Updates in the Management of Seasonal Allergic Rhinitis

G. Blair Sarbacker, PharmD, BCACP


US Pharmacist. 2016;41(7):30-34. 

In This Article

Management of Seasonal Allergic Rhinitis

Commonly referenced guidelines include the 2010 update to Allergic Rhinitis and Its Impact on Asthma (ARIA) and the American Academy of Otolaryngology–Head and Neck Surgery Foundation's (AAO-HNSF's) 2015 clinical practice guideline for allergic rhinitis.[6,8,9]

Nonpharmacologic Measures

Allergen avoidance is a nonpharmacologic strategy often recommended to patients with allergic rhinitis. Interestingly, the majority of measures used to reduce indoor allergens do not have a clinically significant impact on allergic rhinitis when they are practiced individually. It is still recommended that patients with animal allergies avoid the specific animals they react to.[6] It is possible that a multicomponent approach to allergen avoidance would be more effective for allergen-exposure reduction; however, evidence supporting this theory is not available. In patients who are sensitized to occupational allergens, avoidance is recommended; in cases where this is not possible, exposure to the occupational allergen should be controlled.[6]

Nasal saline has long been touted as a nonpharmacologic measure for allergic rhinitis. A 2015 Cochrane review on the use of nasal saline for acute upper respiratory infections, including the common cold and rhinosinusitis, found a minimally significant reduction of nasal discharge and obstruction.[10] Another nonpharmacologic treatment for allergic rhinitis is acupuncture, which in randomized, controlled trials has shown promise in providing some symptom control with minimal risk of harm to the patient.[8]

Pharmacologic Measures

Figure 1 summarizes the treatment-initiation recommendations for seasonal allergic rhinitis from the AAO-HNSF's 2015 clinical practice guideline for allergic rhinitis.[8]

Figure 1.

Initiating therapy based on (a) symptoms or (b) symptom severity

Intranasal Corticosteroids. Intranasal corticosteroids, recognized as the most effective agent for symptom control in allergic rhinitis, are currently recommended as first-line therapy for patients with moderate-to-severe symptoms or those with nasal congestion as the dominant complaint.[8] The onset of action ranges from 3 to 36 hours after the first dose, and continuous use is more effective than intermittent use. If efficacy is not established within 1 week, treatment is considered ineffective. No single product is recommended over another, as studies have shown comparable efficacy among products. In the control of nasal symptoms, intranasal corticosteroids have shown superior efficacy compared with oral antihistamines; however, intranasal antihistamines have a faster onset of action, which may be beneficial. Local stinging and burning, dryness, and nosebleeds are common adverse effects (AEs) of intranasal corticosteroids. Concerns over stunted growth in children precipitated several clinical trials; reduced growth was seen with budesonide and beclomethasone, but not with fluticasone furoate, triamcinolone acetonide, mometasone furoate, or fluticasone propionate. Accordingly, for pediatric patients, guidelines recommend using those agents not shown to reduce growth.[8] The use of nasal saline 5 minutes after taking intranasal corticosteroids may reduce the incidence or severity of side effects. Table 2 summarizes the available intranasal products for seasonal allergic rhinitis.

Oral Antihistamines. Oral antihistamines are recommended as first-line agents in patients with mild symptoms of allergic rhinitis or those with sneezing and itching as the primary complaint.[8] Second-generation antihistamines are used to manage allergic rhinitis because they do not penetrate the central nervous system to the extent that first-generation antihistamines do, and therefore have milder sedative properties. These agents, although less effective than intranasal corticosteroids, are recommended because they are readily available OTC, cost less, have a fast onset of action (average of 150 minutes), and are dosed once daily. Patients who fail treatment with one agent in this class may exhibit a response to an alternative agent. Higher efficacy is demonstrated with regular use than with intermittent use. Common AEs include dryness of the mucous membranes, urinary retention, and occasional sedation.[8] These agents may be dosed at night if a patient experiences sedation. Table 3 summarizes the oral products used to treat seasonal allergic rhinitis.

Intranasal Antihistamines. These agents are the second most effective treatment for seasonal allergic rhinitis and are recommended as second-line therapy for patients with intermittent nasal symptoms in whom congestion is not dominant.[8] They are also next in line after oral antihistamines for patients with mild allergic rhinitis symptoms and may be used in patients with moderate-to-severe symptoms of allergic rhinitis. In clinical trials, intranasal antihistamines have been shown to be equal or superior to oral antihistamines for symptom control. Compared with oral antihistamines, they are superior for reducing intranasal congestion and systemic effects. The available preparations are of equal efficacy. These agents have been shown to be beneficial in patients who fail to respond to oral antihistamines. Some trials found that intranasal antihistamines were equal in efficacy to intranasal corticosteroids, and certain antihistamines were superior. Intranasal antihistamines have an onset of action of 15 to 30 minutes and are approved for use in children aged ≥6 years.[8] See Table 2 for a summary of products used to treat seasonal allergic rhinitis.

Oral Decongestants. These agents are recommended in patients with allergic rhinitis whose primary complaint is nasal congestion.[8] There are currently two available products: pseudoephedrine and phenylephrine. Pseudoephedrine is widely recognized as the more effective of the two agents. These agents are contraindicated in patients with severe coronary artery disease and uncontrolled hypertension (HTN). Caution should be used when recommending these agents to patients with a history of HTN (controlled or uncontrolled), arrhythmias, glaucoma, hyperthyroidism, benign prostatic hyperplasia, ischemic heart disease, and renal failure. Common AEs include HTN, tachyarrhythmia, anxiety, insomnia, and restlessness. Serious AEs include atrial fibrillation and myocardial infarction.[11] See Table 3 for a summary of products used to treat seasonal allergic rhinitis.

Intranasal Decongestants. Because of the possibility of rhinitis medicamentosa (rebound congestion), these agents should be used only as adjuvant therapy for 3 to 5 days.[8] Intranasal decongestants are contraindicated in patients with uncontrolled HTN, narrow-angle glaucoma, and ventricular tachyarrhythmia. Common AEs include burning and stinging in the eye.[11] See Table 2 for a summary of products used to treat seasonal allergic rhinitis.

Leukotriene Receptor Antagonists. No longer recommended as primary therapy in allergic rhinitis, leukotriene receptor antagonists are reserved for combination therapy.[8] This recommendation is based on several factors, including the higher cost, lower efficacy, and more prominent AEs associated with these agents. Postmarketing data have demonstrated drug-induced aggression, depression, suicidal thinking, and behavioral issues. The leukotriene receptor antagonist montelukast was found to be either equally effective or less effective than oral antihistamines, and it was less efficacious than intranasal corticosteroids. Because this agent treats both allergic rhinitis and asthma, a patient with both conditions is the best candidate.[8] See Table 3 for more information on montelukast.

Intranasal Mast Cell Stabilizers. Also called cromones, these products have long been available OTC for the treatment of allergic rhinitis. The intranasal agent cromolyn sodium (e.g., Nasalcrom) is not mentioned in the AAO-HNSF's 2015 guideline, but the ARIA guidelines recommend its use when other, more effective agents are not available. Intranasal antihistamines are preferred over cromolyn sodium, based on efficacy results.[6,8,9] Intranasal cromolyn must be dosed four times daily and titrated up to six times daily if needed, making adherence more difficult compared with other therapies. For seasonal allergic rhinitis, it is recommended to start using intranasal cromolyn sodium 1 to 2 weeks prior to the allergy season. These agents have a long history of safe use, making them a good option for pregnant patients (Category B). The most commonly reported AEs include bad taste in the mouth, cough, and throat irritation.[11] See Table 2 for more information on cromolyn sodium.

Intranasal Anticholinergics. Intranasal anticholinergics are available by prescription only. Currently, only one product is on the market. This agent, ipratropium, exclusively targets rhinorrhea. Although it is discussed in the ARIA guidelines, it is not mentioned in the AAO-HNSF's guideline.[6,8] See Table 2 for more information on ipratropium.

Combination Therapy. In patients with inadequate symptom control on intranasal corticosteroid monotherapy, an intranasal antihistamine or a 3-day regimen of oxymetazoline may be added.[8] In the event of inadequate symptom control with intranasal antihistamine monotherapy, intranasal corticosteroids may be added. Additionally, patients who experience inadequate symptom control on oral antihistamine monotherapy may be switched to intranasal corticosteroids or intranasal antihistamine. If adjunct therapy to an oral antihistamine is preferred, oral decongestants and leukotriene receptor antagonists are options.[8]

The combination of intranasal corticosteroids and oral antihistamine is not recommended owing to the lack of benefit of this combination. The combination of intranasal corticosteroids and leukotriene receptor antagonists also lacks sufficient evidence of benefit to be recommended for use.[8]