Treatment continued...

Surgical Care

Surgical care is not indicated for allergic rhinitis but may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities. The value of turbinectomy is not established.

Consultations

While the general practitioner can effectively treat most cases of straightforward allergic rhinitis, consider consultation with an allergist or immunologist for severe disease, poor response to pharmacotherapy, and the presence of comorbid conditions or complications. Consultation with other specialists also might be needed for comorbid conditions or complications. Consult with an allergy specialist when identification or clarification of specific allergic triggers is needed, when detailed counseling regarding environmental control measures is needed, when quality of life is significantly impaired, or when immunotherapy may be a consideration.

Medication

Most cases of allergic rhinitis respond to pharmacotherapy. Patients with intermittent symptoms are often treated adequately with oral antihistamines, decongestants, or both as needed. Regular use of an intranasal steroid spray may be more appropriate for patients with chronic symptoms. Daily use of an antihistamine, decongestant, or both can be considered either instead of or in addition to nasal steroids. The newer, second-generation (ie, nonsedating) antihistamines are usually preferable to avoid sedation and other adverse effects associated with the older, first-generation antihistamines. Ocular antihistamine drops (for eye symptoms), intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short courses of oral corticosteroids (reserved for severe, acute episodes only) may also provide relief.

Drug Category: Second-generation antihistamines

Often referred to as the nonsedating antihistamines. They compete with histamine for histamine receptor type 1 (H1) receptor sites in the blood vessels, GI tract, and respiratory tract, which, in turn, inhibits physiologic effects that histamine normally induces at the H1 receptor sites. Some do not appear to produce clinically significant sedation at usual doses, while others have a low rate of sedation. Other adverse effects (eg, anticholinergic symptoms) are generally not observed.

All are efficacious in controlling symptoms of allergic rhinitis (ie, sneezing, rhinorrhea, itching) but do not significantly improve nasal congestion. For this reason, some second-generation antihistamines are available as combination preparations containing a decongestant. They are often preferred for first-line therapy of allergic rhinitis, especially for seasonal or episodic symptoms, because of their excellent efficacy and safety profile. They can be used prn or daily.

Topical azelastine is a nasal spray antihistamine that effectively reduces sneezing, itching, and rhinorrhea but also effectively reduces congestion. Used twice per day, especially when combined with a topical nasal corticosteroid, azelastine is effective at managing both allergic and nonallergic rhinitis.

The second-generation oral antihistamines currently available in the United States are cetirizine, desloratadine, fexofenadine, and loratadine. A limited number of studies comparing these agents suggest no major differences in efficacy. Only cetirizine causes drowsiness more frequently than placebo. Cetirizine, fexofenadine, and loratadine are also available in decongestant-containing preparations.