Allergic Rhinitis Treatment Guidelines

Introduction to Antihistamines

Second-generation antihistamines are preferred over first-generation antihistamines for treating allergic rhinitis due to lower sedation risk and similar efficacy, as recommended by the American Academy of Allergy, Asthma, and Immunology 1

Second-generation antihistamines can be considered as first-line treatment for allergic and nonallergic rhinitis, with equal or superior efficacy to oral second-generation antihistamines for seasonal allergic rhinitis 1
Intranasal corticosteroids are typically most effective for controlling sneezing, itching, rhinorrhea, and nasal congestion, and can be combined with oral antihistamines for enhanced symptom control 1

Continuous treatment with antihistamines is more effective than intermittent use for seasonal or perennial allergic rhinitis, and antihistamines should be discontinued before allergy testing to avoid false-negative results, as recommended by the American Academy of Allergy, Asthma, and Immunology and the Mayo Clinic 1, 2

Epinephrine is the first-line treatment for anaphylaxis, with a recommended dose of 0.01 mg/kg, and antihistamines are adjunctive therapy and should not replace epinephrine, as recommended by the American Academy of Pediatrics and the American Academy of Allergy, Asthma, and Immunology 3, 4, 5
H2 blockers like famotidine are considered second-line therapy to epinephrine for anaphylaxis, as recommended by the American Academy of Pediatrics 3, 4

Oral decongestants (pseudoephedrine, phenylephrine) can reduce nasal congestion, but should be used with caution in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism 1
Intranasal anticholinergics (ipratropium bromide) effectively reduce rhinorrhea, and can be combined with intranasal corticosteroids for enhanced effect 1
Topical decongestants should be limited to short-term use (≤3 days) to avoid rhinitis medicamentosa 1
The following medications can be used for allergic reactions:

Medication	Dosing
Cetirizine	5-10 mg once daily
Loratadine	10 mg once daily
Fexofenadine	age-appropriate dosing
Famotidine	0.5 mg/kg/dose twice daily
Prednisone	1 mg/kg/day (maximum 60 mg) for 3-5 days
Montelukast	5 mg daily for children 6-14 years
Epinephrine	0.01 mg/kg (0.15 mg autoinjector is appropriate for a 50-pound child)
Diphenhydramine	1-2 mg/kg per dose (maximum 50 mg) every 6 hours

Monitor for progression of symptoms, and if symptoms worsen despite antihistamine treatment, seek immediate medical attention, as recommended by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology 4, 5
Consider referral to an allergist for identification of triggers if reactions are recurrent, as recommended by the American Academy of Pediatrics and the American Academy of Allergy, Asthma, and Immunology 3, 5
Children with urticaria should be monitored for sedation, improvement or worsening of hives, and development of systemic symptoms, such as respiratory distress or hypotension, as recommended by the British Journal of Dermatology guidelines 6

Using corticosteroids for prolonged periods without specialist supervision should be avoided, as recommended by the British Journal of Dermatology guidelines 6
Failing to provide an emergency action plan for severe reactions should be avoided, as recommended by the Journal of Allergy and Clinical Immunology guidelines 5
Performing allergy testing without clinical suspicion of a specific trigger should be avoided, as recommended by the Mayo Clinic Proceedings guidelines 2
Ensure proper storage of medication out of reach of children to prevent accidental ingestion, and monitor for sedation, which can be significant in young children, as recommended by the American Academy of Pediatrics 5