Treatment Guideline Chart
Nonallergic rhinitis is the inflammation of the nasal lining membranes without any immunoglobulin E mediation, as documented by allergen skin testing.
Major signs and symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Symptoms can reverse spontaneously with or without treatment.

Rhinitis%20-%20nonallergic Treatment

Principles of Therapy

  • If possible, treatment should be aimed at the underlying causative physiology of NAR
  • No single medication or individual medication class can treat the entire spectrum of symptoms
  • Treatment response may be less satisfactory than in allergic rhinitis


Anticholinergics (Nasal)
  • Block the muscarinic receptors of the seromucinous glands
  • Ipratropium is ideal for patients who present with watery rhinorrhea as the main symptom
  • Have no activity against sneezing, itching or nasal congestion
Antihistamines (Nasal)
  • H1-receptor antagonists reduce nasal itching, sneezing and rhinorrhea, but are less effective for nasal obstruction
  • Intranasal antihistamines may be offered as first-line monotherapy option for patients with NAR
  • May have limited benefit in NAR unless symptoms result from histamine release
  • Oral antihistamines may be used as adjunctive therapy in some patients (eg patients with NARES); topical antihistamines have shown better efficacy for NAR
  • Azelastine, Olopatadine, or a combination of Azelastine and Fluticasone can reduce symptoms for over a year
Corticosteroids (Nasal)
  • Reduce airway hyperresponsiveness, amount and activity of inflammatory mediators, and allow relaxation of smooth muscle
  • Decrease sneezing, pruritus, rhinorrhea and nasal obstruction
  • May be offered as a first-line treatment for symptoms of NAR
  • Onset of action is relatively slow (6-12 hours), with maximum efficacy developing after 2-3 weeks
  • Better response is achieved with continuous use rather than with as-required use
  • Patient should be maintained on the lowest dose which achieves symptom control
  • Aqueous preparations are preferred because they are less irritating to the nasal mucosa
  • Intranasal corticosteroids with low bioavailability is suggested since it has been shown to have no effect on growth
  • Provoke vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa
Nasal Decongestants
  • Very effective in relieving nasal obstruction
  • Because of the risk of rebound vasodilation (rhinitis medicamentosa) and atrophic rhinitis with prolonged use, use should be limited to <10 days
    • May be used for short term, intermittent or episodic therapy of nasal congestion
Oral Decongestants
  • Have weaker effect on nasal obstruction than topical preparations, but do not cause rebound vasodilatation
  • May be given to patients with nasal congestion unresponsive to intranasal corticosteroids, intranasal antihistamine, or a combination of both
Aspirin (Nasal)
  • For patients with inflammatory NAR that have not responded to anti-inflammatory therapy and combination therapy, an Aspirin challenge can be done followed by desensitization if positive

Nasal Saline Irrigation

  • Nasal lavage or saline spray is useful for postnasal drainage symptoms
  • Cleanses nasal mucosa when used before intranasal corticosteroids or intranasal antihistamine

Other Investigational Agents

  • Some studies show benefit of Capsaicin, Ribomunyl and Silver nitrate for rhinitis symptoms
    • Capsaicin and Silver nitrate may be used for vasomotor rhinitis and Ribomunyl for infectious rhinitis
    • Topical Capsaicin desensitization reduces symptoms for several months
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