Treatment Guideline Chart
Allergic rhinitis is a symptomatic disorder of the nose secondary to IgE-mediated inflammation of the nasal membranes induced after exposure to allergens.
Major symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Other symptoms include headache, conjunctival symptoms, eye pruritus, impaired smell and morning cough.
Symptoms can reverse spontaneously with or without treatment.

Rhinitis%20-%20allergic Treatment

Principles of Therapy

  • Treatment of allergic rhinitis is based on the duration and severity of symptoms
  • A step-wise approach to treatment is recommended for adolescents and adults
  • Step down therapy as patient’s symptoms improve and step up when symptoms worsen
  • Similar therapeutic principles are applied in children; however, care should be taken to avoid the adverse effects of certain classes of drugs in the pediatric population
  • Drugs used for rhinitis are usually administered either orally or intranasally
  • Combination or step-up therapy is recommended for patients with disease progression after monotherapy or those with severe allergic rhinitis
    • Recommendations depend on the pattern of exposure to allergens
    • For patients with moderate to severe seasonal allergic rhinitis, the following principles are applied:
      • Combination therapy of an intranasal corticosteroid with an oral antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
      • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
      • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine is preferred over monotherapy with an intranasal histamine
      • Leukotriene receptor antagonist or an oral antihistamine: No specific preference
      • Intranasal antihistamine or an oral antihistamine: No specific preference
    • For patients with moderate to severe perennial allergic rhinitis, the following are recommended:
      • Monotherapy with intranasal corticosteroid preferred rather than the combination of an intranasal corticosteroid with an oral antihistamine
      • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with intranasal corticosteroid: No specific preference
      • Intranasal antihistamine or an oral antihistamine: No specific preference
    • Combination of intranasal antihistamine and intranasal steroid should be considered if antihistamine monotherapy, intranasal steroid monotherapy, or oral antihistamine and intranasal corticosteroid combination remains ineffective
    • For patients with persistent rhinorrhea on intranasal corticosteroid therapy, addition of intranasal Ipratropium may be considered



  • Eg Ipratropium bromide
  • Block the muscarinic receptors of the seromucinous glands
  • Effectively controls watery rhinorrhea but does not affect sneezing or nasal congestion, which precludes its use as a first-line medication
  • May be used together with intranasal corticosteroids or antihistamines in patients in whom rhinorrhea is the predominant symptom, or in whom rhinorrhea does not respond well to the other medications


  • H1-receptor antagonists reduce nasal itching, sneezing and rhinorrhea, but are less effective for nasal obstruction
  • First-line treatment for mild-moderate intermittent and mild persistent rhinitis
  • Added to intranasal corticosteroids for moderate-severe persistent rhinitis with eye symptoms uncontrolled by intranasal corticosteroid monotherapy

Nasal Antihistamines

  • Eg Azelastine, Levocabastine, Olopatadine
  • Rapid onset of action (<15-30 minutes)
  • Recommended in patients with seasonal, perennial, or episodic allergic rhinitis
  • Recommended first-line option for patients with intermittent allergic rhinitis
  • Preferred treatment for allergic rhinitis when compared to intranasal cromones
  • Associated with clinically significant effect on nasal congestion
  • Effective at the site of administration
  • May be used for mild, organ-limited disease or as an “as required” medication used together with a continuous one
  • As effective as oral antihistamines but require twice-daily dosing

Oral Antihistamines

  • Have the advantage of relieving other allergic symptoms of other sites (eg conjunctivitis) along with nasal symptoms
  • May be used to prevent symptoms associated with occasional allergy exposure
  • Preferred over leukotriene receptor antagonists (LTRA) in patients with moderate-severe perennial allergic rhinitis
  • Second generation antihistamines are preferred over intranasal antihistamines
  • Use of first generation antihistamines should be limited; may reduce academic ability in school children and may produce performance impairment in adults while driving
  • Onset of action occurs within 1 hour

Second Generation Oral Antihistamines

  • Eg Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, Mequitazine, Rupatadine
  • Should be considered as a first choice treatment
  • Preferred over first generation oral antihistamines
  • Have less undesirable CNS and fewer anticholinergic effects compared to first generation antihistamines
  • Have little or no sedative effect at the recommended dosages

First Generation Oral Antihistamines

  • Eg Chlorpheniramine, Clemastine, Diphenhydramine
  • Use is limited by sedative and anticholinergic side effects and short half-life
  • May further impair cognitive functioning and school performance in children

Intraocular Antihistamines

  • May be used in patients with symptoms of ocular involvement (eg conjunctivitis)

Anti-Immunoglobulin E Antibody

  • Eg Omalizumab
  • Has been shown to be effective in reducing nasal symptoms and improving quality of life in patients with seasonal allergic rhinitis


  • Have a strong anti-inflammatory capacity by reducing cytokine and chemokine release

Intranasal Corticosteroids

  • Eg Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
  • More efficacious than oral or topical nasal antihistamines in relieving symptoms of allergic rhinitis, especially nasal obstruction
  • Considered as first-line treatment in patients with moderate-severe and/or persistent symptoms
    • Preferred over intranasal and oral antihistamines in patients with moderate-severe perennial or seasonal allergic rhinitis
    • Monotherapy with intranasal steroids is preferred over combination with oral antihistamines for patients with perennial allergic rhinitis
    • Combination therapy with intranasal antihistamines is more effective than monotherapy with intranasal steroids in patients with moderate-severe disease
  • Onset of action takes a few hours (6-12 hours) to a few days, with maximum efficacy developing after 2 weeks
  • Aqueous preparations are preferred because they are less irritating to the nasal mucosa
  • Studies have shown reassuring safety data of Fluticasone, Mometasone and Ciclesonide use on long-term growth of children
    • Generally not associated with clinically significant systemic side effects if given in recommended doses 
  • In severe cases, nasal corticosteroids should be started 2 weeks before the start of the pollen season, then given regularly

Systemic Corticosteroids

  • May be used in rare conditions in severe patients unresponsive to other treatments and intolerant to intranasal corticosteroid
  • Prednisolone/Methylprednisolone should be administered in a short period of time (5-7 days)

Cromones (Nasal)

  • Less effective than antihistamines and intranasal corticosteroids
  • Compliance is often poor because of the need for frequent administration
  • May be considered in symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea) to be given prior to allergen exposure
    • Intraocular cromones may be considered for the management of ocular symptoms (eg conjunctivitis)
  • Excellent safety profile make it a suitable option for children and pregnant women


  • Promote vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa

Nasal Decongestants

  • Eg Oxymetazoline, Xylometazoline
  • Very effective in relieving nasal obstruction and rhinorrhea
  • Because of the risk of rebound vasodilation (rhinitis medicamentosa) and atrophic rhinitis with prolonged use, their use should be limited to 3-5 days
  • Short courses may be used to immediately reduce severe nasal obstruction while giving other medications for allergic rhinitis (eg intranasal corticosteroid-decongestant combination)
  • May be added to intranasal corticosteroid or intranasal corticosteroid/antihistamine combination therapy for 4 weeks in patients with persistent nasal congestion

Oral Decongestants

  • Eg Ephedrine, Pseudoephedrine
  • Weaker effect on nasal obstruction than topical preparations but do not cause rebound vasodilatation
  • Help relieve nasal obstruction, rhinorrhea and ocular symptoms
  • Use may be considered in patients with severe allergic rhinitis who are unresponsive to oral antihistamines and intranasal corticosteroids
  • Use should be limited due to known adverse effects (insomnia, agitation, palpitation)

Leukotriene Receptor Antagonists (LTRA)

  • Eg Montelukast, Pranlukast, Zafirlukast
  • Efficacy similar to oral antihistamines for patients with seasonal allergic rhinitis
  • Help relieve sneezing and rhinorrhea and reduce eosinophilic infiltration and nasal secretion
  • Therapeutic option used either alone or in combination with antihistamines; not to be used as initial therapy
    • Should only be considered in patients with treatment failure or intolerance to first-line therapy
  • Preferred in patients with coexisting asthma
    • There is a reduction in beta-agonist use with administration of Montelukast

Saline Solutions

  • May be used as single or adjunctive agents in reducing the symptoms of allergic rhinitis
  • There is no difference in radiologic or symptomatic score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance
Alternative Therapies
  • A variety of herbal preparations have been suggested for allergic rhinitis but there is minimal evidence supporting their efficacy
  • St John's wort may decrease effectiveness of antihistamines, while Echinacea purpurea may cause anaplylaxis in atopic patients

Non-Pharmacological Therapy

Allergen Avoidance

  • The first step to symptom control is identification and avoidance of the trigger allergens
  • Identifying specific causal allergens by skin testing or laboratory testing may encourage patients to comply with allergen avoidance instructions
  • Effectiveness of avoidance will be measured by relief of the patient’s symptoms and by a decrease in the need for medications
  • Elimination of the allergen results in diminished severity of the disease and decreased requirement for medications 
  • In the majority of cases, it is not possible to completely avoid allergens but these measures should be considered where appropriate

House Dust Mites

  • Major allergen found in houses
  • Wash sheets and blankets in hot water (60°C) every week
  • Use anti-mite covers in mattresses, beds and pillows
  • Vacuum-clean beds each week
  • For indoors, use of exhaust circulation-type cleaner is recommended
  • Clean furniture in the bedroom with damp rags


  • Avoid going outdoors on days when pollen counts are high
  • Wear a mask and use glasses during heavy pollen dispersal period
  • Avoid wearing woolen coats
  • Avoid activities which can increase exposure to allergens (eg mowing grass)
  • Shake the dust off (eg suit and hair) before entering the house
  • Shower after outdoor activities where pollen exposure is high
  • Keep doors and windows closed at home and when inside cars
  • Use air conditioning


  • Do not allow animals in the house
  • If this is not possible, exclude pets from bedroom or keep out of doors
  • Clean the rooms and improve the ventilation


  • Discourage smoking by patient (active smoking), household members and visitors (passive smoking)
  • Minimize contact with irritants (eg perfumes, hair spray and other odors, air pollution from traffic)
  • Reduce growth of molds in the home by decreasing humidity or dampness and eliminating sites for mold growth


  • Recommended for patients with moderate or severe persistent allergic rhinitis with inadequate response to usual pharmacologic therapy and allergen avoidance measures under the supervision of a specialist or allergist

Principles of Therapy

  • Repeated administration of specific allergens to patients with IgE-mediated conditions to provide protection against allergic symptoms associated with exposure to these allergens
    • Most effective if secondary to pollen, dust mites and animal dander; less effective if due to mold
  • Specific immunotherapy is effective when optimally administered
  • Only treatment that may cause long-term remission of rhinitis (3-5 years)
  • Initial dose should be performed in a medical facility by a trained personnel
  • Recommended course is usually 4-5 years
  • Immunotherapy may be given to children and adults who have the following factors:
    • Evidence of specific IgE antibody to allergen
    • Any of the following:
      • Patient’s preference
      • Adherence to therapy
      • Required medications
      • Adverse effects to medications
      • Poor response to avoidance measures
      • Prevention of asthma in allergic rhinitis patients
      • Clinically diagnosed with both allergic rhinitis and asthma

Subcutaneous Immunotherapy (SCIT)

  • Indications:
    • Inadequate control with medications
    • Patient refusal to receive pharmacotherapy or to undergo treatment on a long-term basis
    • Intolerable or unacceptable adverse effects from medications
  • Should be considered in patients with seasonal allergic rhinitis due to pollens and perennial allergic rhinitis triggered by house dust mites
  • Efficacy for allergic rhinitis is comparable to that of nasal glucocorticoids 
  • Limited by frequent injections on regular basis and small risk of anaphylactic reaction

Sublingual Immunotherapy (SLIT)

  • Should be considered in patients with allergic rhinitis triggered by house dust mites and grass or ragweed pollen, regardless if patient has asthma 
  • A more viable treatment compared to SCIT as self-administration is encouraged with this form
  • Use should be limited to those who can tolerate systemic reactions and its treatment
  • Has been associated with mild oral and gastrointestinal symptoms and less risk for anaphylaxis compared to SCIT
Editor's Recommendations
Special Reports