====== Allergic Rhinitis – Stepwise Therapy ======

**Definition:** IgE-mediated inflammation of the nasal mucosa triggered by environmental allergens.

Common symptoms:
  * Sneezing
  * Rhinorrhea
  * Nasal congestion
  * Nasal pruritus
  * Postnasal drip
  * Ocular itching/watering

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===== Step 0 – Environmental Control =====

  * Allergen avoidance (dust mites, pollen, pet dander)
  * HEPA filtration
  * Saline nasal irrigation

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===== Step 1 – First-Line Therapy =====

==== Intranasal Corticosteroid (Most Effective Overall) ====

  * [[endocrine:drugs:fluticasone|Fluticasone]]
  * [[endocrine:drugs:mometasone|Mometasone]]
  * [[endocrine:drugs:budesonide|Budesonide]]
  * [[endocrine:drugs:triamcinolone|Triamcinolone]]

**Best for:** Nasal congestion, global symptom control  
**Onset:** Hours to days (max effect ~1–2 weeks)

Clinical Pearl:
  * Congestion dominant → intranasal steroid > antihistamine

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===== Step 2 – Add Symptom-Targeted Therapy =====

==== Oral Second-Generation H1 Antihistamine ====

  * [[allergy:drugs:loratadine|Loratadine]]
  * [[allergy:drugs:cetirizine|Cetirizine]]
  * [[allergy:drugs:levocetirizine|Levocetirizine]]
  * [[allergy:drugs:fexofenadine|Fexofenadine]]
  * [[allergy:drugs:desloratadine|Desloratadine]]

**Best for:** Sneezing, itching, rhinorrhea  
Less effective for congestion

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==== Intranasal Antihistamine ====

  * [[allergy:drugs:azelastine|Azelastine]]
  * [[allergy:drugs:olopatadine|Olopatadine]]

Faster onset than oral agents  
Good for intermittent symptoms

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===== Step 3 – Combination Therapy =====

  * Intranasal corticosteroid + intranasal antihistamine
  * Combination spray:
      * [[endocrine:drugs:fluticasone|Fluticasone]] + [[allergy:drugs:azelastine|Azelastine]]

Improves congestion and breakthrough symptoms.

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===== Step 4 – Leukotriene Pathway (Selected Patients) =====

  * [[respiratory:drugs:montelukast|Montelukast]]

Consider when:
  * Coexisting asthma
  * Aspirin-exacerbated respiratory disease
  * Cannot tolerate antihistamines

Note:
  * Neuropsychiatric warning — counsel patients

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===== Step 5 – Refractory Disease =====

  * Allergy referral
  * Allergen immunotherapy
  * Evaluate for:
      * Chronic sinusitis
      * Nasal polyps
      * Nonallergic rhinitis

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===== Short-Term Decongestant Use (NOT Anti-Inflammatory) =====

==== Topical Alpha-1 Agonist (≤ 3 Days) ====

  * [[autonomics:adrenergic_agonists:phenylephrine|Phenylephrine]]
  * [[autonomics:adrenergic_agonists:oxymetazoline|Oxymetazoline]]

Risk: Rebound congestion (rhinitis medicamentosa)

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==== Oral Sympathomimetic ====

  * [[autonomics:adrenergic_agonists:pseudoephedrine|Pseudoephedrine]]

Caution:
  * Hypertension
  * CAD
  * BPH
  * Anxiety

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===== Treatment Summary =====

  * Mild intermittent → 2nd-gen H1 blocker
  * Persistent or congestion-predominant → Intranasal corticosteroid
  * Inadequate control → Add intranasal antihistamine
  * Asthma overlap → Consider montelukast
  * Refractory → Immunotherapy referral

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===== Board Pearls =====

  * Intranasal corticosteroids are superior to oral antihistamines for congestion.
  * 1st-generation antihistamines are not recommended due to sedation.
  * Montelukast is not first-line monotherapy.
  * Decongestants treat symptoms, not inflammation.