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Am Fam Physician. 2009;80(1):79-85

Guideline source: American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology

Literature search described? Yes

Evidence rating system used? Yes

Published source:Journal of Allergy and Clinical Immunology, August 2008

Rhinitis affects between 10 and 30 percent of adults and 40 percent of children in the United States. It is characterized by one or more of the following nasal symptoms: congestion, rhinorrhea (anterior and posterior), sneezing, and itching. Rhinitis may affect a patient's quality of life through fatigue, headache, cognitive impairment, and sleep disturbance; therefore, it is considered a significant cause of morbidity, medical treatment costs, reduced work productivity, and missed school days.

Allergic rhinitis may be seasonal or perennial. Seasonal allergic rhinitis is caused by seasonal allergens. Perennial allergic rhinitis may be caused by dust mites, molds, animal allergens, occupational allergens, or pollen. Risk factors for allergic rhinitis include a family history of atopy, serum immunoglobulin E (IgE) levels greater than 100 IU per mL (100 kIU per L) before six years of age, higher socioeconomic class, and a positive allergy skin prick test. The diagnosis of rhinitis includes a history of symptoms and a physical examination. Skin testing for specific IgE antibody is the preferred diagnostic test to provide evidence of an allergic cause of the patient's symptoms.

The American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology have created “The Diagnosis and Management of Rhinitis: An Updated Practice Parameter.” The authors incorporated a review of recent medical literature to update the 1998 practice parameter on rhinitis. In addition to providing an overview of the classification and differential diagnosis of rhinitis, the updated parameter focuses on the management of allergic rhinitis.

Environmental Control Measures

Pollens, fungi, dust mites, furry animals, and insect emanations are the most common triggers of allergic rhinitis. Patients who are highly allergic to pollen should avoid going outdoors during periods of high pollen counts. Patients who are allergic to fungi should reduce their exposure by removing sources of moisture, replacing contaminated materials, and cleaning nonporous surfaces with a diluted bleach solution. For allergies to dust mites, patients should control the humidity in their home, cover bedding with dust mite covers, clean floors with a high-efficiency particulate air vacuum, and use acaricides. Avoiding all contact with animals is the most effective way to avoid animal triggers of allergic rhinitis.

Pharmacologic Therapy

Pharmacologic therapy for the management of allergic rhinitis may involve several oral and intranasal medications, such as antihistamines, decongestants, corticosteroids, and anticholinergics (Table 1).

MedicationTherapeutic considerations
Monotherapy
Oral agents
Antihistamines (histamine H1 receptor antagonists)Continuous use most effective for SAR and PAR, but appropriate for as-needed use in episodic AR because of relatively rapid onset of action
Less effective for nasal congestion than for other nasal symptoms
Other options are generally better for more severe AR
Less effective for AR than intranasal corticosteroids, with similar effectiveness for associated ocular symptoms
Generally ineffective for nonallergic rhinitis, therefore other choices are typically better for mixed rhinitis
Second-generation agents generally preferred to avoid sedation, performance impairment, and anticholinergic effects of first-generation antihistamines
Second-generation agents fexofenadine (Allegra), loratadine (Claritin), and desloratadine (Clarinex) do not cause sedation at recommended doses
CorticosteroidsA short course (five to seven days) of oral corticosteroids may be appropriate for severe nasal symptoms
Preferable to single or recurrent administration of intramuscular corticosteroids, which should be discouraged
DecongestantsPseudoephedrine reduces nasal congestion
Side effects include insomnia, irritability, palpitations, and hypertension
Leukotriene receptor antagonistsMontelukast (Singulair) approved for SAR and PAR
No significant difference in effectiveness from oral antihistamines (with loratadine as usual comparator)
Approved for rhinitis and asthma; may be considered in patients who have both conditions
Minimal side effects
Intranasal agents
Anticholinergic (ipratropium [Atrovent])Reduces rhinorrhea but not other symptoms of SAR and PAR
Appropriate for episodic rhinitis because of rapid onset of action
Minimal side effects, but dryness of nasal membranes may occur
AntihistaminesEffective for SAR and PAR
Clinically significant rapid onset of action makes them appropriate for as-needed use in episodic AR
Effectiveness for AR equal or superior to oral second-generation antihistamines, with clinically significant effect on nasal congestion
Less effective than intranasal corticosteroids for nasal symptoms
Appropriate choice for mixed rhinitis because also approved for vasomotor rhinitis
Side effects with intranasal azelastine (Astelin): bitter taste, somnolence
CorticosteroidsMost effective monotherapy for SAR and PAR
Effective for all symptoms of SAR and PAR, including nasal congestion
As-needed use (e.g., used more than 50 percent of days) effective for SAR
May consider for episodic AR
Usual onset of action is less rapid than oral or intranasal antihistamines, usually occurs within 12 hours, and may start as early as three to four hours in some patients
More effective than combination of oral antihistamine and leukotriene receptor antagonists for SAR and PAR
Similar effectiveness to oral antihistamines for associated ocular symptoms of AR
Appropriate choice for mixed rhinitis, because also effective for some nonallergic rhinitis
Without significant systemic side effects in adults
Growth suppression in children with PAR has not been demonstrated when used at recommended doses
Minimal local side effects, but nasal irritation and bleeding may occur, and nasal septal perforation rarely reported
Cromolyn sodium (formerly Intal)Onset of action within four to seven days for maintenance treatment of AR, full benefit may take weeks
For episodic rhinitis, administration just before allergen exposure protects for four to eight hours against allergic response
Less effective than nasal corticosteroids, inadequate data for comparison to leukotriene antagonists and antihistamines
Minimal side effects
DecongestantsFor short-term and possibly for episodic treatment of nasal congestion, but inappropriate for daily use because of the risk of rhinitis medicamentosa
May assist in intranasal delivery of other agents when significant nasal mucosal edema present
Combination therapy
Oral antihistamine with oral decongestantMore effective relief of nasal congestion than antihistamines alone
Oral antihistamine with oral leukotriene receptor antagonistMay be more effective than monotherapy with antihistamine or leukotriene receptor antagonists
Less effective than intranasal corticosteroids
Alternative treatment for patients unresponsive to or not compliant with intranasal corticosteroids
Oral antihistamine with intranasal antihistamineCombination may be considered, although controlled studies of additive benefit are lacking
Oral antihistamine with intranasal corticosteroidCombination may be considered, although supporting studies are limited and many studies do not support the combination
Intranasal anticholinergic with intranasal corticosteroidConcomitant use of ipratropium nasal spray and an intranasal corticosteroid is more effective for rhinorrhea than administration of either drug alone
Intranasal antihistamine with intranasal corticosteroidCombination may be considered based on limited data
Inadequate data about optimal interval between administration of the two sprays
For mixed rhinitis, there may be significant added benefit to the combination
Oral leukotriene receptor antagonist with intranasal corticosteroidSubjective additive relief in limited studies, data inadequate

ORAL ANTIHISTAMINES

Second-generation antihistamines are preferable to first-generation antihistamines for treating allergic rhinitis (Table 2). First-generation antihistamines may cause sedation, performance impairment, and anticholinergic effects; whereas second-generation antihistamines are not as likely to cause these effects. Some second-generation antihistamines that may have sedative properties include loratadine (Claritin) and desloratadine (Clarinex) when taken at doses that exceed the recommended dose, although cetirizine (Zyrtec) and intranasal azelastine (Astelin) may cause sedation at the recommended dose. Fexofenadine (Allegra) is not known to cause sedation.

MedicationMinimum ageAdult dosage
Second generation
Acrivastine/pseudoephedrine*12 years8 mg four times daily
Azelastine (Astelin)Five yearsTwo sprays per nostril twice daily
Cetirizine* (Zyrtec)Six months5 to 10 mg daily
Desloratadine* (Clarinex)Six months5 mg daily
Fexofenadine* (Allegra)Two years180 mg daily or 60 mg twice daily
Levocetirizine (Xyzal)Six years5 mg daily
Loratadine* (Claritin)Two years10 mg daily
Olopatadine (Patanol)12 yearsTwo sprays per nostril twice daily
First generation
BrompheniramineTwo years12 to 24 mg twice daily
Chlorpheniramine*Two years4 mg four times daily
Clemastine* (Tavist)Six years1.34 mg twice or three times daily
CyproheptadineTwo years4 mg three times daily
Diphenhydramine (Benadryl)Two years25 to 50 mg four times daily
Hydroxyzine (Vistaril)All ages25 mg four times daily
Promethazine (Phenergan)Two years25 mg four times daily
Triprolidine (Tripohist)Six years2.5 mg four times daily

INTRANASAL ANTIHISTAMINES

Intranasal antihistamines may be considered a first-line treatment for allergic rhinitis (Table 2), although they are generally less effective than intranasal corticosteroids. Intranasal antihistamines are as effective as or superior to oral second-generation antihistamines for treating seasonal allergic rhinitis; however, because of systemic absorption, they are also associated with sedation and may inhibit skin test reactions. Intranasal antihistamines have a clinically significant effect on nasal congestion.

ORAL AND TOPICAL DECONGESTANTS

Oral decongestants, such as pseudoephedrine and phenylephrine, are alpha-adrenergic agonists that are used to reduce nasal congestion; side effects may include insomnia, irritability, and palpitations. Decongestants should be used with caution in older adults and young children, as well as in patients with a history of cardiac arrhythmia, angina pectoris, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. Topical decongestants are appropriate for short-term, intermittent, or episodic treatment of nasal congestion, but they should not be used daily because of the risk of rhinitis medicamentosa.

OVER-THE-COUNTER COUGH AND COLD MEDICATIONS

The effectiveness of cold and cough medications for treating upper respiratory tract infections has not been established for children younger than six years. These medications should be avoided in this population because of potential toxicity.

INTRANASAL CORTICOSTEROIDS

Intranasal corticosteroids are the most effective medication for controlling symptoms of allergic rhinitis (Table 3). Studies have shown that they are more effective than a combination of antihistamine and leukotriene antagonist in treating seasonal allergic rhinitis. Intranasal corticosteroids may provide relief for patients with seasonal allergic rhinitis when taken on a regular basis or on an as-needed basis, although continuous use may be more effective. Products may differ in topical potency, lipid solubility, and binding affinity; however, this does not appear to affect the overall clinical response of the medication. Intranasal corticosteroids are not generally associated with significant systemic side effects, but nasal irritation and bleeding may occur. Nasal septal perforation is rare.

MedicationAdult dosageChild dosageMinimum ageFDA pregnancy/nursing risk category
Beclomethasone (Beclovent)One or two sprays per nostril twice dailyOne or two sprays per nostril twice dailySix yearsC
Budesonide (Rhinocort)One to four sprays per nostril dailyOne or two sprays per nostril dailySix yearsC
Ciclesonide (Omnaris)Two sprays per nostril dailyNA12 yearsC
Flunisolide (formerly Nasarel)Two sprays per nostril twice or three times dailyTwo sprays per nostril twice dailySix yearsC
Fluticasone furoate (Veramyst)Two sprays per nostril dailyOne spray per nostril dailyTwo yearsC
Fluticasone propionate (Flonase)Two sprays per nostril dailyOne or two sprays per nostril dailyFour yearsC
Mometasone (Nasonex)Two sprays per nostril dailyOne spray per nostril dailyTwo yearsC
Triamcinolone (Nasacort)One or two sprays per nostril dailyOne or two sprays per nostril dailySix yearsC

ORAL CORTICOSTEROIDS

Severe or intractable nasal symptoms or significant nasal polyposis may be treated with five to seven days of oral corticosteroids. However, single administration of parenteral corticosteroids is not advised. Recurrent administration is contraindicated because of an increased risk of long-term corticosteroid side effects.

INTRANASAL CROMOLYN SODIUM

Intranasal cromolyn sodium (formerly Intal) may be effective for the prevention and treatment of allergic rhinitis, although it is less effective than corticosteroids in most patients. It is associated with minimal side effects, but has not been studied sufficiently in comparison with leukotriene antagonists and antihistamines.

INTRANASAL ANTICHOLINERGICS

Intranasal anticholinergics may reduce rhinorrhea, but may have no effect on other nasal symptoms. Side effects are minimal; however, intranasal anticholinergics may cause dryness of the nasal membranes. To increase effectiveness in treating rhinorrhea, ipratropium nasal spray (Atrovent) should be used with an intranasal corticosteroid.

ORAL ANTILEUKOTRIENE AGENTS

Oral antileukotriene agents, alone or in combination with antihistamines, are effective in treating allergic rhinitis.

OMALIZUMAB

Although omalizumab (Xolair) is effective for treating allergic rhinitis, the U.S. Food and Drug Administration (FDA) has approved it for use only in patients with allergic asthma.

NASAL SALINE

Topical saline is effective for treating symptoms of chronic rhinorrhea and rhinosinusitis when used alone or as adjunctive treatment.

Allergen Immunotherapy

Allergen immunotherapy is effective in treating allergic rhinitis and should be considered in patients with evidence of specific IgE antibodies to relevant allergens. It may prevent the development of new allergen sensitizations and reduce the risk of asthma in patients with allergic rhinitis.

Surgery

There is no surgical treatment for allergic rhinitis; however, it may be recommended for management of comorbid conditions, such as nasal obstruction from severe nasal septal deviation or inferior turbinate hypertrophy, adenoidal hypertrophy, or refractory sinusitis.

Management Decisions

The patient's treatment plan should be based on the spectrum, duration, and severity of symptoms; the physical examination findings; comorbidities; age; and personal preferences. Rhinitis management requires a partnership between the patient and the physician; the avoidance of environmental triggers; and the appropriate use of pharmacologic therapy. Patients and caretakers should be educated on the importance of treatment adherence to achieve optimal outcomes.

Special Considerations

Physicians should use FDA risk categories to select medications for treating rhinitis in pregnant women. Observational data have demonstrated safety for first- and second-generation antihistamines. Oral decongestants should be avoided during the patient's first trimester. Topical decongestants may have a better safety profile when used on a short-term basis. Cromolyn sodium, montelukast (Singulair), and intranasal corticosteroids are considered safe for use during pregnancy. Immunotherapy for allergic rhinitis may be continued during pregnancy but without an increase in dosage.

Older patients may experience rhinitis caused by age-related physiologic changes, such as cholinergic hyperactivity, anatomic changes, and medications taken for other conditions.

When choosing a treatment for rhinitis in competitive athletes, physicians should prescribe a product that has been approved by the competition's governing body and that does not adversely affect the patient's performance.

Consultations and Referrals

A referral or consultation with an allergist or immunologist has been shown to improve patient outcomes, and should be considered if patients have symptoms that are not adequately controlled; their quality of life is reduced; they have adverse reactions to medications; they want to identify specific allergens; they have comorbid conditions such as asthma or recurrent sinusitis; or they are considering allergen immunotherapy.

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