These treatment strategies work for allergic rhinitis AS WELL AS non-allergic rhinitis.
First-line therapy for nasal symptoms: steroid nasal spray.
- Fluticasone propionate=Flonase
- Fluticasone furoate=Veramyst
- Triamcinolone=Nasacort Allergy
Relief should occur within several hrs, but maximal effect may take days-weeks. Start with the max dose and taper down. May combine with nasal decongestants.
Oral steroids should be used only for severe allergic rhinitis that prevents the pt from sleeping or working, for a few days at a time. Avoid repeated courses if possible.
Itching, sneezing, and mild, intermittent sx: oral antihistamines.
First-generation: diphendyramine, hydroxyzine, chlorpheniramine. May cause sedation or paradoxical agitation, or anticholinergic effects (dry eyes, mouth, urinary retention)
Second-generation: onset of action within 1 hour
- Azelastine=Astelin, Optivar
Antihistamines are also available as nasal sprays, and can have onset in 15 mins. They may be combined with steroid sprays (Dymista).
They can be combined with decongestants, like pseudoephedrine, which provides better sx relief than antihistamines alone. Side effects: HTN, insomnia, headache, and due to abuse potential, many have been replaced with phenylephrine, which is less effective than pseudoephedrine.
Cromolyn: Less effective than antihistamines, but better than placebo. Requires 4x/day dosing.
Leukotriene inhibitors: only montelukast approved for allergic rhinitis. ?May increase anxiety, dream abnormalities
Ipratropium bromide (Atrovent): useful as an adjunctive therapy for more severe sx, or nasal congestion associated with a cold
Other therapies: Netipot devices can be mildly helpful. Use boiled or distilled water. Complementary/alternative treatments include acupuncture, dietary therapy, herbal mixtures, which appear better than placebo although long-term safety data is lacking.