Medication		Therapeutic 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
	Corticosteroids	A 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
	Decongestants	Pseudoephedrine reduces nasal congestion
		Side effects include insomnia, irritability, palpitations, and hypertension
	Leukotriene receptor antagonists	Montelukast (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
	Antihistamines	Effective 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
	Corticosteroids	Most 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
	Decongestants	For 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 decongestant		More effective relief of nasal congestion than antihistamines alone
Oral antihistamine with oral leukotriene receptor antagonist		May 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 antihistamine		Combination may be considered, although controlled studies of additive benefit are lacking
Oral antihistamine with intranasal corticosteroid		Combination may be considered, although supporting studies are limited and many studies do not support the combination
Intranasal anticholinergic with intranasal corticosteroid		Concomitant use of ipratropium nasal spray and an intranasal corticosteroid is more effective for rhinorrhea than administration of either drug alone
Intranasal antihistamine with intranasal corticosteroid		Combination 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 corticosteroid		Subjective additive relief in limited studies, data inadequate