Allergic Rhinitis Management

Introduction

Allergic rhinitis is a common condition that requires effective management to prevent complications and improve quality of life, as stated by the American Academy of Allergy, Asthma, and Immunology 1

The American Academy of Allergy, Asthma, and Immunology recommends intranasal corticosteroids, such as fluticasone and budesonide, as the most effective medication class for controlling symptoms of allergic rhinitis, including sneezing, itching, rhinorrhea, and nasal congestion, in patients with allergic rhinitis 2
Both fluticasone and budesonide should be administered by directing the spray away from the nasal septum to minimize local side effects, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
Montelukast is an effective treatment for both seasonal and perennial allergic rhinitis, with similar efficacy to antihistamines when used as monotherapy, and it may be particularly useful in patients with coexisting asthma and allergic rhinitis, with an excellent safety profile and approved for use in children as young as 6 months, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
Combination therapy with intranasal corticosteroid plus intranasal antihistamine provides greater symptom reduction than either agent alone, with absolute nasal symptom reductions of -5.31 to -5.7 for combination vs. -3.84 to -5.1 for corticosteroid alone, as suggested by the Journal of Allergy and Clinical Immunology 3, 4, 5

Elderly patients are more likely to experience prominent clear rhinorrhea due to cholinergic hyperactivity associated with the aging process, and medications taken for other medical issues can also contribute to the development of rhinitis in this age group, with caution advised when using first-generation antihistamines due to increased risk of falls and anticholinergic effects, as recommended by the Journal of Allergy and Clinical Immunology 2
In children, growth concerns should be considered, and it is prudent to use intranasal steroid preparations that have not shown negative impact on growth, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6
For pregnant patients, intranasal corticosteroids generally have good safety profiles but individual risk-benefit assessment is needed, with moderate-strength evidence, as recommended by the American College of Allergy, Asthma, and Immunology and the American Academy of Otolaryngology-Head and Neck Surgery 6

The American Academy of Allergy, Asthma, and Immunology suggests periodically examining the nasal septum to check for mucosal erosions, which may increase the risk of septal perforation, although rare, in patients using intranasal corticosteroids 2
For patients with persistent symptoms, the American Academy of Allergy, Asthma, and Immunology recommends that intranasal corticosteroids can be used long-term with minimal risk of systemic side effects when used as directed 2
Symptom control should be assessed after 2-4 weeks, as suggested by the American Academy of Allergy, Asthma, and Immunology 2
The American Academy of Allergy, Asthma, and Immunology recommends not delaying escalation of therapy if symptoms persist, as chronic inflammation can lead to complications including sinusitis, otitis media, and sleep disturbance 2

Patients with persistent rhinitis symptoms should be assessed for asthma, as rhinitis and asthma frequently coexist 1
Patients with allergic rhinitis should be assessed for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 5
The American Academy of Otolaryngology-Head and Neck Surgery suggests considering referral for allergen immunotherapy if symptoms remain inadequately controlled after 4-6 weeks of optimal pharmacotherapy 6

Saline nasal irrigations can be used as an adjunctive therapy to help reduce inflammation and improve muco-ciliary clearance, although they are insufficient as a primary treatment for moderate to severe symptoms, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
Allergen immunotherapy (sublingual or subcutaneous) may be considered for long-term management of allergic rhinitis, based on moderate-strength evidence, as recommended by the American College of Physicians 3
The Vivaer Intranasal Procedure, which uses radiofrequency to the nasal valve, is considered experimental, investigational, and unproven for the treatment of nasal obstruction, according to current clinical guidelines from the American Academy of Allergy, Asthma, and Immunology 2