Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.
Guideline summary
- Allergic rhinitis is a common illness.
- History and physical examination (H&P) is the starting point in establishing the diagnosis of rhinitis.
Introduction
Allergic rhinitis is a common illness affecting an estimated 30 to 60 million Americans and resulting in 10 million lost days of school or work each year. Often caused by pollen from trees, grass or weeds, it is most commonly known as hay fever. In temperate climates, hay fever subsides with the onset of cold weather. Perennial allergic rhinitis, however, occurs year-round and is caused by indoor allergens such as dust, mites, mold spores and animal dander. Other risk factors include: family history of atopy, serum immunoglobulin E (IgE) >100 international units (IU)/mL before age 6 years, higher socioeconomic status and presence of a positive allergy skin prick test (SPT).
Goals/desired outcomes
- Increase the use of prophylactic medications for patients with seasonal allergic rhinitis. One possible measurable result is the percentage of patients with seasonal allergic rhinitis prescribed prophylactic medication
- Decrease use of injectable corticosteroid therapy for patients with allergic rhinitis. One possible measurable result is the percentage of patients with allergic rhinitis being treated with injectable corticosteroids
Diagnosis
The history and physical (H&P) examination is the starting point in establishing the diagnosis of rhinitis. It is characterized by one or more of the following symptoms: nasal congestion, rhinorrhea (anterior and posterior), sneezing, and itching.
Rhinitis should first be classified by etiology as allergic or nonallergic and differentiated from other conditions that mimic symptoms of rhinitis. Episodic allergic rhinitis is a new rhinitis category that expresses allergic nasal symptoms elicited from sporadic exposure to inhalant aeroallergens. Mixed rhinitis (combined allergic and nonallergic rhinitis) is found in approximately 44 percent to 87 percent of allergic rhinitis patients and is more common than either only allergic rhinitis or nonallergic rhinitis.
Evaluation
A patient’s history should include evaluation of the quality of life and specific factors that would define the classification of the rhinitis. The physical exam should include ears, eyes, nose, and mouth. Nasal cytology may be valuable to differentiate allergic rhinitis or nonallergic rhinitis eosinophilia syndrome (NARES) from nonallergic rhinitis. Other effective evaluations include: a determination of the pattern, chronicity, and seasonality of nasal and related symptoms (or lack thereof), response to medications, presence of coexisting conditions, occupational exposure and a detailed environmental history and identification of precipitating factors.
Table 4 shows appropriate physical examination procedures for patients presenting with symptoms compatible with rhinitis.
Consultation
Consultation is most appropriate for patients with severe or atypical symptoms and those who are not responding as expected to appropriate medical care. Results of consultation with an ENT or allergist may further define the classification and rule out polyps and other nasal pathology. Allergists also may conduct skin testing to better define potential specific allergens.
Treatment summary
- Avoidance of triggers is the best treatment for any allergy
- Pharmacologic management:
- Nasal steroids
- Oral antihistamines
- Intranasal antihistamines
Treatment
Avoidance of triggers is the best treatment for any allergy whenever possible. Controls and specific treatments based on the patient's classification should include an avoidance of inciting factors (dust, carpets, pollen, etc.) and the treatment of infections as obvious first steps in effective management prior to using medication specifically targeting rhinitis.
Pharmacological management/chronic and first-line medications
Nasal steroids
These agents are recommended as first-line therapy for both allergic and nonallergic rhinitis that is chronic, frequently recurrent, and which have a significant influence on the patient’s quality of life. It takes several days for the nasal steroids to reach maximum effect. They are administered on a continuous regimen and should not be used as a rescue medication. The importance of the delay in effectiveness should be stressed to the patient.
Oral antihistamines
Non-sedating oral antihistamines may be used as first-line therapy or in conjunction with other agents.
Intranasal antihistamines
Intranasal antihistamine may be useful as first-line treatment particularly for mild and intermittent symptoms. It does not reduce nasal congestion. The medication has a bitter taste; there may be significant systemic absorption that can result in sedation.
Alternative and acute medications
Oral decongestants
These medications may be used for acute symptoms or in combination with first-line medication. Use should be limited in patients with hypertension, angina pectoris and arrhythmia. Side effects may include insomnia and excessive nervousness.
Nasal decongestants
Topical sympathomimetics are useful for acute relief but should not be used for more than two to three days because of the potential rebound effect and exacerbation of nasal congestion.
Oral steroids
A short course of oral steroids is appropriate for severe or intractable nasal symptoms or significant nasal polyposis.
Intranasal cromolyn
Intranasal cromolyn is effective in some patients in controlling allergic rhinitis and can be used as first-line or adjuvant therapy.
Intranasal anticholinergics
These agents may be used for acute relief of rhinorrhea. Intranasal anticholinergics do not reduce other symptoms. They would be second-line agents for select patients.
Oral anti-leukotrienes
In several studies, anti-leukotriene agents have been proven as effective as second-generation antihistamines for treating symptoms of allergic rhinitis. They may not be as helpful as intranasal corticosteroids.
Allergen immunotherapy
Allergen immunotherapy is a treatment option for selected patients with allergic rhinitis. The decision to use immunotherapy should be based on the severity of symptoms and the response to other medications.
Sedating antihistamines
Sedating antihistamines may be used for relief of acute symptoms. Chronic use may influence performance. Recent studies suggest that first generation (sedating) antihistamines can cause impaired performance even when a patient is unaware of sedation. Sedating antihistamines are not recommended for children and adults who drive or participate in activities required to be performed at an alert functional level. The sedative effect can last up to 24 hours. Antihistamines are effective for most allergic symptoms but have little objective effect on nasal congestion.
The Medications Table shows the recommended medications for use in the treatment of rhinitis. These medications are preferred agents on the HMSA Select formulary and on the formulary for HMSA QUEST.
Additional reference documents
Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.
Sources
-
Institute for Clinical Systems Improvement. (2004). Diagnosis and Treatment of Respiratory Illness in Children and Adults (Guideline).
Copyright 2004. Institute for Clinical Systems Improvement. Used with permission.
- Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Kahn DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA, Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology. (2008). The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol, 122(2 Suppl):S1-84.
References
- Dykewicz MS, Fineman S, Skoner DP. (1998). Joint task force summary statements on diagnosis and management of rhinitis. Ann Allergy Asthma Immunol, 81:474-77.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |