Non-allergic rhinitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Management focuses on treating individual symptoms, and varies depending on symptom severity and whether the patient is suffering from intermittent or persistent non-allergic rhinitis. Management needs to take into consideration patient preference and the speed of symptom relief.[3] In addition, triggers should be discussed with patients alongside counselling on avoidance when appropriate. First-line treatments include intranasal antihistamines, intranasal corticosteroids, or a combination of these drugs. Nasal irrigation may be used to treat symptoms or help improve delivery of a given therapy.[3]

Intermittent non-allergic rhinitis with mild symptoms

The first-line treatment of mild (visual analogue scale [VAS] <5/10) and intermittent (<4 days a week or for <4 consecutive weeks a year) symptoms of non-allergic rhinitis should be intranasal antihistamines. Intranasal antihistamines should be trialled for 5-7 days. If symptoms are not controlled, use alternative monotherapy.[3] Studies have demonstrated that azelastine is very effective in alleviating symptoms of vasomotor rhinitis.[17][23][24][25][26] These studies defined their vasomotor rhinitis subjects by negative allergen skin prick testing and absent nasal eosinophilia prior to enrolment.

The second-line option includes intranasal corticosteroid monotherapy. This may be preferred when monotherapy and/or avoidance of adverse taste from intranasal antihistamine are desired. Intranasal corticosteroids may be preferred over intranasal antihistamine monotherapy when dosed over several days as intranasal corticosteroids may become more effective with longer use. Intranasal corticosteroids use can minimise risk of rebound when used with intranasal decongestants.[3] Most studies investigating the role of nasal corticosteroids in NAR indicate that they are more effective in treating NAR with eosinophilia syndrome than vasomotor rhinitis.[27][28][29][30][31][32]

Oral or intranasal decongestants can be a useful adjunct therapy, particularly for a short course of 3-5 days when mucosal oedema impairs delivery of other intranasal agents or if the patient requires rapid relief.[3]

If symptoms are controlled, the treatment can be continued on a when-required basis, stepped down, or stopped. If symptoms are not controlled, consider additional treatments based on the presence of specific symptoms. If nasal congestion is a symptom, consider adding an oral or intranasal decongestant. If anterior rhinorrhoea is present, an intranasal anticholinergic should be considered.[3]

Treatment should be reassessed in 10-14 days and if symptoms are controlled, the treatment can be continued on a when-required basis, stepped down, or stopped. If symptoms are not controlled, escalate therapy to that for intermittent NAR, moderate or severe.

Intermittent non-allergic rhinitis with moderate/severe symptoms

The first-line treatment of moderate/severe (VAS >5/10) and intermittent (<4 days a week or for <4 consecutive weeks a year) symptoms of non-allergic rhinitis should be intranasal antihistamines. Intranasal antihistamines should be trialled for 5-7 days. If symptoms are not controlled, use alternative monotherapy.[3]

The third-line treatment is a combination of intranasal corticosteroids and intranasal antihistamines.

Oral or intranasal decongestants can be a useful adjunct therapy, particularly for a short course of 3-5 days when mucosal oedema impairs delivery of other intranasal agents, the patient requires rapid relief, or nasal congestion is a leading symptom.[3]

Persistent non-allergic rhinitis with mild symptoms

The first-line treatment of mild (VAS <5/10) and persistent (>4 days a week or for >4 consecutive weeks a year) symptoms of non-allergic rhinitis should be intranasal antihistamines. Intranasal antihistamines should be trialled for 5-7 days. If symptoms are not controlled, use alternative monotherapy.[3]

If symptoms are controlled, the treatment can be continued on a when-required basis, stepped down, or stopped. If they are not controlled, consider additional treatments based on the presence of specific symptoms. If nasal congestion is a symptom, consider adding an oral or intranasal decongestant. If anterior rhinorrhoea is present, an intranasal anticholinergic should be considered.

Persistent non-allergic rhinitis with moderate/severe symptoms

The first-line treatment of moderate/severe (VAS >5/10) and persistent (>4 days a week or for >4 consecutive weeks a year) symptoms of non-allergic rhinitis should be a combination of intranasal antihistamines and intranasal corticosteroids. If a combination therapy is not suitable, second-line treatment should be either an intranasal antihistamine or an intranasal corticosteroid.

Treatment should be reassessed in 10 days and if symptoms are controlled, the treatment can be continued on a when-required basis, stepped down, or stopped. If symptoms are not controlled, an oral corticosteroid should be considered in order to reduce oedema to allow other intranasal therapies to work. If this is unsuccessful, specialists may recommend surgery.

A surgical procedure would be tried only when all other medical therapies have failed to reduce symptoms and symptoms are affecting quality of life sufficiently to warrant an invasive surgical intervention. Surgical approaches are often prematurely attempted in persistent NAR patients when they fail therapy directed at treatment of allergic rhinitis conditions. Therefore, it is appropriate to consider consultation with an allergy specialist to confirm accurate diagnosis and complete trial of appropriate medical therapy prior to surgical evaluation. The two major options are CO₂ turbinectomy and partial laser turbinectomy, and the choice between them is based on surgeon preference. Limited studies have demonstrated that partial turbinectomy reduces nasal congestion. Controversy still exists as to whether turbinectomy leads to atrophic rhinitis.[33][34]

Oral or intranasal decongestants

These can be a useful adjunct therapy, particularly for a short course of 3-5 days when mucosal oedema impairs delivery of other intranasal agents, the patient requires rapid relief, or nasal congestion is a leading symptom.[3] Rebound effect upon stopping decongestants can be a cause of chronic rhinitis symptoms. Failure to respond to decongestants acutely is an indication to proceed to evaluation for structural problems.

Studies have demonstrated that intranasal decongestants can be used in patients with perennial allergic rhinitis for longer periods of time, without causing rebound congestion, when used in conjunction with an intranasal corticosteroid. Anecdotal experience has indicated this approach is also very effective in some NAR patients with refractory nasal congestion.[35][36]

Decongestants should also be used with an intranasal corticosteroid if the topical decongestant is needed for more than 5-7 days.

Intranasal decongestants such as oxymetazoline are alpha-adrenergic agonists and can cause improvement in nasal conductance for up to 10 hours, resulting in nasal vasoconstriction and decreased nasal oedema. Studies have shown that topical nasal decongestants can be used up to 4-6 weeks continuously if used in conjunction with an intranasal corticosteroid as the later medication is believed to prevent down-regulation of alpha receptors, thereby preventing tolerance.[3]

The American Academy of Allergy, Asthma, and Immunology recommends that oral decongestants should be avoided during the first trimester of pregnancy.[3]

Intranasal anticholinergics

Intranasal ipratropium should be used if anterior rhinorrhoea is a leading symptom.[3] It can reduce rhinorrhoea significantly compared with saline alone.[37] It is typically used to treat anterior and, to a lesser extent, posterior rhinorrhoea. It is effective for gustatory rhinitis (watery rhinorrhoea after eating spicy food) and weather-induced NAR.[38] It is a recommended option in European guidelines.[4][39] It can be used as an adjunct in patients with congestion-predominant or mixed congestion and rhinorrhoea NAR.[4][38]

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