Allergic rhinitis is a symptomatic disorder of the nose secondary to IgE-mediated inflammation of the nasal membranes induced after exposure to allergens.
Major symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Other symptoms include headache, conjunctival symptoms, eye pruritus, impaired smell and morning cough.
Symptoms can reverse spontaneous w/ or w/o treatment.

Principles of Therapy

  • Treatment of allergic rhinitis is based on the duration & severity of symptoms
  • A step-wise approach to treatment is recommended for adolescents & adults
  • Step down therapy as patient’s symptoms improve & step up when symptoms worsen
  • Similar therapeutic principles are applied in children; however, care should be taken to avoid the adverse effects of certain classes of drugs in the pediatric population
  • Combination/step-up therapy may be used in patients w/ inadequate response to monotherapy
    • Intranasal corticosteroids & oral antihistamines: has better symptom control than monotherapy
    • Oral antihistamines & oral decongestant or leukotriene modifiers: showed better symptom control compared to monotherapy
    • Intranasal corticosteroids & leukotriene modifiers: use should be limited if symptoms lessen or disappear w/ intranasal corticosteroids alone
    • Intranasal corticosteroids & intranasal antihistamines or intranasal Oxymetazoline: showed better efficacy than monotherapy
  • Drugs used for rhinitis are usually administered either orally or intranasally



  • Eg Ipratropium bromide
  • Block the muscarinic receptors of the seromucinous glands
  • Effectively controls watery rhinorrhea, but does not affect sneezing or nasal congestion, which precludes its use as a 1st-line medication
  • May be used together with intranasal corticosteroids or antihistamines in patients in whom rhinorrhea is the predominant symptom, or in whom rhinorrhea does not respond well to the other medications


  • H1-receptor antagonists reduce nasal itching, sneezing & rhinorrhea, but are less effective for nasal obstruction
  • 1st-line treatment for mild-moderate intermittent & mild persistent rhinitis
  • Added to intranasal corticosteroids for moderate-severe persistent rhinitis uncontrolled by intranasal corticosteroid monotherapy

Nasal Antihistamines

  • Eg Azelastine, Olopatadine, Levocabastine
  • Rapid onset of action (<15-30 minutes)
  • Recommended in patients with seasonal, perennial, or episodic allergic rhinitis
  • Associated with clinically significant effect on nasal congestion
  • Effective at the site of administration
  • May be used for mild, organ limited disease or as an “as required” medication used together with a continuous one
  • As effective as oral antihistamines but require twice-daily dosing

Oral Antihistamines

  • With the advantage of relieving other allergic symptoms of other sites along w/ nasal symptoms
  • May be used to prevent symptoms associated with occasional allergy exposure
  • 2nd generation antihistamines are preferred over intranasal antihistamines
  • Use of 1st generation antihistamines should be limited; may reduce academic ability in school children
  • Onset of action occurs within 1 hour

Second-generation Oral Antihistamines

  • Eg Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, Bilastine, Mequitazine
  • Should be considered as a 1st choice treatment
  • Have less undesirable CNS and fewer anticholinergic effects compared to 1st-generation antihistamines
  • Have little or no sedative effect at the recommended dosages

First-generation Oral Antihistamines

  • Eg Diphenhydramine, Chlorpheniramine, Clemastine
  • Use is limited by sedative and anticholinergic side effects and short half-life
  • May further impair cognitive functioning and school performance in children

Intraocular Antihistamines

  • May be used in patients with symptoms of ocular involvement (eg conjunctivitis)

Anti-Immunoglobulin E Antibody

  • Eg Omalizumab
  • Has been shown to be effective in reducing nasal symptoms and improving quality of life in patients with seasonal allergic rhinitis
  • Use for allergic rhinitis is currently limited in clinical setting until more evidence is available


  • Have a strong anti-inflammatory capacity by reducing cytokine & chemokine release

Intranasal Corticosteroids

  • Eg Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
  • More efficacious than oral or topical nasal antihistamines in relieving symptoms of allergic rhinitis, especially nasal obstruction
  • Considered as 1st-line treatment in patients with moderate-severe and/or persistent symptoms
  • Onset of action is relatively slow (6-12 hours), with maximum efficacy developing after 2 weeks
  • Aqueous preparations are preferred because they are less irritating to the nasal mucosa
  • Studies have shown reassuring safety data of Fluticasone, Mometasone and Ciclesonide use on long-term growth of children
    • Generally, not associated with clinically significant systemic side effects if given in recommended doses 
  • In severe cases, nasal corticosteroids should be started 2 weeks before the start of the pollen season, then given regularly

Systemic Corticosteroids

  • May be used in rare conditions in severe patients unresponsive to other treatments and intolerant to intranasal corticosteroid
  • Prednisolone/Methylprednisolone should be administered in a short period of time


  • Promote vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa

Nasal Decongestants

  • Eg Oxymetazoline, Xylometazoline
  • Very effective in relieving nasal obstruction, & rhinorrhea
  • Because of the risk of rebound vasodilation (rhinitis medicamentosa) & atrophic rhinitis with prolonged use, their use should be limited to <5 days
  • Short courses may be used to immediately reduce severe nasal obstruction while giving other medications for allergic rhinitis

Cromoglicic acid

  • Less effective than antihistamines & intranasal corticosteroids
  • Compliance is often poor because of the need for frequent administration
  • May be considered in symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea)
    • Intraocular cromones may be considered for the management of ocular symptoms (eg conjunctivitis)
  • Excellent safety profile may make it a suitable option for children and pregnant women

Oral Decongestants

  • Eg Pseudoephedrine, Ephedrine
  • Weaker effect on nasal obstruction than topical preparations, but do not cause rebound vasodilatation
  • Helps relieve nasal obstruction, rhinorrhea and ocular symptoms
  • Use may be considered in patients with severe allergic rhinitis who are unresponsive to oral antihistamines & intranasal corticosteroids
  • Use should be limited due to known adverse effects (insomnia, agitation, palpitation)

Leukotriene Receptor Antagonists

  • Eg Montelukast, Zafirlukast
  • Efficacy similar to oral antihistamines
  • Therapeutic option used either alone or in combination with antihistamines; not to be used as initial therapy
    • Based on some studies, the combination of Montelukast and antihistamine is more effective for nasal and ocular symptoms compared to placebo 
  • Preferred in patients with coexisting asthma
    • There is a reduction in beta-agonists use with administration of Montelukast

Saline Solutions

  • May be used as single or adjunctive agents in reducing the symptoms of allergic rhinitis
  • There is no difference in radiologic or symptomatic score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance

Non-Pharmacological Therapy

Allergen Avoidance

  • The 1st step to symptom control in allergic rhinitis is identification and avoidance of the trigger allergens
  • Elimination of the allergen results in diminished severity of the disease and decreased requirement for medications
  • Identifying specific causal allergens by skin testing or laboratory testing may encourage patients to comply with allergen avoidance instructions
  • Effectiveness of avoidance will be measured by relief of the patient’s symptoms and by a decrease in the need for medications
  • In the majority of cases it is not possible to completely avoid allergens but these measures should be considered where appropriate

House dust mites

  • Major allergen found in houses
  • Wash sheets and blankets in hot water (60o C) every week
  • Use anti-mite covers in mattresses, beds and pillows
  • Vacuum-clean beds each week
  • For indoors, use of exhaust circulation-type cleaner is recommended
  • Clean furniture in the bedroom with damp rags


  • Avoid going outdoors on days when pollen counts are high
  • Use of air conditioning
  • Keep doors and windows closed at home and when inside cars
  • Wear a mask and use glasses during heavy pollen dispersal period
  • Avoid wearing of woolen coats
  • Shake the dust off (eg suit and hair) before entering the house


  • Do not allow animals in the house
  • If this is not possible, exclude pets from bedroom or keep out of doors
  • Clean the rooms and improve the ventilation


  • Discourage smoking by patient, household members and visitors
  • Minimize contact with irritants (eg perfumes, hair spray and other odors)
  • Reduce growth of molds in the home by decreasing humidity and eliminating sites for mold growth


  • Recommended for patients with moderate or severe persistent allergic rhinitis with inadequate response to usual pharmacologic therapy and allergen avoidance measures

Principles of Therapy

  • Repeated administration of specific allergens to patients with IgE-mediated conditions, to provide protection against allergic symptoms associated with exposure to these allergens
    • Most effective if secondary to pollen & dust mites; less effective if due to mold & animal dander
  • Specific immunotherapy is effective when optimally administered
  • Only treatment that may cause long term remission of rhinitis (3-5 years)
  •  Activates regulatory T cells, thereby altering humoral response to allergens by increasing CD8+ T cells & IL-10, & reducing IL-13 production 
  • Initial dose should be performed in a medical facility by a trained personnel
  • Recommended course is usually 4-5 years
  • Immunotherapy may be given to children and adults who have the following factors:
    • Evidence of specific IgE antibody to allergen
    • Any of the following:
      • Patient’s preference
      • Adherence to therapy
      • Required medications
      • Adverse effects to medications
      • Poor response to avoidance measures
      • Prevention of asthma in allergic rhinitis patients
      • Clinically diagnosed with both allergic rhinitis and asthma

Subcutaneous Immunotherapy

  • Indications for subcutaneous immunotherapy:
    • Inadequate control with medications
    • Patient refusal to receive pharmacotherapy, or to undergo treatment on a long-term basis
    • Intolerable or unacceptable adverse effects from medications
  • Should be performed by trained personnel
  • Efficacy for allergic rhinitis is comparable to that of nasal glucocorticoids 
  • Limited by frequent injection on regular basis and small risk of anaphylactic reaction

Sublingual Immunotherapy

  • A more viable treatment compared to SCIT as self-administration is encouraged with this form
  • Use should be limited to those who can tolerate systemic reactions & its treatment
  • Auto/self-injectable Epinephrine should be prescribed to all patients receiving SLIT
  • Has been associated with mild oral and gastrointestinal symptoms and less risk for anaphylaxis compared to SCIT
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