Rhinitis Treatment Care

There is significant overlap in the pharmacologic treatment of allergic and non-allergic rhinitis. While the treatment of non-allergic rhinitis is almost solely with medications, successful treatment of allergic rhinitis can also involve allergen avoidance and immunotherapy.

Treatment With Medications

1. Oral antihistamines are often used as first line therapy in patients with rhinitic symptoms. The use of these H1 receptor antagonists had long been limited due to sedating side effects; however the newer second-generation drugs are extremely safe and efficacious with far less sedation. These drugs block the effects of released histamine that is present in high concentrations during allergic reactions. Oral non-sedating antihistamines are most beneficial for the suppression of nasal pruritus, sneezing, rhinorrhea, and accompanying ocular symptoms. These drugs have some, but limited effects on congestion. Because of their lack of decongestant properties, and the fact that histamine is rarely involved in non-allergic rhinitis, oral antihistamines are of little benefit in treating this disorder. Some older, sedating antihistamines do have drying properties that can have additive benefit in treating rhinorhhea and postnasal drip.
2. The intranasal antihistamine azelastine is not only indicated for allergic rhinitis but also is effective in treating non-allergic rhinitis. In allergic rhinitis, it works similarly to oral antihistamines, blocking the histamine receptor and thus decreasing rhinorrhea, itch, and sneeze. Azelastine is also effective at reducing congestion, probably because topical application places a much higher concentration of antihistamine on the nasal mucosa than is possible with oral antihistamines. In non-allergic rhinitis, azelastine likely acts by both anti-inflammatory activity and neuropetide depletion. Because of the efficacy of topical treatment in rhinitis, there is a move towards using more topical medications such as azelastine and nasal corticosteroids whenever possible, rather than oral systemic medications.
3. Nasal corticosteroids are the mainstay of therapy for both non-allergic and allergic rhinitis. With potent but local anti-inflammatory effects, they are efficacious in treating most rhinitis syndromes regardless of etiology. By decreasing inflammation, nasal corticosteroids decrease mucosal edema and vascular leak improving the symptoms of rhinorrhea and nasal congestion. They also decrease the number of histamine containing mast cells in the nasal mucosa, thus decreasing nasal pruritus and sneezing. Nasal corticosteroids are extremely safe, well tolerated and systemic steroid effects are rare. The most frequent side effects are local irritation and epistaxis, both of which can typically be lessened by utilizing proper spray technique and thus avoiding the nasal septum. Perhaps the greatest difficulty with this class of medication is patient compliance. As it typically takes 1 to 2 weeks of constant use to achieve maximum relief, and nasal corticosteroids frequently are needed chronically, educating the patient of their prophylactic benefits is necessary. Using both nasal corticosteroids and antihistamines (either oral or topical) in combination is almost certain to effectively treat either allergic or non-allergic rhinitis symptoms.
4. Intranasal cromolyn sodium is a mast cell stabilizer indicated for allergic rhinitis. Like nasal corticosteroids, this drug must be used prophylactically and has no beneficial effect on relieving symptoms that are already present. This drug prevents the release of histamine from mast cells and thus primarily prevents sneezing, itch and rhinorrhea. Though it has an unsurpassed safety profile, cromolyn has fallen out of favor because in order to achieve significant benefit it needs to be used 3 to 5 times per day.
5. Antileukotrienes (LTRA) are a relatively new class of medication. These drugs were originally indicated for asthma but have recently been approved in the United States for the treatment of allergic rhinitis. These medications block the effects of leukotrienes, inflammatory mediators produced through the arachadonic acid pathway. Antileukotrienes have been shown to decrease eosinophil counts and nitric oxide production from areas of allergic inflammation. The end result is nasal symptom relief similar to that of non-sedating anti-histamines with modestly decreased rhinorrhea, sneezing, and pruritus. Montelukast, the most commonly used LTRA, is extremely safe in both adults and children. It is well tolerated though not nearly as efficacious as nasal corticosteroids.
6. Oral decongestants can be beneficial in the treatment of congestion associated with both allergic and non-allergic rhinitis; but can have undesirable side effects. Oral pseudoephedrine hydrochloride used alone or in combination with antihistamines is the most common decongestant. Pseudoephedrine is a sympathomimetic agent that causes vasoconstriction of the superficial blood vessels in the nasal mucosa, as well in other areas of the body. This action decreases swelling of the mucosal tissue and decreases vascular leak improving both rhinorrhea and nasal congestion. Because it is not mediator specific, decongestants can be used in both allergic and non-allergic rhinitis. Unfortunately, tolerance of pseudoephedrine is variable. Side effects include hypertension, nervousness, insomnia, irritability, urinary hesitancy and loss of appetite. It is contraindicated in patients with hypertension.
7. Topical decongestants can provide rapid temporary relief of nasal congestion in allergic and non-allergic rhinitis, however chronic use can lead to complications. They are best used for symptomatic relief of acute severe nasal congestion for very short periods of time. Like oral decongestants, these medications are sympathomimetic and have a similar side effect profile. However, chronic use for even relatively short periods of time (>3-7 days) can lead to rebound nasal congestion. More prolonged use can lead to rhinitis medicamentosa, rebound congestion with gross changes in the nasal mucosa. Both short-acting (phenylephrine hydrochloride) and long-acting (oxymetazoline) preparations are available.
8. Nasal ipratropium bromide is a topical anti-cholinergic spray that may be beneficial in certain patients with allergic and/or non-allergic rhinitis. As cholinergic stimulation can lead to rhinorrhea, this medication can be used to reduce rhiniorrhea in both rhinitis and colds. Ipratropium can be beneficial in patients with difficult to treat rhinorrhea but usually does not help postnasal drip.

Treatment With Allergen Avoidance and Immunotherapy

1. There are numerous non-pharmacologic measures that deserve consideration when treating rhinitis. Allergen avoidance can both reduce acute exacerbations and lessen the likelihood of a priming effect in patients with allergic rhinitis. Allergen avoidance is the first line of management for allergic rhinitis. Reducing the allergens in a patient’s immediate environment can have a significant impact on symptom frequency and severity. A range of measures can be employed, depending on the allergen involved. Aggressive cleaning of the home, effective filtering of the air, hot washing of bedding, replacement of carpets with hard flooring and regular wet-wiping of surfaces are general measures that eradicate most allergens. Allergen avoidance can only be attempted after skin testing or RAST has identified specific allergens.
2. Immunotherapy has been demonstrated to be extremely beneficial in selected patients with allergic rhinitis. Immunotherapy has no benefit for non-allergic rhinitis patients and thus it is important to distinguish these diseases before considering starting immunotherapy. Though poorly studied, nasal saline lavage has minor decongestant benefits and improves mucociliary function in both patients with allergic and non-allergic rhinitis. In patients where chronic sinusitis contributes to non-allergic rhinitic symptoms, antibiotics may be of benefit. Finally, for many of the underlying conditions contributing to non-allergic rhinitis, it is the treatment of that underlying condition which will be most helpful in alleviating rhinitis symptoms.