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Allergic rhinitis is a common and chronic immunoglobulin E–mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma.
Treatment should be based on the patient's age and severity of symptoms.
More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.
Use for more than three to five days is usually not recommended because patients may develop rhinitis medicamentosa, or may have rebound or recurring congestion.23 Oral decongestants may cause headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia; therefore, these medications should be used with caution in patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism.23Intranasal cromolyn is available over the counter and is thought to inhibit the degranulation of mast cells.1 Although safe for general use, it is not considered first-line therapy for allergic rhinitis because it is less effective than antihistamines and intranasal corticosteroids and is given three or four times daily.134Although evidence supports the use of intranasal ipratropium (Atrovent) for severe rhinorrhea, one study showed that it may also improve congestion and sneezing in children, but to a lesser extent than intranasal corticosteroids.35 Adverse effects include dryness of the nasal mucosa, epistaxis, and headache, and the recommended administration is two to three times daily.1The leukotriene D4 receptor antagonist montelukast (Singulair) is comparable to oral antihistamines but is less effective than intranasal corticosteroids.236 It may be particularly useful in patients with coexistent asthma because it reduces bronchospasm and attenuates the inflammatory response.2Although most patients should be treated with just one medication at a time, combination therapy is an option for patients with severe or persistent symptoms. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Sublingual immunotherapy with once-daily grass allergen tablets: a randomized controlled trial in seasonal allergic rhinoconjunctivitis.
For information about the SORT evidence rating system, go to https://org/afpsort Source: For more information on the Choosing Wisely Campaign, see
For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://org/afp/recommendations/Source: For more information on the Choosing Wisely Campaign, see
For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://org/afp/recommendations/Symptoms of allergic rhinitis are classified based on the temporal pattern (seasonal, perennial, or episodic), frequency, and severity.
Frequency can be divided into intermittent or persistent (more than four days per week and more than four weeks per year, respectively).