Allergic Rhinitis Treatment Guidelines

Initial Treatment Selection

The American Academy of Otolaryngology-Head and Neck Surgery recommends intranasal corticosteroids as the first-line treatment for patients with allergic rhinitis whose symptoms affect their quality of life, representing the most effective monotherapy available 1, 2
For patients with mild symptoms, second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are recommended for primary complaints of sneezing and itching, as they are preferred over first-generation antihistamines due to significantly less sedation and performance impairment 1, 2
Intranasal antihistamines (azelastine, olopatadine) may be offered as an alternative for seasonal, perennial, or episodic allergic rhinitis 1

The American Academy of Otolaryngology-Head and Neck Surgery recommends intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) as the primary treatment for moderate to severe symptoms, as they are more effective than leukotriene receptor antagonists 3
For patients aged 12 years or older with moderate to severe seasonal allergic rhinitis, combination therapy with intranasal corticosteroid plus intranasal antihistamine may be recommended for initial treatment, as this provides greater efficacy than either agent alone 3, 4

Oral leukotriene receptor antagonists should not be offered as primary therapy for allergic rhinitis, as they are generally less efficacious than intranasal corticosteroids 1, 2
Oral corticosteroids are contraindicated for routine treatment due to the greater potential for long-term adverse effects 2
Prolonged use of intranasal decongestants (beyond 10 days) must be avoided to prevent rhinitis medicamentosa (rebound congestion) 2

Clinicians may advise avoidance of known allergens or environmental controls (removal of pets, air filtration systems, bed covers, acaricides) for patients with identified allergens that correlate with clinical symptoms 1
Nasal saline irrigation is beneficial for treating symptoms of chronic rhinorrhea and rhinosinusitis, either as monotherapy or adjunctive treatment 2

Allergen immunotherapy (sublingual or subcutaneous) should be offered or referred for patients with inadequate response to pharmacologic therapy with or without environmental controls, as it is the only disease-modifying treatment that can alter the natural history of allergic rhinitis 1, 2
Immunotherapy may prevent development of new allergen sensitivities and reduce the risk of future asthma development 2

Allergy testing (specific IgE skin or blood testing) should be performed or referred when patients do not respond to empiric treatment, when diagnosis is uncertain, or when knowledge of specific causative allergens is needed to target therapy 1
Routine sinonasal imaging should not be performed in patients presenting with symptoms consistent with allergic rhinitis 1

Clinicians must assess and document the presence of associated conditions, including asthma 2, atopic dermatitis 1, sleep-disordered breathing 1, conjunctivitis 1, rhinosinusitis 2, and otitis media 1

Using first-generation antihistamines as primary therapy 2
Prolonged use of intranasal decongestants leading to rhinitis medicamentosa 2
Recurrent administration of parenteral corticosteroids 2
Failing to direct intranasal corticosteroid spray away from the nasal septum, which can cause mucosal erosions and potential septal perforations 2

Referral should be considered for patients who have required systemic corticosteroids 2, have inadequately controlled symptoms despite treatment 2, or are being considered for allergen immunotherapy 3