Diagnosis
H&P
Treatment
Algorithm for treating allergic rhinitis from AAFP.
-Allergen avoidance and patient education.
Pharmacotherapy
-Intranasal Steroids (1st-line tx): Fluticasone Nasal Spray – 2 sprays/nostril QD or 1 spray/nostril BID OR combination tx with Azelastine/fluticasone (Dymista)
–Antihistamine: Oral antihistamine (Loratidine, desloratadine, fexofenadine etc.) or a nasal antihistamine (Azelastine).
-Nasal irrigation with Neti pot (using only sterile saline). Proper intranasal therapy technique explained. Direct spray superiorly/laterally “toward ipsilateral ear”
-Immunotherapy if symptoms persist. Subcutaneous or sublingual immunotherapy. Pt understands immunotherapy may take 3 to 5 years of treatment. And often involves multiple treatments per week during the build-up phase before being spaced out during the maintenance phase. The patient is aware that the effects of immunotherapy may only last up to 7 to 12 years after the treatment is discontinued.
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Allergic rhinitis pearls and important links
- Intranasal steroids reduce inflammation of the nasal mucosa. They do so by 1) decreasing the influx of inflammatory cells into the nose and 2) preventing the release of cytokines by these cells. The result is a reduction in inflammation of the nasal mucosa.
- Intranasal steroids are more effective than oral antihistamines and intranasal antihistamines for treating persistent or severe allergic rhinitis.
- 2nd generation antihistamines like Loratidine, desloratadine, and fexofenadine have better side effect profiles and are less sedating than first-generation antihistamines, except for cetirizine (Zyrtec). Zyrtec is very sedating.
Reference / Further Reading