Targeted Therapy for Allergic Rhinitis

Introduction to Treatment Options

Intranasal antihistamines are recommended for patients with seasonal allergic rhinitis, as suggested by the American College of Internal Medicine and the American College of Chest Physicians 1, 2
The American College of Chest Physicians recommends intranasal antihistamines for Upper Airway Symptom Complex (UACS) due to allergic rhinitis 2

Intranasal antihistamines effectively reduce rhinorrhea and postnasal drip, which are the likely causes of throat clearing and cough in patients with UACS, as reported by 3
Intranasal corticosteroids, such as fluticasone propionate nasal spray, are the most effective medication for treating allergic rhinitis, according to the American Academy of Allergy, Asthma, and Immunology 4

First-generation antihistamines, such as oral diphenhydramine, are not recommended as first-line therapy for allergic rhinitis due to their side effect profile, according to the American Academy of Family Physicians and the American College of Internal Medicine 1, 5
Second-generation antihistamines, including loratadine, desloratadine, cetirizine, and fexofenadine, are well-tolerated in young children 4

Decongestants like oral pseudoephedrine only relieve nasal congestion but not other symptoms like cough and postnasal drip, as reported by the American Academy of Family Physicians 5
Prolonged use of topical decongestants is not recommended due to the potential development of rhinitis medicamentosa, which may develop within 3 days of use, according to the American Academy of Allergy, Asthma, and Immunology 4

Adequate hydration, warm facial packs, sleeping with head elevated, and avoiding irritants (such as cigarette smoke, pollution, and allergens) are recommended as non-pharmacological approaches to manage postnasal drip pharyngitis 6
Ensure adequate fluid intake and monitor for signs of dehydration in elderly patients with post nasal drip and cough, and consider nutritional support with small, frequent meals and nutritional supplements for patients with poor oral intake, as suggested by the American College of Chest Physicians and the European Respiratory Society 7, 8

Complete resolution of cough may take several weeks to months, and premature discontinuation of therapy may lead to treatment failure 9
Evaluate response after 3-5 days of treatment, and if minimal improvement after 10-14 days, consider changing therapy 6
For partial response, continue treatment for another 10-14 days 6

In patients with allergic components, antihistamines should be considered more prominently in the treatment plan 10, 2
For elderly patients, monitoring for dehydration and considering nutritional support if oral intake is poor is recommended 7, 8
COVID-19 should be considered in the current epidemiological context, particularly in elderly patients with anosmia, cough, and systemic symptoms, as recommended by the European Rhinology society 11
First-generation antihistamine/decongestant combinations are not recommended for children under 6 years due to safety concerns, and over-the-counter (OTC) cough and cold medications are not recommended for children under 6 years due to potential toxicity and lack of efficacy 4

Overuse of antibiotics is a common pitfall, as most cases of rhinosinusitis are not bacterial in origin, and relying on mucus color to dictate antibiotic use is not recommended, as the color of mucus relates to the presence of neutrophils, not bacteria, according to the Mayo Clinic Proceedings 12
Approximately 60% of presumed bacterial rhinosinusitis cases resolve spontaneously without antibiotics, highlighting the need for judicious use of antibiotics, as noted in the Mayo Clinic Proceedings 12
Most cases of rhinosinusitis are viral, with only 0.5% to 2.0% having bacterial etiology 12
Antibiotics, such as amoxicillin, may be considered if bacterial infection is suspected, with a first-line dosage of 500 mg twice daily for adults, and a duration of 10-14 days, however, overuse of antibiotics contributes to antimicrobial resistance and puts patients at risk of adverse events, according to the Mayo Clinic Proceedings 6, 12, 10