ABSTRACT: Many pharmacological options exist for allergic rhinitis. Intranasal corticosteroids are the most effective medication class for patients with moderate to severe symptoms; those with milder intermittent symptoms can be treated with a second-generation oral or intranasal antihistamine. Allergen avoidance measures may also be helpful. In patients whose symptoms are refractory to standard pharmacological therapy, allergen immunotherapy can be effective. A 3- to 5-year treatment course of subcutaneous injection immunotherapy can produce lasting benefit years after completion of therapy. In the future, sublingual immunotherapy may emerge as an alternative approach in the United States as it has in Europe in recent years.
Key words: allergic rhinitis, nonallergic rhinitis, primary care
Allergic rhinitis is a common disorder that dramatically affects patients' quality of life and consumes billions of dollars each year in health care costs and lost productivity. Rhinitis may be allergic (IgE-mediated) or nonallergic. Pure allergic rhinitis is about 3 times more prevalent than pure nonallergic rhinitis; however, many patients have both types.
In this article, we review pharmacological treatments for the different types of rhinitis; we focus on their relative efficacy and the symptoms for which each is best employed (Table). We also discuss immunotherapy options for the treatment of allergic rhinitis. In a previous article ("Allergic Rhinitis: Update on Diagnosis"), we addressed issues related to the diagnosis of allergic rhinitis.
INTRANASAL CORTICOSTEROIDS
Intranasal corticosteroids are the most effective class of medication for allergic rhinitis, and they are effective for all of its symptoms.1 While a patient may prefer and/or respond better to a given agent, none of the currently available intranasal corticosteroids has known superior efficacy over another.1,2 Intranasal corticosteroids are also effective in nonallergic rhinitis,3 including vasomotor rhinitis4 and rhinitis medicamentosa.5 Even though symptoms may initially abate within approximately 12 hours,6 maximum efficacy requires several weeks of daily use.
In our experience, most patients who report that allergic rhinitis symptoms have not responded to an intranasal corticosteroid are not using the medication regularly. Advise patients to give the medication at least a 1-month trial. In addition, teach them to direct the spray laterally within the nasal vestibule; this technique minimizes the nasal irritation and bleeding that can be associated with intranasal corticosteroids. These strategies should improve adherence and consequently efficacy. Intranasal corticosteroids are generally free from significant systemic side effects, including growth suppression in children.1
| Table — Selected pharmacotherapy options for allergic rhinitis | ||||
| Class | Agent | Trade name | Mechanism | Symptom(s) treated |
| Second-generation oral antihistamine | Cetirizine, Fexofenadine(Drug information on fexofenadine), Levocetirizine(Drug information on levocetirizine), Loratadine, Desloratadine(Drug information on desloratadine) | Zyrtec, Allegra, Xyzal, Claritin, Clarinex | Stabilizes H1 receptor in inactive conformation9 | Itching, sneezing, rhinorrhea; not as effective for nasal congestion |
| Intranasal antihistamine | Azelastine, Olopatadine(Drug information on olopatadine) | Astelin, Astepro, Patanase | Stabilizes H1 receptor in inactive conformation9 | Itching, sneezing, rhinorrhea and nasal congestion |
| Leukotriene receptor antagonist | Montelukast | Singulair | Leukotriene receptor antagonist | Itching, sneezing, rhinorrhea; not as effective for congestion |
| Anticholinergic agent | Ipratropium nasal spray | Atrovent nasal spray | Anticholinergic | Rhinorrhea (only) |
| Intranasal corticosteroid | Mometasone(Drug information on mometasone), Budesonide(Drug information on budesonide), Triamcinolone(Drug information on triamcinolone), Flunisolide(Drug information on flunisolide), Ciclesonide(Drug information on ciclesonide) | Flonase, Veramyst, Nasonex, Nasarel, Omnaris | Multiple anti-inflammatory effects (corticosteroid) | Itching, sneezing, rhinorrhea and nasal congestion; the most effective class of agents |
