eMedicine Specialties > Allergy and Immunology > Major Allergic Diseases
Rhinitis, Allergic: Treatment & Medication
Updated: Jun 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The management of allergic rhinitis consists of 3 major categories of treatment, (1) environmental control measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy.- Environmental control measures and allergen avoidance: These involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis.43 However, global environmental control without identification of specific triggers is inappropriate.
- Pollens and outdoor molds
- Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist (see Causes).
- Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.
- Despite all of these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal molds may be difficult.
- Indoor allergens
- Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure.44 Bed linens should be washed every 2 weeks in hot (at least 130°F) water to kill any mites present.45,46 Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.47
- Indoor environmental control measures for mold allergy focus on reduction of excessive humidity and removal of standing water. The environmental control measures for dust mites can also help reduce mold spores.
- For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping it entirely out of the bedroom can be of some benefit.48 Cat allergen levels in the home can be reduced with high-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may be impractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.
- Occupational allergens: As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.
- Nonspecific triggers: Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoor pollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of these situations or triggers if they seem to aggravate symptoms.
- Pollens and outdoor molds
- Pharmacotherapy: See Medication.
- Immunotherapy (desensitization): A considerable body of clinical research has established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements.49 Success rates have been demonstrated to be as high as 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observed for 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefully consider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits of immunotherapy against the risks and benefits of the other management options.
- Indications: Immunotherapy may be considered more strongly with severe disease, poor response to other management options, and the presence of comorbid conditions or complications. Immunotherapy is often combined with pharmacotherapy and environmental control.
- Administration: Administer immunotherapy with allergens to which the patient is known to be sensitive and that are present in the patient's environment (and cannot be easily avoided). The value of immunotherapy for pollens, dust mites, and cats is well established.50,51,52,53,54 The value of immunotherapy for dogs and mold is less well established.49,50
- Contraindication: A number of potential contraindications to immunotherapy exist and need to be considered. Immunotherapy should only be performed by individuals who have been appropriately trained, who institute appropriate precautions, and who are equipped for potential adverse events.
Surgical Care
Surgical care is not indicated for allergic rhinitis but may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities. The value of turbinectomy is not established.
Consultations
While the general practitioner can effectively treat most cases of straightforward allergic rhinitis, consider consultation with an allergist or immunologist for severe disease, poor response to pharmacotherapy, and the presence of comorbid conditions or complications. Consultation with other specialists also might be needed for comorbid conditions or complications. Consult with an allergy specialist when identification or clarification of specific allergic triggers is needed, when detailed counseling regarding environmental control measures is needed, when quality of life is significantly impaired, or when immunotherapy may be a consideration.
Medication
Most cases of allergic rhinitis respond to pharmacotherapy. Patients with intermittent symptoms are often treated adequately with oral antihistamines, decongestants, or both as needed. Regular use of an intranasal steroid spray may be more appropriate for patients with chronic symptoms. Daily use of an antihistamine, decongestant, or both can be considered either instead of or in addition to nasal steroids. The newer, second-generation (ie, nonsedating) antihistamines are usually preferable to avoid sedation and other adverse effects associated with the older, first-generation antihistamines. Ocular antihistamine drops (for eye symptoms), intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short courses of oral corticosteroids (reserved for severe, acute episodes only) may also provide relief.
Second-generation antihistamines
Often referred to as the nonsedating antihistamines. They compete with histamine for histamine receptor type 1 (H1) receptor sites in the blood vessels, GI tract, and respiratory tract, which, in turn, inhibits physiologic effects that histamine normally induces at the H1 receptor sites. Some do not appear to produce clinically significant sedation at usual doses, while others have a low rate of sedation.55,56,57 Other adverse effects (eg, anticholinergic symptoms) are generally not observed.
All are efficacious in controlling symptoms of allergic rhinitis (ie, sneezing, rhinorrhea, itching) but do not significantly improve nasal congestion. For this reason, some second-generation antihistamines are available as combination preparations containing a decongestant. They are often preferred for first-line therapy of allergic rhinitis, especially for seasonal or episodic symptoms, because of their excellent efficacy and safety profile. They can be used prn or daily.
Topical azelastine and olopatadine are nasal sprays antihistamines that effectively reduce sneezing, itching, and rhinorrhea but also effectively reduces congestion.58,59,60 Used twice per day, especially when combined with a topical nasal corticosteroid, azelastine is effective at managing both allergic and nonallergic rhinitis.
The second-generation oral antihistamines currently available in the United States are cetirizine, levocetirizine, desloratadine, fexofenadine, and loratadine. A limited number of studies comparing these agents suggest no major differences in efficacy. Only cetirizine causes drowsiness more frequently than placebo.57 Cetirizine, fexofenadine, and loratadine are also available in decongestant-containing preparations.
Cetirizine (Zyrtec)
Competes with histamine for H1 receptors in GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Once-daily dosing is convenient. Bedtime dosing may be useful if sedation is a problem.
Adult
5-10 mg PO qd
Pediatric
<6 months: Not established
6-12 months: 2.5 mg PO qd
12-24 months: 2.5 mg PO qd/bid
2-5 years: 2.5-5 mg PO qd
>6 years: 5-10 mg PO qd
Increases toxicity of CNS depressants; theophylline decreases clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal dysfunction (adjust dose); 10 mg/d may cause drowsiness in approximately 10% of patients; caution driving or operating heavy machinery
Levocetirizine (Xyzal)
Histamine1-receptor antagonist. Active enantiomer of cetirizine. Peak plasma levels reached within 1 h and half-life is about 8 h. Available as a 5-mg breakable (scored) tab. Indicated for seasonal and perennial allergic rhinitis.
Adult
5 mg PO qd in evening
CrCl 50-80 mL/min: 2.5 mg (half tab) PO qd in evening
CrCl 30-49 mL/min: 2.5 mg PO qod
CrCl 10-29 mL/min: 2.5 mg PO 2 times/wk
Pediatric
<6 years: Not established
6-12 years: 2.5 mg (half tab) PO qd in evening
>12 years: Administer as in adults
Coadministration with CNS depressants (eg, alcohol, sedative-hypnotics) may increase somnolence; ritonavir increased plasma AUC of measurable cetirizine by 42% and half-life by 53%
Documented hypersensitivity; CrCl <10 mL/min or hemodialysis; children aged 6-11 y with renal impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common adverse effects include somnolence, nasopharyngitis, fatigue, xerostomia, and pharyngitis in adults and children >12 y; pyrexia, somnolence, cough, and epistaxis commonly observed in children 6-12 y; caution with activities requiring mental alertness
Fexofenadine (Allegra)
Second-generation agent with a rate of sedation not significantly different from that of placebo. Competes with histamine for H1 receptors in GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Available in qd and bid preparations.
Adult
60 mg PO bid or 180 mg PO qd
Pediatric
<6 years: Not established
6-12 years: 30 mg PO bid
>12 years: Administer as in adults
Levels may increase with coadministration of erythromycin or ketoconazole; pseudoephedrine antagonizes antihypertensives; may cause increased ectopic pacemaker activity with digitalis
Documented hypersensitivity; in combination with pseudoephedrine, do not use if severe hypertension or coronary artery disease present; do not use within 14 d of MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal impairment (can be used safely in hepatic impairment without dose reduction); caution in pregnancy and breastfeeding, narrow-angle glaucoma or increased intraocular pressure, mild-to-moderate hypertension, diabetes, hyperthyroidism, prostatic hypertrophy, urinary retention, seizure disorders, elderly population; anxiety or insomnia may occur because of pseudoephedrine component; can be used safely with hepatic impairment without a reduction of dose
Loratadine (Claritin)
Selectively inhibits peripheral histamine H1 receptors. Tolerated well, with rate of sedation not significantly different from placebo.
Adult
10 mg PO qd
Pediatric
<2 years: Not established
2-5 years: 5 mg PO qd
>5 years: Administer as in adults
Ketoconazole, erythromycin, procarbazine, cimetidine, and alcohol may increase loratadine levels; limited data exist for desloratadine; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase observed in clinically relevant adverse effects, including QTc
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Desloratadine is pregnancy category C; initiate therapy at lower dose in liver and renal impairment; caution in pregnancy and breastfeeding; may rarely cause pharyngitis or dry mouth
Loratadine and pseudoephedrine (Claritin-D 24 Hour, Claritin-D 12 Hour)
Tolerated well, with rate of sedation not significantly different from that of placebo. Some patients may notice anxiety or insomnia owing to pseudoephedrine component.
Adult
10 mg loratadine/240 mg pseudoephedrine (Claritin-D 24 Hour): 1 tab PO qd
5 mg loratadine/120 mg pseudoephedrine (Claritin-D 12 Hour): 1 tab PO bid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Ketoconazole, erythromycin, procarbazine, cimetidine, and alcohol may increase loratadine levels; pseudoephedrine antagonizes antihypertensives; may cause increased ectopic pacemaker activity with digitalis
Documented hypersensitivity; severe hypertension or coronary artery disease; do not use within 14 d of MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Initiate therapy at lower dose in renal impairment; avoid use with hepatic impairment; caution in pregnancy and breastfeeding, narrow-angle glaucoma or increased intraocular pressure, mild-to-moderate hypertension, diabetes, hyperthyroidism, prostatic hypertrophy, urinary retention, seizure disorders, elderly population
Fexofenadine and pseudoephedrine (Allegra-D)
Fexofenadine is a nonsedating second-generation medication with fewer adverse effects than first-generation medications. Competes with histamine for H1 receptors on GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Does not sedate.
Pseudoephedrine stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Induces also bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors.
Adult
60 mg with 120 mg pseudoephedrine; 1 tab PO bid
Pediatric
Not established
Levels may increases with coadministration of erythromycin or ketoconazole; pseudoephedrine antagonizes antihypertensives, may cause increased ectopic pacemaker activity with digitalis
Documented hypersensitivity; severe hypertension or coronary artery disease; do not use within 14 d of MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Initiate therapy at lower dose in renal impairment; caution in pregnancy and lactation; narrow-angle glaucoma or increased intraocular pressure; mild-to-moderate hypertension; diabetes; hyperthyroidism; prostatic hypertrophy; urinary retention; seizure disorders; elderly population; anxiety or insomnia may occur due to pseudoephedrine component; can be used safely with hepatic impairment without a reduction of dose
Desloratadine (Clarinex)
Relieves nasal congestion and systemic effects of seasonal allergy. Long-acting tricyclic histamine antagonist selective for H1-receptor. Major metabolite of loratadine, which after ingestion is extensively metabolized to active metabolite 3-hydroxydesloratadine.
Adult
5 mg PO qd
Pediatric
<6 months: Not established
6-12 months: 1 mg PO qd
12 months to 5 years: 1.25 mg PO qd
6-12 years: 2.5 mg PO qd
>12 years: Administer as in adults
Limited data exists; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase was observed in clinically relevant adverse effects including QTc
Documented hypersensitivity to desloratadine or loratadine
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in hepatic impairment; rarely causes pharyngitis or dry mouth
Leukotriene receptor antagonists
Alternative to oral antihistamine to treat allergic rhinitis. One of the leukotriene receptor antagonists, montelukast (Singulair), has been approved in the United States for treatment of seasonal and perennial allergic rhinitis.61,62,63 When used as single agent, produces modest improvement in allergic rhinitis symptoms.64
Montelukast (Singulair)
Selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene (CysLT 1) receptor. Selectively prevents action of leukotrienes released by mast cells and eosinophils. When used as a single agent, has been shown to result in a reduction of seasonal allergic rhinitis symptoms, similar in degree to that of loratadine.
Adult
10 mg PO qd
Pediatric
<2 years: Not established
2-6 years: 4 mg PO qd
6-15 years: 5 mg PO qd
>15 years: Administer as in adults
Phenobarbital and rifampin may reduce AUC of montelukast
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not indicated to reverse acute asthma attacks; not for use as monotherapy in management of exercise-induced bronchospasm; patients with known aspirin sensitivity should continue avoidance of aspirin or NSAIDS while taking montelukast
Neuropsychiatric events have been reported, and following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor
First-generation antihistamines
The older, first-generation H1 antagonists (eg, diphenhydramine, hydroxyzine) are effective in reducing most symptoms of allergic rhinitis, but they produce a number of adverse effects (eg, drowsiness, anticholinergic effects). They can be used prn, but adverse effects may limit their usefulness when taken on a daily basis. Some patients tolerate the adverse effects with prolonged use, but they may experience cognitive impairment, and driving skills may be affected.65,66,67,68,69 Administration at bedtime may help with drowsiness, but sedation and impairment of cognition may continue until the next day.
The second-generation antihistamines are nonsedating in most patients and are preferred as first-line therapy. Few adverse effects are reported (cetirizine may cause drowsiness in as many as 10% of patients); therefore, many specialists prefer the use of second-generation agents for allergic rhinitis. Caution patients taking medications with sedative effects about driving and operating heavy machinery.68,69
Chlorpheniramine (Chlor-Trimeton)
First-generation agent, available OTC in the United States. One of the safest antihistamines to use during pregnancy. Competes with histamine on H1-receptor sites on effector cells in blood vessels and respiratory tract.
Adult
4 mg PO q4-6h; alternatively, 8 mg SR PO q8h or 12 mg SR PO q12h; not to exceed 24 mg/d
Pediatric
<2 years: Not established
2-6 years: 1 mg PO q4-6h; not to exceed 4 mg/d
6-12 years: 2 mg PO q4-6h; not to exceed 12 mg/d
>12 years: Administer as in adults
Toxicity increases with coadministration of other CNS depressants, TCAs, MAOIs, and phenothiazines
Documented hypersensitivity; severe asthma; narrow-angle glaucoma; symptomatic prostate hypertrophy; bladder neck obstruction; pyloroduodenal obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause significant confusion
Diphenhydramine (Benadryl, Benylin)
Common first-generation agent available OTC in the United States. Competes with histamine on H1-receptor sites on effector cells in blood vessels and respiratory tract. For symptomatic relief of symptoms caused by release of histamine in allergic reactions.
Adult
25-50 mg PO q4-6h; not to exceed 400 mg/d
Pediatric
<3 years: Not established
3-12 years: 5 mg/kg/d PO divided tid/qid; not to exceed 300 mg/d
>12 years: Administer as in adults
Potentiates effect of CNS depressants; syrup contains alcohol; caution with concurrent use of medications with disulfiramlike reactions; caution with anticholinergic effects
Documented hypersensitivity; MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, urinary tract obstruction; xerostomia may occur
Hydroxyzine (Atarax, Vistaril, Vistazine)
Effective first-generation agent but frequently produces sedation. Considerable sedation may occur with higher doses. Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS.
Adult
10-25 mg PO q6-8h
Pediatric
0.6 mg/kg/dose PO q6h
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate porphyria (may not be safe for these patients); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness; adjust dose in hepatic dysfunction
Decongestants
Stimulate vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Pseudoephedrine produces weak bronchial relaxation (unlike epinephrine or ephedrine) and is not effective for treating asthma. Increases heart rate and contractility by stimulating beta-adrenergic receptors. Used alone or in combination with antihistamines to treat nasal congestion. Anxiety and insomnia may occur. Expectorants may thin and loosen secretions, although experimental evidence for their efficacy is limited. Numerous preparations are available containing combinations of various decongestants, expectorants, or antihistamines. Alternatively, a separate decongestant and antihistamine can be administered to allow for individual dose titration of each drug.
Pseudoephedrine (Sudafed)
Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Available OTC in the United States. Helpful for nasal and sinus congestion.
Adult
30-60 mg PO q4-6h; not to exceed 240 mg/d; alternatively, 120 mg SR PO q12h
Pediatric
<2 years: Not established
2-6 years: 15 mg PO q4-6h; not to exceed 4 doses/d
6-12 years: 30 mg PO q4-6h; not to exceed 4 doses/d
>12 years: Administer as in adults
Hypertensive crisis with MAOIs; increased pressor effects with beta-blockers; arrhythmias with epinephrine or isoproterenol; antagonizes methyldopa, reserpine, and guanethidine
Documented hypersensitivity; severe anemia; postural hypotension or severe hypertension; closed-angle glaucoma; head trauma; cerebral hemorrhage; coronary artery disease; do not use within 14 d of MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution with mild-to-moderate hypertension; caution with diabetes, glaucoma, hyperthyroidism, GI obstruction, urinary obstruction, prostatic hypertrophy, epilepsy, cardiac disease, elderly patients, pregnancy and breastfeeding; adjust dose in renal dysfunction; may produce anxiety and insomnia
Nasal corticosteroids
Nasal steroid sprays are highly efficacious in treating allergic rhinitis.70,71,72,73,74 They control the 4 major symptoms of rhinitis (ie, sneezing, itching, rhinorrhea, congestion). They are effective as monotherapy, although they do not significantly affect ocular symptoms. Studies have shown nasal steroids to be more effective than monotherapy with nasal cromolyn or antihistamines.71,72 Greater benefit may occur when nasal steroids are used with other classes of medication. They are safe to use and not associated with significant systemic adverse effects in adults (this may also be true for children, but the data are less clear).
Local adverse effects are limited to minor irritation or nasal bleeding, which resolve with temporary discontinuation of the medication. Nasal septal perforations are rarely reported and are less common with the newer corticosteroids and delivery systems. Safety during pregnancy has not been established; however, clinical experience suggests nasal corticosteroids (particularly beclomethasone, which has most experience in use) are not associated with adverse fetal effects.
The nasal steroids can be used prn, but seem to be maximally effective when used on a daily basis as maintenance therapy. They may also be helpful for vasomotor rhinitis or mixed rhinitis (a combination of vasomotor and allergic rhinitis) and can help to control nasal polyps.
Mometasone (Nasonex)
Nasal spray; may decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.75 Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells).
Adult
2 sprays (50 mcg/spray) each nostril qd
Pediatric
<2 years: Not established
2-11 years: 1 spray (50 mcg/spray) each nostril qd
>11 years: Administer as in adults
None reported
Documented hypersensitivity, nasal septal perforation, nasal surgery, nasal trauma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution in patients with active or quiescent tuberculosis of the respiratory tract; untreated fungal, bacterial, systemic viral infections; or ocular herpes; rare instances of decreased growth velocity in pediatric patients have been reported; also, rare instances of nasal septum perforation and increased IOP have been reported; nasal and inhaled corticosteroids have been associated with development of glaucoma and/or cataracts
Beclomethasone (Beconase, Beconase AQ, Vancenase Pockethaler, Vancenase AQ)
Older topical nasal steroid. Most reliable during pregnancy, as it has been in use for many years with no significant problems observed. May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.
Adult
1-2 puffs/nostril (42 mcg/puff) qd/bid; titrate to lowest effective dose
Vancenase AQ Double Strength (84 mcg/puff): 1-2 puffs/nostril qd; titrate to lowest effective dose
Pediatric
<6 years: Not established
>6 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for growth suppression in children; caution in pregnancy and breastfeeding
Budesonide (Rhinocort Aqua)
Newer topical steroid considered efficacious and safe for allergic rhinitis. May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.
Adult
1-4 puffs/nostril (32 mcg/puff) qd or divided bid; titrate to lowest effective dose
Pediatric
<6 years: Not established
6-12 years: 1-2 puffs/nostril qd or divided bid; titrate to lowest effective dose
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for growth suppression in children; caution in pregnancy and breastfeeding
Fluticasone (Flonase)
Newer topical steroid considered efficacious and safe for allergic rhinitis. May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.
Adult
1-2 puffs/nostril (50 mcg/puff) qd or 1 puff/nostril bid; titrate to lowest effective dose; not to exceed 4 puffs/d (200 mcg)
Pediatric
<4 years: Not established
>4 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for growth suppression in children; caution in pregnancy and breastfeeding; nosebleeds may occur
Ciclesonide (Omnaris)
Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg.
Adult
2 sprays (50 mcg/spray) in each nostril qd (ie, 200 mcg/d)
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Data limited; oral ketoconazole increases desciclesonide AUC by approximately 3.5-fold at steady state
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution when replacing systemic corticosteroids because of risk of adrenal insufficiency; may decrease growth velocity in pediatric patients; caution with active or quiescent tuberculosis infection or with untreated fungal, viral, or bacterial infections; rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure reported
Fluticasone furoate (Veramyst)
Intranasal corticosteroid. Indicated for seasonal and perennial allergic rhinitis. Relieves nasal symptoms associated with allergic rhinitis. Has also demonstrated improvement in allergic eye symptoms. Contains 27.5 mcg/spray.
Adult
110 mcg intranasally qd initially (ie, 2 sprays each nostril qd); once symptoms improve, may decrease to 55 mcg qd (ie, 1 spray each nostril qd)
Pediatric
<2 years: Not established
2-12 years: 55 mcg intranasally qd (ie, 1 spray each nostril qd)
>12 years: Administer as in adults
Coadministration with other corticosteroids could increase risk of hypercorticism and/or suppression of HPA; coadministration with CYP450 3A4 isoenzyme inhibitors (eg, amprenavir, atazanavir, darunavir, delavirdine, fosamprenavir, indinavir, ketoconazole, nelfinavir, ritonavir, tipranavir) decreases fluticasone elimination and increases plasma fluticasone levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Prime before using for first time by shaking contents and releasing 6 test sprays into air away from face; common adverse effects include headache, nose bleed, and nasal sores; fever occurred more frequently in children aged 2-11 years compared to placebo; epistaxis or sensations of nasal burnings may occur; local candidal infections of nasopharynx have been reported with topical steroid use; always consider potential risk of suppression of HPA when using large dose for prolonged periods; rare cases of cataract, glaucoma, and increased intraocular pressure have been reported following intranasal use of corticosteroids; concomitant use of intranasal corticosteroids and other inhaled and/or systemically absorbed corticosteroids may cause hypercorticism and/or HPA suppression; if exposed to measles or chickenpox, consider prophylactic therapy
Triamcinolone (Nasacort AQ)
Injectable corticosteroid used to treat inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
0.5 cc into each inferior turbinate q6-8wk
Pediatric
Not established
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
A percentage of topical drug might be absorbed systemically; if application is repeated, some systemic effects of the corticosteroids may occur
Intranasal antihistamines
Alternative to oral antihistamines to treat allergic rhinitis.
Azelastine (Astelin)
Use prn or on a regular basis. Use alone or in combination with other medications. Unlike oral antihistamines, has some effect on nasal congestion. Helpful for vasomotor rhinitis. Some patients experience a bitter taste. Systemic absorption may occur, resulting in sedation (reported in approximately 11% of patients).
Adult
2 puffs/nostril (137 mcg/puff) bid
Pediatric
<5 years: Not established
5-11 years: 1 puff/nostril (137 mcg/puff) bid
>11 years: Administer as in adults
Potentiates CNS depression with alcohol and other CNS depressants; caution with concurrent oral antihistamines; cimetidine increases serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with eyes; may cause sedation; caution in pregnancy and breastfeeding
Olopatadine (Patanase)
For relief of symptoms of seasonal allergic rhinitis. Before initial use, prime product by releasing 5 sprays or until fine mist appears. When product has not been used for more than 7 days, re-prime by releasing 2 sprays. Avoid spraying into eyes.
Adult
2 sprays/nostril bid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid spraying into eyes
Intranasal cromolyns
Produce mast cell stabilization and antiallergic effects that inhibit degranulation of mast cells.76 Have no direct anti-inflammatory or antihistaminic effects. Effective for prophylaxis. May be used just before exposure to a known allergen (eg, animal, occupational). Begin treatment 1-2 wk before pollen season and continue daily to prevent seasonal allergic rhinitis. Effect is modest compared with that of intranasal corticosteroids. Excellent safety profile and are thought to be safe for use in children and pregnancy.
Cromolyn sodium (Nasalcrom)
Available OTC in the United States. Used daily for seasonal or perennial allergic rhinitis. Significant effect may not be observed for 4-7 d. For patients with isolated and predictable periods of exposure (eg, animal allergy, occupational allergy), administer just before exposure. Generally less effective than nasal corticosteroids. Protective effect lasts 4-8 h, frequent dosing is necessary.
Adult
1 puff/nostril (5.3 mg/puff) q4-6h
Pediatric
<2 years: Not established
>2 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for use in severe renal or hepatic impairment; symptoms may recur when withdrawing drug
Intranasal anticholinergic agents
Used for reducing rhinorrhea in patients with allergic or vasomotor rhinitis. No significant effect on other symptoms. Can be used alone or in conjunction with other medications. In the United States, ipratropium bromide (Atrovent Nasal Spray) is available in a concentration of 0.03% (officially indicated for treatment of allergic and nonallergic rhinitis) and 0.06% (officially indicated for the treatment of rhinorrhea associated with common cold). The 0.03% strength is discussed.
Ipratropium bromide (Atrovent Nasal Spray 0.03%)
Chemically related to atropine. Has anti-secretory properties, and when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Poor absorption by nasal mucosa; therefore, not associated with adverse systemic effects. Local adverse effects (eg, dryness, epistaxis, irritation) may occur.
Adult
2 puffs/nostril (21 mcg/puff) bid/tid
Pediatric
<6 years: Not established
>6 years: Administer as in adults
Drugs with anticholinergic properties (eg, dronabinol) may increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with eyes; caution in narrow-angle glaucoma, prostatic hypertrophy, and bladder neck obstruction
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Further Reading
Keywords
allergic rhinitis, rhinitis, nasal allergies, sneezing, nasal congestion, nasal itching, rhinorrhea, nasal inflammation, rhinitis allergic, rhinitis treatment, allergy treatment, nasal allergy treatment, nasal congestion treatment
