allergy:clinical:allergic_rhinitis
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
Step 0 – Environmental Control
- Allergen avoidance (dust mites, pollen, pet dander)
- HEPA filtration
- Saline nasal irrigation
Step 1 – First-Line Therapy
Intranasal Corticosteroid (Most Effective Overall)
Best for: Nasal congestion, global symptom control Onset: Hours to days (max effect ~1–2 weeks)
Clinical Pearl:
- Congestion dominant → intranasal steroid > antihistamine
Step 2 – Add Symptom-Targeted Therapy
Oral Second-Generation H1 Antihistamine
Best for: Sneezing, itching, rhinorrhea Less effective for congestion
Intranasal Antihistamine
Step 3 – Combination Therapy
- Intranasal corticosteroid + intranasal antihistamine
- Combination spray:
Improves congestion and breakthrough symptoms.
Step 4 – Leukotriene Pathway (Selected Patients)
Consider when:
- Coexisting asthma
- Aspirin-exacerbated respiratory disease
- Cannot tolerate antihistamines
Note:
- Neuropsychiatric warning — counsel patients
Step 5 – Refractory Disease
- Allergy referral
- Allergen immunotherapy
- Evaluate for:
- Chronic sinusitis
- Nasal polyps
- Nonallergic rhinitis
Short-Term Decongestant Use (NOT Anti-Inflammatory)
Topical Alpha-1 Agonist (≤ 3 Days)
Oral Sympathomimetic
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
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.
allergy/clinical/allergic_rhinitis.txt · Last modified: by andrew2393cns