Allergic Rhinitis

Allergic rhinitis is common in primary care, affecting up to 20% of Americans. It can have a variable presentation with IgE-mediated symptoms including runny nose, congestion, sneezing, mucosal pruritus, postnasal drip, and conjunctival inflammation. Diagnosis is typically made on history and physical examination. At this initial stage, laboratory and/or imaging studies are not generally needed. Ruling out other etiologies with similar presentations is often challenging. Reassessment of alternative diagnoses is important when treatments are ineffective. When allergic rhinitis is mild, properly per -formed nasal saline rinses provide significant relief. In both mild and moderate-severe allergic rhinitis, first-line treatment with intranasal glucocorticoid sprays can provide symptom improvement. Educating patients in proper technique to administer nasal spray can optimize drug efficacy. An alternative treatment shown to provide benefit either as monotherapy or in combination with steroid nasal spray is a second-or third-generation antihistamine. First-generation antihistamines are not first-line op-tions because of potential side effects of sedation and urinary retention. Leukotriene receptor antagonists can reduce the inflammatory response in nasal and respiratory mucosa. These continue to be an option for adjunctive therapy in patients with asso-ciated asthma. When nasal steroid sprays and/or second-generation antihistamines are insufficient, and symptoms are at a level to create secondary effects (eg, fatigue, cognitive impairment, sleep disruption), allergen testing can be performed. Once trig-gering allergens are identified, desensitizing immunotherapy (allergy shots) can reduce symptom burden. At initiation of treatment, use of temporary symptom relief measures such as intranasal or systemic decongestants can provide benefit while waiting for intranasal glucocorticoids to become effective. In more severe presentations, a short, 5-to 7-day course of oral corticosteroids can be considered while waiting for first-line treatments to become therapeutic. A shared decision-making approach incorporating a risk-benefit discussion and patient education is advisable.