Approach

The goal of symptom relief or cessation is achieved by institution of allergen avoidance measures, pharmacotherapy, immunotherapy, or a combination thereof. The clinician should ask about nasal, palate, and eye symptoms, so that pharmacotherapy can be selected to target all of the affected areas. Common non-nasal symptoms contribute to impaired quality of life but may be unintentionally overlooked.

  • Allergen avoidance is one of the guiding principles of treatment. While environmental control measures can sometimes lead to complete symptom control (e.g., by removing a pet), they can at other times be difficult to implement.

  • After an initial pharmacologic treatment regimen has been initiated, follow-up should occur within 7-14 days and therapy be stepped up or stepped down, as deemed necessary.[67]

  • Second-generation, nonsedating antihistamines are recommended for initial treatment of mild symptoms.[3] They are considered to be safe and relatively free of adverse effects. Sedation associated with the use of first-generation antihistamines diminishes their utility.

  • Intranasal corticosteroids remain the single most effective class of medications for treating AR.[3][4] However, for many patients, especially those with mild symptoms, antihistamines may be trialed prior to starting intranasal corticosteroids.[52]

  • Second-generation antihistamines (e.g., loratadine and cetirizine) are preferred for breast-feeding mothers.[68] Caution is advised if use of first-generation antihistamines is required in breast-feeding mothers.[68] Case reports and studies report somnolence and irritability in breastfed infants when first-generation antihistamines are taken by the mother.[69]

  • Leukotriene receptor antagonists (e.g., montelukast) are an option for patients who have failed or are intolerant of other agents, but they are used infrequently due to lack of efficacy and possible risk of neuropsychiatric events.[3][70]

Allergen avoidance and control

Pollen (grasses, trees, weeds)[71]

  • Keep windows of homes and cars closed and employ an air conditioner in the recycling/indoor mode.

  • Minimize time spent outdoors during times of high pollen count, when practical.

  • Avoid activities known to cause exposure to pollen, such as mowing grass.

  • Shower after outdoor activities where exposure to pollen is high.

  • Use recirculated air in the car when pollen levels are high.

  • Wear sunglasses (to protect eyes from airborne pollen).

  • Dry bedding and clothing inside or in a tumble dryer.

House dust mite minimization[71][72]

  • Physical measures include heating ventilation, freezing, washing, and barrier methods.

  • Wash bedding weekly in hot water (>140°F [>60°C]) to kill dust mites and denature the allergens they produce. Hot tumble drying of washed items for an additional 10 minutes after they are dry will kill dust mites.

  • Cover mattress, pillow, and quilt with dust mite-resistant covers. Wash covers every 2 months.

  • Remove all soft toys and woolen bedding from the bedroom. Freezing soft toys overnight kills mites but does not remove the allergen; they can then be tumbled in the dryer to help with this.

  • Where possible replace carpets with hard floors.

  • Damp dust or use cloths to clean hard surfaces (including hard floors) weekly.

  • Vacuum carpets weekly.

  • Reduce humidity – have a dry and well ventilated house, and adequate floor and wall insulation.

  • Venetian blinds or flat blinds are easier to clean than heavy curtains.

  • Consider leather or vinyl sofas instead of fabric.

Pet dander

  • Individuals allergic to cats and dogs have few effective ways to reduce their exposure to pet allergens short of ridding themselves of the animals. It is important to counsel patients that pet allergen levels only slowly decline over several months when a pet is removed from the home; therefore, rapid improvement is not expected.[71] Ultimately though, the affected individual willing to part with their cat or dog will frequently experience significant symptom relief.

  • While some people may react differently to individual dogs, "hypoallergenic" dogs are a myth that has been debunked.[73][74]

  • Washing of cats has not been shown to be an effective approach to reducing allergen exposure. Although weekly washings can reduce allergens, clinical studies have shown neither a persistent reduction of airborne allergens nor a clear reduction in rhinitis symptoms.[75][76]

  • High-efficiency particulate air (HEPA) filters did not lead to significant symptom improvement in controlled trials of cat-sensitized individuals.[77][78]

Cockroach infestation

  • Cockroach infestation is associated with AR and asthma, especially in the inner city.[79]

  • Control measures are based on eliminating suitable environments and restricting access by sealing, caulking, and controlling the food supply as well as using chemical control and traps.

  • While cockroach extermination by professionals may reduce allergen levels by 80% to 90%, the clinical significance of this finding requires further research.[80]

  • Reinfestation from adjacent apartments is a frequent problem, and thus extermination efforts will likely need to be repeated and extended beyond the affected space.

Molds[71]

  • Mold-allergic individuals should carefully inspect their home for mold damage, with special attention to more humid areas of the dwelling.

  • Appropriate steps should be taken to mitigate or prevent sources of humidity and/or water ingress associated with indoor mold growth. Ensure adequate natural ventilation, including the use of extractor fans; seal leaks in bathrooms and roofs.

  • Clear overflowing gutters and blocked under-floor vents.

  • Remove indoor pot plants (which promote mold growth).

  • Dry or remove wet carpets.

  • Avoid working with garden compost or mulch, or mowing lawns.

  • Remove localized mold growth with a dilute bleach solution. More extensive mold damage may require aggressive measures such as replacing the affected surface/material.

Mild or intermittent symptoms

First-line management is with either an intranasal corticosteroid or a nonsedating oral antihistamine.[67] Monotherapy with an intranasal corticosteroid is generally recommended because oral antihistamines are less effective.[67][81] However, many patients may prefer oral drugs.

Oral antihistamines are effective for rhinorrhea, sneezing, and itching, but have only a modest effect on nasal congestion.[52] Cetirizine, a second-generation antihistamine, has been found to be particularly effective in AR, but may cause some mild sedation.[82] Second-generation oral antihistamines are preferred to first-generation agents because they cause less sedation, dizziness, and incoordination.[3] Paradoxical hyperactivity with use of sedating antihistamines has been reported, particularly in children.[83] 

Intranasal antihistamines are another first-line option when symptoms are intermittent and do not require daily medication.[3] Intranasal antihistamines are particularly effective for rhinorrhea and congestion, but they do not improve symptoms at non-nasal sites.[53] They have a fast onset of action after initial dosing (usually 15-30 minutes, and no later than 3 hours) and are effective over a 12-hour period.[3][67] Intranasal antihistamines may cause sedation.

Patient reassessment

The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5 to 7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[67]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.

Patients may have tried using over-the-counter decongestants, which may provide temporary relief from symptoms; however, there is no evidence to support their ongoing use in allergic rhinitis, and guidelines do not recommend them.

Persistent and moderate or severe symptoms

Intranasal corticosteroids should be the first consideration if symptoms are persistent and moderate or severe.[3] They may provide additional benefit in reducing AR-associated ocular symptoms.[84][85] Oral and intranasal antihistamines are also first-line options in these patients.

The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5-7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[67]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.

Immunotherapy

Immunotherapy may be offered by an allergy specialist (through a shared decision-making model) to a patient who remains symptomatic despite allergen avoidance measures and pharmacotherapy.[3] Immunotherapy is also commonly used by patients either unwilling to take or unable to tolerate medications.[3] Immunotherapy should be targeted to include allergens that are clinically relevant to both the patient and the geographic locale.

Allergen immunotherapy has been shown to improve symptoms, medication use, and combined symptom/medication use scores in patients with rhinoconjunctivitis.[86][87] Subcutaneous immunotherapy (SCIT) may alter the natural history of allergic disease (induce long-term remission after discontinuation of therapy and prevent new sensitizations), as well as reduce the progression from AR to asthma when given in children ages 6 to 14 years for a minimum of 3 years.[88]

Sublingual immunotherapy (SLIT), an alternative to SCIT depending on the allergen involved, is effective in treating AR in adults and children and may also have disease-modifying potential.[87][89][90][91][92][93] [ Cochrane Clinical Answers logo ] It is considered to be safer than SCIT because adverse effects are usually limited to mucosal symptoms, and it is easier to administer (patient self-administers).[94] However, SLIT may be less effective than SCIT.[93] Direct comparisons using standardized and validated outcome measures between SLIT and SCIT are not available.[95] SLIT is more appropriately used in monosensitized patients, especially those sensitized to dust mites, grass, or ragweed.[96][97][98][99][100]

If immunotherapy is not available or there is a significant wait, a short course (7 days) of an oral corticosteroid may also be considered if symptoms are severe.[67]

Usual therapy not effective

Evaluation by an allergy specialist is advisable when there is:

  • An incomplete response to trial of therapy of environmental and pharmacologic interventions, and a persistent and significant impact on quality of life (interference with hobbies, family life, activities of daily living, sleep, emotional well-being)

  • An inability to adequately control associated conditions such as asthma or sinus disease.

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