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
Available at:http://www.jacionline.org/article/S0091-6749(08)01123-8/fulltext (subscription required)
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).
| 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 | |
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.
| Medication | Minimum age | Adult dosage |
|---|---|---|
| Second generation | ||
| Acrivastine/pseudoephedrine* | 12 years | 8 mg four times daily |
| Azelastine (Astelin) | Five years | Two sprays per nostril twice daily |
| Cetirizine* (Zyrtec) | Six months | 5 to 10 mg daily |
| Desloratadine* (Clarinex) | Six months | 5 mg daily |
| Fexofenadine* (Allegra) | Two years | 180 mg daily or 60 mg twice daily |
| Levocetirizine (Xyzal) | Six years | 5 mg daily |
| Loratadine* (Claritin) | Two years | 10 mg daily |
| Olopatadine (Patanol) | 12 years | Two sprays per nostril twice daily |
| First generation | ||
| Brompheniramine | Two years | 12 to 24 mg twice daily |
| Chlorpheniramine* | Two years | 4 mg four times daily |
| Clemastine* (Tavist) | Six years | 1.34 mg twice or three times daily |
| Cyproheptadine | Two years | 4 mg three times daily |
| Diphenhydramine (Benadryl) | Two years | 25 to 50 mg four times daily |
| Hydroxyzine (Vistaril) | All ages | 25 mg four times daily |
| Promethazine (Phenergan) | Two years | 25 mg four times daily |
| Triprolidine (Tripohist) | Six years | 2.5 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.
| Medication | Adult dosage | Child dosage | Minimum age | FDA pregnancy/nursing risk category |
|---|---|---|---|---|
| Beclomethasone (Beclovent) | One or two sprays per nostril twice daily | One or two sprays per nostril twice daily | Six years | C |
| Budesonide (Rhinocort) | One to four sprays per nostril daily | One or two sprays per nostril daily | Six years | C |
| Ciclesonide (Omnaris) | Two sprays per nostril daily | NA | 12 years | C |
| Flunisolide (formerly Nasarel) | Two sprays per nostril twice or three times daily | Two sprays per nostril twice daily | Six years | C |
| Fluticasone furoate (Veramyst) | Two sprays per nostril daily | One spray per nostril daily | Two years | C |
| Fluticasone propionate (Flonase) | Two sprays per nostril daily | One or two sprays per nostril daily | Four years | C |
| Mometasone (Nasonex) | Two sprays per nostril daily | One spray per nostril daily | Two years | C |
| Triamcinolone (Nasacort) | One or two sprays per nostril daily | One or two sprays per nostril daily | Six years | C |
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.