Allergic Rhinitis – Stepwise Therapy

Definition: IgE-mediated inflammation of the nasal mucosa triggered by environmental allergens.

Common symptoms:

Step 0 – Environmental Control

Step 1 – First-Line Therapy

Intranasal Corticosteroid (Most Effective Overall)

Best for: Nasal congestion, global symptom control Onset: Hours to days (max effect ~1–2 weeks)

Clinical Pearl:

Step 2 – Add Symptom-Targeted Therapy

Oral Second-Generation H1 Antihistamine

Best for: Sneezing, itching, rhinorrhea Less effective for congestion

Intranasal Antihistamine

Faster onset than oral agents Good for intermittent symptoms

Step 3 – Combination Therapy

Improves congestion and breakthrough symptoms.

Step 4 – Leukotriene Pathway (Selected Patients)

Consider when:

Note:

Step 5 – Refractory Disease

Short-Term Decongestant Use (NOT Anti-Inflammatory)

Topical Alpha-1 Agonist (≤ 3 Days)

Risk: Rebound congestion (rhinitis medicamentosa)

Oral Sympathomimetic

Caution:

Treatment Summary

Board Pearls