Rhinitis Treatment

SUMMARY:

Rhinitis, whether allergic (AR) or non-allergic (NAR), is an exceedingly common medical condition that can lead to decreased quality of life, loss of productivity, and increased healthcare spending. Rhinitis is a clinical diagnosis, and determining the underlying etiology is critical in selecting appropriate treatment, as many cases can be improved with avoidance of environmental triggers. The American Academy of Allergy, Asthma, and Immunology (AAAAI) has published a guideline to assist providers with the diagnosis and treatment of rhinitis, with the therapeutic approach summarized below.

Treatment

Oral drugs

Oral antihistamines
- 2^nd generation antihistamines do not pass blood brain barrier and are non-sedating (e.g., Cetirizine (Zyrtec) | Loratadine (Claritin) | Fexofenadine (Allegra) | Levocetrizine (Xyzal) are recommended as treatment for AR
- NOTE: In May of 2025 the FDA issued a warning that discontinuing long term i.e.,few months to years of usage of Cetirizine or Levocetirizine may lead to rare but severe pruritus even in patients without prior symptoms
- If patients develop withdrawal pruritis, may need to restart medication and taper gradually
- 1^st generation antihistamines (e.g., Diphenhydramine | Hydroxyzine | Chlorpheniramine) should be avoided due to increased sedating and anticholinergic effects, as well as increased risk of dementia
Oral leukotriene receptor antagonists (LTRA)
- Montelukast (Singulair) should not be used as first line therapy for AR given reduced efficacy compared to oral antihistamines
- Recent evidence suggests oral LTRA can have significant psychiatric side effects, and the FDA has issued a box warning recommending restricting use in patients with AR (see “Primary sources – learn more” below)
- Montelukast should be reserved for patients with AR who are not effectively managed or unable to tolerate other treatments
Systemic corticosteroids
- Short courses (i.e., 5 to 7 days) of oral corticosteroids may be used in patients with severe or intractable AR
- Prolonged steroid use, or depot steroid use (i.e., IM injection) may increase risk of adrenal suppression and is generally avoided
Oral decongestants
- Pseudoephedrine (Sudafed) is effective at relieving nasal congestion in patients with rhinitis and rhinosinusitis
- Phenylephrine (Sudafed PE), despite its abundant use and availability over the counter, is ineffective and should not be used
- Should be avoided in patients with a history of: Cardiac arrhythmia | Older age | Angina | Cerebrovascular disease | Uncontrolled hypertension | Bladder outlet obstruction | Glaucoma | Hyperthyroidism | Tourette syndrome | Monoamine oxidase inhibitor use

Intranasal agents

Intranasal antihistamines (INAH)
- Includes Azelastine and Olopatadine
- Recommended as 1^st line therapy for patients with: Seasonal AR (SAR) | NAR | Intermittent AR
- Has a more rapid onset than oral antihistamines and INCS and is more efficacious than oral antihistamines
- Azelastine use may lead to a temporary bitter taste lasting 30 to 60 minutes, but formulations that include sucralose are better tolerated
Intranasal corticosteroids (INCS)
- Fluticasone furoate (Flonase) | Mometasone furoate (Nasonex) | Triamcinolone acetonide (Nasacort)
- Effective as first line monotherapy for patients with persistent AR or moderate to severe AR
- In addition to management of AR, can also be of benefit for allergic ocular symptoms
- Most common side effects are local and include: Dryness | Burning | Epistaxis
- Septal perforation is a rare but more serious side effect in patients on continuous INCS (e.g., continuous use for over 1 year)
Intranasal capsaicin
- Not FDA approved for rhinitis treatment
- Has been used in NAR and mixed rhinitis for symptom management
- Further study is needed and research is ongoing
Intranasal decongestants
- Oxymetazoline (Afrin) and Xylometazoline
- Should only be used in short courses in patients with intermittent or episodic rhinitis to avoid rebound congestion (e.g., rhinitis medicamentosa) associated with longer courses
- Intranasal decongestant use can be considered for up to 5 days in patients with significant nasal mucosa edema to improve delivery of other intranasal agents (e.g., INCS)
Intranasal ipratropium
- Comes in two formulations (e.g., 0.03% or 0.06% concentrations)
- Not as effective as INCS or INAH, but can be used for patients with rhinorrhea due to perennial AR or NAR
Intranasal cromolyn
- Effective when used 30 minutes prior to allergen exposure in patients with intermittent AR from episodic allergen exposure
Nasal saline
- Effective in moisturizing dry nasal passages and clearing out mucus
- If tap water is used, it should first be boiled for 1 to 5 minutes and then cooled before administration to decrease the risk of bacterial or parasitic infection

Combination therapy

For patients with moderate to severe symptoms, or AR that is resistant to monotherapy, a combination of INCS and INAH has been shown to be an effective
- This includes Azelastine-fluticasone (Dymista) and Olopatadine-mometasone (Ryaltris) nasal sprays
Patients on INCS monotherapy with persistent rhinorrhea can consider the addition of intranasal ipratropium
Intranasal or oral decongestants may be added to patients on INCS or oral antihistamine therapy for brief courses to assist with symptom control

Allergen Immunotherapy (AIT)

AIT is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance.
- Delivered via subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT)
- Contraindicated in pregnant patients | uncontrolled asthma | inability to tolerate injectable epinephrine
- Avoid in patients taking beta-blockers | history of anaphylaxis | systemic immunosuppression | EoE (sublingual only)
- AIT can prevent new allergen sensitizations|reduce the risk of developing allergic asthma|alter natural course of disease via continued benefit after cessation of AIT
  - Minimum of 3 years treatment
- For patients with AR, with or without allergic asthma, that is inadequately controlled with medical therapy and/or allergen avoidance

Alternative therapies

Acupuncture | Herbal medications
- Studies on the efficacy of acupuncture and Chinese herbal medicine for AR have been mixed, and thus the AAAAI does not recommend for or against its use

Surgical treatment

Refer to ENT for inferior turbinate reduction surgery for patients who have failed medical therapy for AR symptoms due to nasal airway obstruction and enlarged inferior turbinates

KEY POINTS:

Intranasal antihistamines (e.g., Azelastine | Olopatadine) are 1^st line agents for treatment of SAR, AR, and NAR due to their fast onset of action and well documented efficacy
Intranasal corticosteroids (e.g., Fluticasone furoate (Flonase) | Mometasone furoate (Nasonex) | Triamcinolone acetonide (Nasacort)) are 1^st line therapies in patients with persistent or moderate to severe AR
2^ND generation oral antihistamines (e.g., Cetirizine (Zyrtec) | Loratadine (Claritin)) are also effective and generally well tolerated treatments for patients with allergic rhinitis
Combination of oral and intranasal agents can increase efficacy and help manage patients with severe AR that impacts quality of life
1^st generation oral antihistamines, oral LTRAs, and phenylephrine (Sudafed PE) use should be avoided
Patients with NAR can often be treated by targeting the underlying etiology and avoiding triggers
Consider referral for AIT for refractory cases