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First-line treatment of mild to moderate disease is intranasal corticosteroids, which is the most effective treatment available. For patients with moderate to severe allergic rhinitis refractory to intranasal corticosteroids, second-line treatments include antihistamines, decongestants, intranasal cromolyn, leukotriene receptor antagonists, intranasal anticholinergics, and nonpharmacologic interventions such as nasal irrigation.
Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
- For mild to moderate allergic rhinitis, an intranasal corticosteroid alone should be the initial treatment. For moderate to severe disease, second-line treatments should be used (level of evidence, A).
- Compared with first-generation antihistamines, second-generation antihistamines have less sedation and a better adverse effect profile (with the exception of cetirizine; level of evidence, A).
- As first-line or second-line therapy for allergic rhinitis, intranasal antihistamines are of limited use because of adverse effects, higher cost, and decreased efficacy vs intranasal corticosteroids (level of evidence, A).
- Intranasal cromolyn is safe for general use for allergic rhinitis, but it is not considered first-line treatment because of its lower efficacy for symptom relief and its inconvenient dosing schedule (level of evidence, C).
- The symptoms of chronic rhinorrhea may respond to nasal saline irrigation, which may be used alone or as adjuvant therapy (level of evidence, B).
- Despite the high prevalence of dust mite allergies, mite-proof impermeable mattress and pillow covers have not been shown to be effective against allergic rhinitis in any studies (level of evidence, A).
- Breast-feeding, delayed exposure to solid foods in infancy, and the use of air filtration systems have no documented efficacy in preventing allergic rhinitis (level of evidence, B).
“The International Primary Care Respiratory Group, British Society for Allergy and Clinical Immunology, and American Academy of Allergy Asthma and Immunology recommend initiating therapy with an intranasal corticosteroid alone for mild to moderate disease and using second-line therapies for moderate to severe disease,” the review authors conclude. “Patients with moderate to severe disease not responding to oral or topical treatments should be referred for consideration of immunotherapy.”
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