Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

intermittent

1st line – intranasal antihistamine

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
1st line – 

intranasal antihistamine

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 an intranasal antihistamine. These 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.

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

Plus – intranasal saline irrigation

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3]​ Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]​  

Plus – trigger avoidance

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]​​​​

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

2nd line – intranasal corticosteroid

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
2nd line – 

intranasal corticosteroid

The second-line treatment of mild (VAS <5/10) and intermittent (<4 days a week or for <4 consecutive weeks a year) symptoms of non-allergic rhinitis should be an intranasal corticosteroid.[3]​ Intranasal corticosteroid monotherapy 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.[3] 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]

Primary options

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

OR

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

​Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3]​ Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]​​​

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
intermittent
|
mild (VAS score <5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

1st line – intranasal antihistamine

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
1st line – 

intranasal antihistamine

The first-line treatment of moderate/severe (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.

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

Plus – intranasal saline irrigation

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]​ 

Plus – trigger avoidance

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

2nd line – intranasal corticosteroid

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
2nd line – 

intranasal corticosteroid

The second-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 an intranasal corticosteroid. 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]

Primary options

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

OR

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

3rd line – intranasal antihistamine plus intranasal corticosteroid

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
3rd line – 

intranasal antihistamine plus intranasal corticosteroid

The American Academy of Allergy, Asthma, and Immunology suggests that the clinician consider the combination of an intranasal antihistamine (e.g., azelastine) plus an intranasal corticosteroid for moderate/severe NAR that is resistant to pharmacological monotherapy.[3]

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

-- AND --

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

or

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

or

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

or

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
intermittent
|
moderate/severe (VAS score ≥5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

persistent

1st line – intranasal antihistamine

Back
ONGOING
|
persistent
|
mild (VAS score <5)
1st line – 

intranasal antihistamine

The first-line treatment of mild (visual analogue scale [VAS] <5/10) and persistent (≥4 days a week and for ≥4 consecutive weeks a year) symptoms of non-allergic rhinitis should be an intranasal antihistamine. These 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.

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

Plus – intranasal saline irrigation

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

2nd line – intranasal corticosteroid

Back
ONGOING
|
persistent
|
mild (VAS score <5)
2nd line – 

intranasal corticosteroid

The second-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 an intranasal corticosteroid. Intranasal corticosteroid monotherapy 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]

Primary options

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

OR

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
persistent
|
mild (VAS score <5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

1st line – intranasal antihistamine plus intranasal corticosteroid

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
1st line – 

intranasal antihistamine plus intranasal corticosteroid

Clinicians should consider the combination of an intranasal antihistamine (e.g., azelastine) and an intranasal corticosteroid for persistent moderate or severe non-allergic rhinitis. A single device is preferred, if available, but this is based primarily on convenience.

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

-- AND --

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

or

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

or

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

or

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

2nd line – intranasal antihistamine or intranasal corticosteroid

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
2nd line – 

intranasal antihistamine or intranasal corticosteroid

Although a combination of an intranasal antihistamine (e.g., azelastine) and an intranasal corticosteroid is recommended as the first-line option for moderate/severe persistent symptoms, it may be suitable to provide these individually if a combination is contraindicated.

Primary options

azelastine nasal: (0.1%) 2 sprays in each nostril twice daily

OR

budesonide nasal: (32 micrograms/dose) 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/dose) 100 micrograms (2 sprays) in each nostril once daily

OR

beclometasone nasal: (50 micrograms/dose) 50-100 micrograms (1-2 sprays) in each nostril twice daily

OR

triamcinolone nasal: (55 micrograms/dose) 55-110 micrograms (1-2 sprays) in each nostril once daily

Plus – intranasal saline irrigation

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Plus – 

intranasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Nasal saline can be beneficial for moisturising dry nasal passages and clearing out mucus. It should be used on a when-required basis.[3] Topical saline has been shown to reduce symptoms of post-nasal drainage, sneezing, and congestion in some patients.[40][41][42]​ The use of topical saline is associated with minimal side effects, such as burning, irritation, and nausea; has low cost; and has overall good patient acceptance.[3]

Plus – trigger avoidance

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

All patients should be counselled on avoidance of triggers.[3]

Consider – oral or intranasal decongestant

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Consider – 

oral or intranasal decongestant

Additional treatment recommended for SOME patients in selected patient group

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

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]

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.[3]

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

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal anticholinergic

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Consider – 

intranasal anticholinergic

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

ipratropium nasal: (0.03%) 2 sprays in each nostril two to three times daily

Consider – short-course oral corticosteroid

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
Consider – 

short-course oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

If the patient has severe initial presentation and severe oedema that may impact the delivery of intranasal agents (and decongestants have failed), a burst of oral corticosteroids should be considered.

Primary options

prednisolone: 5-60 mg orally once daily for 5-7 days

3rd line – surgery

Back
ONGOING
|
persistent
|
moderate/severe (VAS score ≥5)
3rd line – 

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 patients with persistent NAR 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]​​

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