Treatment of Allergic Rhinitis

DENISE K. SUR, MD, and STEPHANIE SCANDALE, MD, David Geffen School of Medicine,
University of California, Los Angeles, California

Patient information:
A handout on this topic is
available at http://
familydoctor.org/083.xml.

llergic rhinitis is an immunoglobulin Emediated disease, thought

to occur after exposure to indoor
and outdoor allergens such as
dust mites, insects, animal danders, molds,
and pollens. Symptoms include rhinorrhea,
nasal congestion, obstruction, and pruritus.1
Optimal treatment includes allergen avoidance, targeted symptom control, immunotherapy, and asthma evaluation, when appropriate.2
In 2001, Allergic Rhinitis and Its Impact on
Asthma guidelines were published in cooperation with the World Health Organization, suggesting that the treatment of allergic rhinitis
make use of a combination of patient education, allergen avoidance, pharmacotherapy,
and immunotherapy.3 In contrast with previous guidelines, these recommendations are
based on symptom severity and age, rather than
the type or frequency of seasonal, perennial, or
occupational exposures. Table 1 lists recommended treatments based on symptoms.

ILLUSTRATION BY Mark lefkowitz

Allergic rhinitis is a common chronic respiratory illness that affects

quality of life, productivity, and other comorbid conditions, including asthma. Treatment should be based on the patients age and severity of symptoms. Patients should be advised to avoid known allergens
and be educated about their condition. Intranasal corticosteroids
are the most effective treatment and should be first-line therapy for
mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line
therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g.,
nasal irrigation). With the exception of cetirizine, second-generation
antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less
than adequate response to usual treatments. Evidence does not support the use of mite-proof impermeable covers, air filtration systems,
or delayed exposure to solid foods in infancy. (Am Fam Physician.
2010;81(12):1440-1446. Copyright 2010 American Academy of
Family Physicians.)
corticosteroids, oral and topical antihistamines, decongestants, intranasal cromolyn
(Nasalcrom), intranasal anticholinergics,
and leukotriene receptor antagonists.4,5 The
International Primary Care Respiratory
Group, British Society for Allergy and Clinical Immunology, and American Academy of
Allergy Asthma and Immunology recommend initiating therapy with an intranasal
corticosteroid alone for mild to moderate
disease and using second-line therapies for
moderate to severe disease.4-7 Patients with
moderate to severe disease not responding to
oral or topical treatments should be referred
for consideration of immunotherapy.3,8
Table 2 gives a summary of pharmacologic
treatments for allergic rhinitis.
INTRANASAL CORTICOSTEROIDS

Intranasal corticosteroids are the mainstay

of treatment of allergic rhinitis. They act
by decreasing the influx of inflammatory
cells and inhibiting the release of cytokines,
Pharmacotherapy
thereby reducing inflammation of the nasal
Pharmacologic options for the treat- mucosa.3 Their onset of action is 30 minutes,
ment of allergic rhinitis include intranasal although peak effect may take several hours

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Allergic Rhinitis
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating

References

The initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone,
with the use of second-line therapies for moderate to severe disease.

4, 5, 7

Compared with first-generation antihistamines, second-generation antihistamines have a better adverse

effect profile, including less sedation (with the exception of cetirizine [Zyrtec]).

22

The adverse effects and higher cost of intranasal antihistamines, as well as their decreased effectiveness
compared with intranasal corticosteroids, limit their use as first- or second-line therapy for allergic rhinitis.

28, 29

Although safe for general use, intranasal cromolyn (Nasalcrom) is not considered first-line therapy for
allergic rhinitis because of its decreased effectiveness at relieving the symptoms of allergic rhinitis and
its inconvenient dosing schedule.

1, 3

Nasal saline irrigation is beneficial in treating the symptoms of chronic rhinorrhea and may be used alone
or as adjuvant therapy.

53

Although dust mite allergies are common, studies have not found any benefit to using mite-proof
impermeable mattress and pillow covers.

54-56

Interventions without documented effectiveness in the prevention of allergic rhinitis include breastfeeding,
delayed exposure to solid foods in infancy, and the use of air filtration systems.

57-61

Clinical recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.

to days, with maximum effectiveness usually noted after are a few studies that looked specifically at the effects of
two to four weeks of use.9
intranasal corticosteroids on skeletal growth and adreMany studies have demonstrated that nasal corticoste- nal activity. One RCT found the rate of skeletal growth
roids are more effective than oral and intranasal antihis- unaffected in children using mometasone for one year.17
tamines in the treatment of allergic rhinitis.4,5,10-12 One Similarly, a well-designed prospective study did not
randomized controlled trial (RCT) looking at quality- show any difference in growth in children using nasal
of-life measures compared the antihistamine
loratadine (Claritin) with the nasal cortiTable 1. Allergic Rhinitis Treatment Based on Symptoms
costeroid fluticasone (Flonase) in 88 adults
over a four-week period.13 The studys results
Ocular
Nasopharyngeal
showed that symptom scores were comparaTreatment type
symptoms
itching
Sneezing
Rhinorrhea
ble, but quality-of-life scores were superior in
the nasal corticosteroid group.

Intranasal
corticosteroids
Although there is no evidence that one
intranasal corticosteroid is superior to

Oral antihistamines
another, many of the available products

Intranasal

have different age indications from the U.S.

antihistamines
Food and Drug Administration (FDA). Only

Decongestants

budesonide (Rhinocort) carries the FDA

pregnancy category B safety rating, and only

Intranasal

cromolyn
mometasone (Nasonex) has a delivery device
(Nasalcrom)
that received recognition from the National
14
Arthritis Foundation for ease of use.

Intranasal

anticholinergics
The adverse effects most commonly experienced with the use of intranasal corti

Leukotriene

costeroids are headache, throat irritation,

receptor
antagonists
epistaxis, stinging, burning, and nasal dryness.3,15 Although the use of intranasal cor
Nasal saline

ticosteroids has raised concern for potential

irrigation
systemic adverse effects, including the sup

Immunotherapy

pression of the hypothalamic-pituitary axis,

note: Listed in order of treatment preference.
the products currently available have not
been shown to have such effects.16 There
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American Family Physician 1441

Allergic Rhinitis
Table 2. Summary of Treatments for Allergic Rhinitis
Pregnancy
category

Minimum
age

Mechanism and onset

of action

Beclomethasone (Beconase)

Six years

Budesonide (Rhinocort)

Six years

Ciclesonide (Omnaris)

Six years

Flunisolide

Six years

Inhibits the influx of

inflammatory cells;
onset of action is less
than 30 minutes

Fluticasone furoate (Veramyst)

Two years

Bitter aftertaste, burning, epistaxis,

headache, nasal dryness, potential
risk of systemic absorption, rhinitis
medicamentosa, stinging, throat
irritation

Fluticasone propionate (Flonase)

12 years

Mometasone (Nasonex)

Two years

Triamcinolone (Nasacort)

12 years

Cetirizine (Zyrtec)

Six months

Desloratadine (Clarinex)

Six months

Blocks H1 receptors; onset of

action is 15 to 30 minutes

Dry mouth, sedation at higher than

recommended doses

Fexofenadine (Allegra)

Six months

Levocetirizine (Xyzal)

12 years

Loratadine (Claritin)

Two years

Azelastine (Astelin)

Five years

Olopatadine (Patanase)

Six years

Blocks H1 receptors; onset of

action is 15 minutes

Bitter aftertaste, epistaxis, headache,

nasal irritation, sedation

12 years

Vasoconstriction; onset of
action is 15 to 30 minutes

Arrhythmias, dizziness, headache,

hypertension, insomnia, nervousness,
tremor, urinary retention

Two years

Inhibits histamine release;

results typically noted in one
week, but may take two to
four weeks for full effect

Epistaxis, nasal irritation, sneezing

Six years

Blocks acetylcholine receptors;

onset of action is 15 minutes

Epistaxis, headache, nasal dryness

Six months

Blocks leukotriene receptors;

onset of action is two hours

Elevated levels of alanine transaminase,

aspartate transaminase, and bilirubin

Treatment

Adverse effects

Intranasal corticosteroids

Oral antihistamines

Intranasal antihistamines

Oral decongestants
Pseudoephedrine

Intranasal cromolyn
Cromolyn (Nasalcrom)

Intranasal anticholinergics
Ipratropium (Atrovent)

Leukotriene receptor antagonists

Montelukast (Singulair)

note:

Listed in order of treatment preference.

corticosteroids for at least three years.18 However, one

randomized trial of 90 children (six to nine years of
age) who were treated with beclomethasone (Beconase)
or placebo for one year showed suppressed growth rates
in the group taking beclomethasone compared with the
placebo group.19 Although nasal fluticasone has been
shown to reduce endogenous cortisol excretion in one
study, its impact on growth is unknown.20 Despite the
data, all intranasal corticosteroids carry a warning that
long-term use may restrict growth in children.
ORAL ANTIHISTAMINES

Histamine is the most studied mediator in early allergic

response. It causes smooth muscle constriction, mucus
secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis.21
1442 American Family Physician

The first-generation antihistamines include brompheniramine, chlorpheniramine, clemastine, and diphenhydramine (Benadryl). They may cause substantial adverse
effects, including sedation, fatigue, and impaired mental
status. These adverse effects occur because the older antihistamines are more lipid soluble and more readily cross
the blood-brain barrier than second-generation antihistamines. The use of first-generation antihistamines has
been associated with poor school performance, impaired
driving, and an increase in automobile collisions and
work injuries.22-25 Although one RCT of 63 children eight
to 10 years of age did not show that the short-term use of
first- or second-generation antihistamines caused drowsiness or impaired school performance, the children in this
study were only treated for three days, and the sample size
was small.26

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Allergic Rhinitis

Compared with first-generation antihistamines,

second-generation antihistamines have a better adverseeffect profile and cause less sedation, with the exception
of cetirizine (Zyrtec).21,22 The second-generation oral
antihistamines include desloratadine (Clarinex), levocetirizine (Xyzal), fexofenadine (Allegra), and loratadine.
Second-generation antihistamines have more complex
chemical structures that decrease their movement across
the blood-brain barrier, reducing central nervous system
adverse effects such as sedation. Although cetirizine is
a second-generation antihistamine and a more potent
histamine antagonist, it does not have the benefit of
decreased sedation. As a group, the second-generation
oral antihistamines are thought to stabilize and control
some of the nasal and ocular symptoms, but have little
effect on nasal congestion.21
In general, first- and second-generation antihistamines have been shown to be effective at relieving the
histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular
symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Because their onset
of action is typically within 15 to 30 minutes and they
are considered safe for children older than six months,
antihistamines are useful for many patients with mild
symptoms requiring as needed treatment.27
INTRANASAL ANTIHISTAMINES

Compared with oral antihistamines, intranasal antihistamines offer the advantage of delivering a higher
concentration of medication to a specific targeted area,
resulting in fewer adverse effects.3 Currently, azelastine
(Astelin; approved for ages five years and older) and
olopatadine (Patanase; approved for ages six years and
older) are the two FDA-approved intranasal antihistamine preparations for the treatment of allergic rhinitis.
As a class, their onset of action occurs within 15 minutes and lasts up to four hours. Adverse effects include
a bitter aftertaste, headache, nasal irritation, epistaxis,
and sedation. Although intranasal antihistamines are
an option in patients whose symptoms did not improve
with second-generation oral antihistamines, their use as
first- or second-line therapy is limited by their adverse
effects and cost compared with second-generation oral
antihistamines, and by their decreased effectiveness
compared with intranasal corticosteroids.28,29
DECONGESTANTS

Oral and topical decongestants improve the nasal congestion associated with allergic rhinitis by acting on
adrenergic receptors, which causes vasoconstriction in
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the nasal mucosa, resulting in decreased inflammation.3-5

Although the most commonly available decongestants
are phenylephrine, oxymetazoline (Afrin), and pseudoephedrine, the abuse potential for pseudoephedrine
should be weighed against its benefits.
Common adverse effects that occur with the use of
intranasal decongestants are sneezing and nasal dryness.
Duration of use for more than three to five days is usually
not recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion.3 However, a study of 35 patients found no rebound
when oxymetazoline was used for 10 days.30 Because oral
decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia,
and insomnia, patients with underlying cardiovascular
conditions, glaucoma, or hyperthyroidism should only
use these medications with close monitoring.3-5 A study
of 25 patients with controlled hypertension provides
some reassurance about the use of oral decongestants;
compared with placebo, this randomized crossover
study found minimal effect on blood pressure with pseudoephedrine use.31
INTRANASAL CROMOLYN

Intranasal cromolyn is available over the counter and is

thought to act by inhibiting the degranulation of mast
cells.1 Although safe for general use, it is not considered first-line therapy for allergic rhinitis because of its
decreased effectiveness at relieving symptoms compared
with antihistamines or intranasal corticosteroids, and
its inconvenient dosing schedule of three or four times
daily.1,3
INTRANASAL ANTICHOLINERGICS

Ipratropium (Atrovent) has been shown to provide relief

only for excessive rhinorrhea. Advantages include that
it does not cross the blood-brain barrier and is not systemically absorbed.1 Adverse effects include dryness of
the nasal mucosa, epistaxis, and headache. Compliance
is also an issue because it needs to be administered two
or three times daily.1
LEUKOTRIENE receptor antagonists

Although the leukotriene LTD4 receptor antagonist

montelukast (Singulair) is FDA approved for the treatment of allergic rhinitis, a systematic review of 20 trials
involving adults treated with montelukast for allergic
rhinitis showed only minimal improvement (which was
not clinically relevant) in the symptom of nasal congestion.32 Another RCT involving 58 adults comparing montelukast with pseudoephedrine for two weeks

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Allergic Rhinitis

showed no difference between the two therapies.33

In addition, two large, independent meta-analyses concluded that although montelukast is better than placebo, it is not as effective as intranasal corticosteroids
or antihistamines and should only be considered as
second- or third-line therapy.32,34
COMBINATION THERAPY

Although many studies have looked at the combination

of an intranasal corticosteroid with an antihistamine
or leukotriene receptor antagonist, most have concluded that combination therapy is no more effective
than monotherapy with intranasal corticosteroids.11,35-37
However, one study looking at the combination of fluticasone and azelastine found this treatment combination to be superior to either treatment alone in patients
with moderate to severe allergic rhinitis.38 Therefore,
although patients should not have therapy initiated with
more than one agent, combination therapy is an option
for patients with severe or persistent symptoms.

rhinosinusitis symptoms, medication use, and skin sensitivities when compared with placebo.43
Omalizumab (Xolair), an anti-immunoglobulin E
antibody, has been shown to be effective in reducing
nasal symptoms and improving quality-of-life scores in
patients with allergic rhinitis.44 The main limitations of
its current use are its high cost (average wholesale price
is $679 to $3,395 per month45) and lack of FDA approval
for home use.
Nonpharmacologic Therapies
ACUPUNCTURE

Although the precise mechanism by which acupuncture works is unclear, proponents suggest that it releases
neurochemicals such as beta-endorphins, enkephalins,
and serotonin, which in turn mediate the inflammatory
pathways involved in allergic rhinitis. Based on RCTs
looking at acupuncture as a treatment for allergic rhinitis in adults and children, there is insufficient evidence
to support or refute its use.46-49

Immunotherapy
Immunotherapy should be considered for
Treatment of Allergic Rhinitis
patients with moderate or severe persisAllergic rhinitis
tent allergic rhinitis that is not responsive
8
to usual treatments. Targeted immunotherapy is the only treatment that changes
Allergen avoidance and patient education
the natural course of allergic rhinitis,
preventing exacerbation.39 It consists of
a small amount of allergen extract given
Mild to moderate
Severe persistent
Mild intermittent
sublingually or subcutaneously over the
persistent symptoms
symptoms
symptoms
course of a few years, with maintenance
periods typically lasting between three
to five years. The greatest risk associated
Intranasal corticosteroids
Intranasal corticosteroids
Second-generation
alone as first-line treatment
plus oral or intranasal
oral or intranasal
with immunotherapy is anaphylaxis.
antihistamine, oral
antihistamine, as
Although the usefulness of sublingual
leukotriene receptor
needed
immunotherapy in adults with allergic
antagonist, or intranasal
Consider nasal irrigation or
cromolyn (Nasalcrom)
decongestants for nasal
rhinitis has been supported by several
congestion*
large trials, studies in children have met
Consider ipratropium
with mixed results, and the FDA has yet
Symptoms persist
(Atrovent) or intranasal
to approve a commercial product for subantihistamines for rhinorrhea
lingual use.8,40-42
Consider oral or intranasal
Consider immunotherapy
antihistamine for persistent
Recombinant DNA technology has
referral or alternative
nasal ocular symptoms
also played a role in immunotherapy,
treatments (e.g., allergen
avoidance, nasal irrigation,
allowing for the development of allergen-
acupuncture, probiotics,
specific vaccines. In a multicenter RCT
herbal preparations)
involving 134 adults receiving a recom*Use of nasal decongestants for longer than three days is cautioned because of risk of
binant birch pollen vaccine for 12 conrebound congestion.
secutive weeks followed by monthly
injections for 15 months, patients noted
statistically significant improvements in Figure 1. Algorithm for the treatment of allergic rhinitis.
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Allergic Rhinitis

PROBIOTICS

Based on the limited data to date, probiotics cannot be

endorsed as a useful alternative therapy for allergic rhinitis. Studies of probiotics gave mixed results and included
12 RCTs and one study looking at prenatal treatment.50,51
HERBAL PREPARATIONS

3. Bousquet J, Van Cauwenberge P, Khaltaev N; ARIA Workshop Group;

World Health Organization. Allergic rhinitis and its impact on asthma.
J Allergy Clin Immunol. 2001;108(5 suppl):S147-S334.
4. Price D, Bond C, Bouchard J, et al. International Primary Care Respiratory Group (IPCRG) Guidelines: management of allergic rhinitis. Prim
Care Respir J. 2006;15(1):58-70.
5. Scadding GK, Durham SR, Mirakian R, et al.; British Society for Allergy
and Clinical Immunology. BSACI guidelines for the management of
allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38(1):19-42.

Many herb and plant-extract compounds have been

studied with respect to allergic rhinitis treatment, but
the effectiveness and safety of these compounds have not
been established.52

6. Plaut M, Valentine MD. Clinical practice. Allergic rhinitis. N Engl J Med.

2005;353(18):1934-1944.

Other

8. Calderon MA, Alves B, Jacobson M, Hurwitz B, Sheikh A, Durham

S. Allergen injection immunotherapy for seasonal allergic rhinitis.
Cochrane Database Syst Rev. 2007;(1):CD001936.

Patients with allergic rhinitis should avoid exposure to

cigarette smoke, pets, and allergens to which they have
a known sensitivity. Nasal irrigation is beneficial in the
treatment of chronic rhinorrhea and may be used alone
or as adjuvant therapy.53 Irrigation using a neti pot is
superior to saline sprays; it may also be done with a lowpressure squeeze bottle.53
Prevention has been a large focus in the study of allergic rhinitis, but few interventions have proven effective.
Although dust mite allergies are common, studies have
not found any benefit to using mite-proof impermeable mattress and pillow covers.54-56 Other examples of
proposed interventions without documented effectiveness include breastfeeding, delayed exposure to solid
foods in infancy, and use of air filtration systems.57-61
Figure 1 provides an algorithm for the treatment of
allergic rhinitis with pharmacologic and nonpharmacologic therapies.
The Authors
DENISE K. SUR, MD, is clinical professor, vice chair for education, and residency director in the Department of Family Medicine at the David Geffen
School of Medicine, University of California, Los Angeles.
STEPHANIE SCANDALE, MD, is an assistant clinical professor in the
Department of Family Medicine at the David Geffen School of Medicine.
Address correspondence to Denise K. Sur, MD, UCLA Family Health
Center, Department of Family Medicine, 1920 Colorado Ave., Santa
Monica, CA 90404 (e-mail: [email protected]). Reprints are not
available from the authors.
Author disclosure: Nothing to disclose.

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28. Corren J, Storms W, Bernstein J, Berger W, Nayak A, Sacks H; Azelastine

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4 8. Brinkhaus B, Witt CM, Jena S, Liecker B, Wegscheider K, Willich SN.

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29. Berger WE, White MV; Rhinitis Study Group. Efficacy of azelastine nasal
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Allergy Asthma Immunol. 2003;91(2):205-211.

49. Roberts J, Huissoon A, Dretzke J, Wang D, Hyde C. A systematic review

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1446 American Family Physician

www.aafp.org/afp

Volume 81, Number 12

June 15, 2010