoms or combined with intranasal steroids for moderate to severe cases.
• For immediate relief of nasal congestion, intranasal decongestants like oxymetazoline (Afrin) can be used, but only for 3-5 days to avoid rebound congestion, as cautioned in the diagnosis and management of rhinitis: an updated practice parameter 1.

Additional Considerations

• Saline nasal irrigation helps clear allergens and mucus.
• Environmental control measures are crucial, including keeping windows closed during high pollen seasons, using air purifiers with HEPA filters, washing bedding weekly in hot water, and showering after outdoor exposure.
• For patients with persistent symptoms despite optimal medical therapy, allergen immunotherapy (allergy shots or sublingual tablets) may be considered, which works by gradually desensitizing the immune system to specific allergens over 3-5 years, as discussed in the diagnosis and management of rhinitis: an updated practice parameter 1.

Prioritizing Treatment

The 2017 joint task force on practice parameters recommends intranasal corticosteroids as the first-line treatment for allergic rhinitis, due to their effectiveness in reducing symptoms and improving quality of life 1.

• This approach is supported by the most recent and highest quality evidence, which prioritizes morbidity, mortality, and quality of life as the primary outcomes.
• By following this recommendation, healthcare providers can provide the most effective treatment for patients with allergic rhinitis, while minimizing the risk of adverse effects and improving overall health outcomes.

From the FDA Drug Label

The efficacy of SINGULAIR tablets for the treatment of seasonal allergic rhinitis was investigated in 5 similarly designed, randomized, double-blind, parallel-group, placebo- and active-controlled (loratadine) trials conducted in North America. The efficacy of SINGULAIR tablets for the treatment of perennial allergic rhinitis was investigated in 2 randomized, double-blind, placebo-controlled studies conducted in North America and Europe.

Treatment of Allergic Rhinitis:

• Seasonal Allergic Rhinitis: Montelukast (SINGULAIR) 10-mg tablets have been shown to significantly reduce symptoms of seasonal allergic rhinitis in four out of five trials compared to placebo 2.
• Perennial Allergic Rhinitis: Montelukast (SINGULAIR) 10-mg tablets have been shown to significantly reduce symptoms of perennial allergic rhinitis in one out of two studies compared to placebo 2. Key Points:
• Montelukast is effective in reducing symptoms of allergic rhinitis.
• The recommended dose for adults and children 15 years and older is 10 mg once daily 2.

From the Research

Treatment Options for Allergic Rhinitis

• Allergen avoidance, pharmacotherapy, and immunotherapy are the main treatment approaches for allergic rhinitis 3, 4, 5, 6, 7
• Pharmacotherapy includes oral and intranasal antihistamines, intranasal corticosteroids, oral and intranasal decongestants, oral and intranasal anticholinergics, and leukotriene receptor antagonists 4
• Second-generation oral antihistamines and intranasal corticosteroids are the mainstays of treatment, with practice guidelines recommending intranasal corticosteroids as first-line treatment for moderate to severe allergic rhinitis 4, 5

First-Line Treatment

• Oral H1 antihistamines are first-line therapy for mild-to-moderate allergic rhinitis, with newer, nonsedating agents recommended over first-generation antihistamines 3
• Intranasal steroids are first-line therapy for patients with more severe symptoms 3
• Second-generation H1 antihistamines (e.g., cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (e.g., azelastine, olopatadine) are recommended for mild intermittent or mild persistent allergic rhinitis 5

Combination Therapy

• Combination therapy of an intranasal corticosteroid and an oral antihistamine may be effective for patients with moderate to severe allergic rhinitis 4
• A fixed combination of intranasal corticosteroid and intranasal antihistamines (e.g., MP-AzeFlu) may be considered the most beneficial, particularly in monotherapy and AR resistant to previous treatment 7

Patient-Specific Treatment

• Pharmacotherapy should be patient-specific, based on type, duration, and severity of symptoms, comorbidities, prior treatment, and patient preference 4, 5
• Tools like visual analogue scales and mobile applications can facilitate monitoring and management of rhinitis, optimizing care and improving patient self-management 6, 7