• An inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens.
  • Mediated by immunoglobulin E (IgE). Exposure to allergens results in the release of histamine and other inflammatory agents from mast cells.
  • Rhinitis occurs in up to 40% of the population. Lifetime prevalence of allergic rhinitis in the adult population is 10 to 30%. Some studies suggest the incidence is increasing.
  • Genetic predisposition; children have a 30% chance of developing allergic rhinitis if 1 parent is affected and a 50% chance if both are affected.
  • Often associated with asthma, atopic dermatitis, allergic conjunctivitis, nasal polyps, sinusitis & sleep apnea. 
  • Initial presentation of AR or exacerbation of pre-existing AR symptoms occurs commonly in pregnancy. It may also be rhinitis of pregnancy due to hormones (non allergic).
  • Common allergens: Seasonal - pollens, molds; Perennial: house dust mite, pets.
  • Can significantly impair quality of life. Symptoms can interfere with work and school performance, cause absenteeism and even traffic accidents. 
  • Classification based on symptom frequency/duration and severity, and the effect on the following:
    • Sleep
    • Impairment of daily activities, sport, leisure
    • Impairment of work and school
    • Troublesome symptoms
  1. Frequency/Duration of symptoms
        Intermittent: symptoms up to 4 days per week or for less than 4 consecutive weeks.
        Persistent:  symptoms on more than 4 days per week or for more than 4 consecutive weeks.
  2. Severity/Effect
        Mild: symptoms are present but do not interfere with normal daily activities (work, school, leisure) or sleep.
        Moderate to Severe: symptoms are very bothersome, interfere significantly in performance of normal daily activities and disturb sleep.
  • Early phase:
    • Rhinorrhea - discharge usually clear and watery
    • Sneezing
    • Itching - nose, eyes and throat
    • Minor congestion

  • Late phase:
    • Major congestion
    • Early phase symptoms 
  • Allergic salute is a sign more commonly seen in children (hand frequently wipes the nose in an upward motion).
  • Allergic shiners (dark circles under the eyes that are due to nasal congestion).

AR is diagnosed based on the presence of typical symptoms (listed above). Rule out the following conditions that may present with similar signs/symptoms:

Hypersensitivity reaction:

  • Rapid onset (within hours)
  • Anaphylaxis - symptoms associated with difficulty breathing, difficulty swallowing, swelling of face, mouth or throat.
  • Ensure patient receives medical attention immediately.

Infective rhinitis: colds, influenza, sinusitis

  • Rapid onset, short duration
  • Sudden onset, duration 1 week or less, associated with upper respiratory tract infection symptoms such as fever, purulent nasal discharge, swollen glands which are not typical of AR. Other distinguishing features of AR are itchiness (throat, eyes) and persistent symptoms.
  • Recommend appropriate nonpharmacological, and/or over-the-counter treatment.

Irritant (non-allergic, vasomotor) rhinitis:

  • Symptoms follow a known physical or chemical irritant - change in temperature, humidity; exercise; exposure to chemicals, odours. Patient history is important in differentiating irritant and allergic rhinitis because symptoms are similar.
  • Identify irritant and avoid when possible.

Drug-induced rhinitis:

  • AR symptoms following start of treatment with drugs such as angiotensin-converting enzyme inhibitors, methyldopa, alpha-blockers, beta-blockers, chlorpromazine, nonsteroidal anti-inflammatory drugs (including ASA).
  • Rebound symptoms after discontinuing use of nasal decongestants (for longer than 3-5 days).
  • Can medication be changed /discontinued?
Hormonal rhinitis:
  • AR symptoms coinciding with pregnancy, starting oral contraceptives or thyroid dysfunction (hypo or hyper).

Occupational rhinitis:

  • Intermittent or persistent symptoms including sneezing, itchiness, limited airflow & hypersecretion.

  • Symptoms are due to stimuli encountered in a particular work environment  ie/ farmers, veterinarians, manufacturing professions, laboratory workers, etc.

  • Usually develops within first 2 years of employment.

Structural or mechanical factors:

  • Deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy.
  • Foreign bodies and nasal tumours (rare) suggested by unilateral symptoms (only one nostril involved).

Systemic conditions:

  • Primary defects in mucus (e.g. cystic fibrosis), primary ciliary dyskinesia (Kartagener's syndrome), and granulomatous disease (e.g. Wegener's granulomatosis, sarcoidosis).

Patients with typical symptoms of AR often do not require further investigation, however, an assessment by the patient's primary care provider should be recommended in the following situations:

  • Children with moderate to severe symptoms – immunotherapy may alter progression of allergies, and may prevent subsequent asthma.
  • Patient is interested in allergy testing and/or immunotherapy.
  • Pregnancy (since the symptoms could be due to hormonal rhinitis, rather than allergic rhinitis)
  • Co-morbidities - uncontrolled asthma, recurrent or chronic sinusitis, otitis media. (treatment plan may be different in these patients)
  • Shortness of breath, wheezing (uncontrolled asthma).
  • Symptoms primarily unilateral nasal symptoms (polyps, foreign body, structural problem, etc.).
  • Suspected adverse effect of a prescription medication.
  • Pain in eyes (infection, iritis, etc.).
  • Persistent headache, facial pain (sinusitis, etc.).

 Non-pharmacological treatment

  • The goal of treatment is symptom relief
  • Patient education regarding allergen and irritant avoidance is considered 1st line non-pharmacological treatment:
    • Keep windows closed & use air conditioning
    • Remove dusty furniture
    • Use hypo-allergenic mattress covers
    • Use a dehumidifier
    • Avoid tobacco smoke
    • Keep pets out of bedrooms, or remove the pet
  • Saline rinses
    • Symptomatic relief by washing out mucus & allergens
    • Adherence difficult
    • Only distilled or boiled/cooled water should be used
    • System must be regularly cleaned
  • Saline sprays and drops
    • Shown to reduce symptoms & the need for pharmacological therapy in children and non pregnant adults
    • Recommended for children <6 years old to clear nasal passages (decongestants are not indicated) 
    • Reduces irritation
    • Preferred initial therapy in pregnancy, during breastfeeding, or patients with comorbidities

Over-The-Counter Drug Options

Oral antihistamines

  • Second generation antihistamines (ie/ cetirizine, loratadine, desloratadine & fexofenadine) are first line pharmacological therapy for mild, intermittent AR.
  • First generation antihistamines (ie/ diphenhydramine & chlorpheniramine) have limited roles due to their negative impact on cognition & functioning. 
  • Effective in reducing symptoms of itching, sneezing, and rhinorrhea.
  • First generation and older second generation antihistamines have little effect on nasal congestion. Fexofenadine, cetirizine and desloratadine have some decongestant activity, although only desloratadine has an actual indication. 
  • May also reduce symptoms of allergic conjunctivitis associated with AR.
  • Little or no benefit in other forms of rhinitis (e.g., vasomotor, infectious).
  • Effective on an as needed basis, but work best to control AR symptoms when taken regularly.
  • When exposure to an allergen is anticipated, antihistamines can be administered as prophylaxis prior to exposure.

Decongestants

  • Oral and nasal decongestants are effective in reducing AR-induced nasal congestion.
  • Can be used in combination with antihistamine and intranasal corticosteroids.
  • Long-term use may be required in AR, so intranasal decongestants are generally not recommended. If used, limit duration to 3-5 days to prevent rebound congestion.
  • Avoid use in children under 6 years old.

Intranasal corticosteroid

  • Triamcinolone acetate (Nasacort Allergy 24HR®) is available as an OTC preparation.
    • Dose: Two sprays in each nostril once daily 
      • Note: the OTC product is ONLY indicated for patients 12 years and older. A prescription is required for patients <12 years old.
  • Fluticasone Propionate (Flonase®)  is available as an OTC preparation.
    • Dose: Two sprays in each nostril once daily
    • Can use one spray in each nostril once daily once symptoms controlled.
      • Note: the OTC product is ONLY indicated for patients 18 years and older. A prescription is required for patients <18 years old.

Prescription Drug Options

Intranasal corticosteroids (INCS) (Table 1)

  • Note: Some Fluticasone propionate & Triamcinolone acetate products are now available OTC, and are not eligible for billing the assessment fee.
  • INCS fall under the MAC pricing policy of the Saskatchewan Drug Plan.
  • Drugs of choice for moderate to severe intermittent symptoms or mild persistent rhinitis.[Grade A recommendation (consistent high-quality evidence)].
  • Control the four major symptoms of AR- sneezing, itching, rhinorrhea and nasal congestion  - may also improve ocular symptoms.
  • Superior to oral and intranasal antihistamines, antileukotrienes and cromolyn in relieving AR symptoms.
  • A combination of oral antihistamine and INCS is needed in some patient with severe or resistant cases. There is insufficient evidence to support this combination, however, some patients may wish to try it. If no effect seen after a 2-4 week trial, it should be discontinued. 
  • Available prescription products: beclomethasone, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate, mometasone & triamcinolone. (See Table 1 below).
  • No evidence that any one agent is more effective than the other.
  • Considerations in choice of product:
    • aqueous solution provides better intranasal deposition than dry powder
    • patient preference for scented (formulations containing phenylethyl alcohol) versus non-scented products
    • newer products (ciclesonide, mometasone & fluticasone furoate) have a smaller spray volume
    • convenience of once daily dosing versus multiple daily doses
    • cost
    • pediatric dosing limits vary (See Table 1 below)
  • An unobstructed airway is necessary for optimal effect. Use of an intranasal decongestant spray prior to the intranasal corticosteroid for first 2–3 days of therapy may be recommended to improve deposition of the corticosteroid.
  • Prescribe maximum dose to start, then taper dose at intervals of one week to the lowest effect dose. Some patients can be adequately controlled with one dose every other day or as needed dosing.
  • Can be dosed "as needed" in seasonal AR but regular use is likely to provide better symptom relief.
  • Well tolerated: some nasal irritation or nose bleeds possible if spraying on septum. Educate patients on proper technique. Minor headache in some patients.
  • Pregnancy: Refer pregnant patients to their primary care provider. Note that INCS are not effective for hormonal rhinitis in pregnancy (nasal congestion without any signs of upper respiratory infection or known allergic cause). If the patient has previously diagnosed allergic rhinitis, treatment with antihistamines and/or intranasal corticosteroids is considered safe.
  • Lactation: Use of nasal corticosteroids while breastfeeding is considered acceptable.
  • Children: Mometasone or fluticasone propionate recommended because systemic absorption is minimal and there is no evidence of growth suppression with long-term use. Once daily dosing in the morning is preferred as this appears to reduce risk of growth suppression.

Other prescription drug options for AR (primary care provider prescription required)

  • Intranasal ipratropium - decreases rhinorrhea but little effect on congestion - may be useful for vasomotor rhinitis
  • Leukotriene receptor antagonists - montelukast has modest effect, approved for AR when other agents are ineffective or not tolerated
  • Intranasal and ocular antihistamines
  • Short course of prednisone for severe symptoms
  • Immunotherapy

TABLE 1: Intranasal Corticosteroids for Allergic Rhinitis

Drug

Adult Dose

Pediatric Dose

Beclomethasone
50 ug/spray 

2 sprays in each nostril BID

Max: 600 ug/day

> 6 yrs: As per adults

Max: 400 ug/day

Budesonide

Susp:64 ug/dose

       :100ug/dose


Pwdr: 100 ug/dose

Susp: 2 sprays in each nostril once daily or 1 spray in each nostril BID

Pwdr: 2 applications in each nostril AM or 1 application in each nostril BID

Max: 400 ug/day

> 6 yrs: As per adults

Ciclesonide
50 ug/spray

2 sprays in each nostril once daily 

Max: 200 ug/day

> 12 yrs: As per adults

Fluticasone furoate*
27.5 ug/spray

2 sprays in each nostril once daily

Max: 110 ug/day

> 12 yrs: As per adults

2–11 yrs: 1 spray in each nostril daily.     

Max: 110 ug/day

Fluticasone propionate ∅
50 ug/spray 

Note: OTC product is only for ≥ 18 yo ∇

2 sprays in each nostril once daily

Max: 400 ug/day

> 12 yrs: As per adults

4 - 11 yrs: 1-2 sprays in each nostril once daily.     

Max: 200 ug/day

Mometasone
50 ug/spray

2 sprays in each nostril once daily

Max: 800 ug/day

> 12 yrs: As per adults

3–11 yrs: 1 spray in each nostril once daily.

Triamcinolone ∅

55 ug/spray

Note: OTC product is only for ≥ 12 yo ∇

2 sprays in each nostril once daily

 

Max: 220 ug/day 

>12 yrs: As per adults

4-11 yrs: 1 spray in each nostril once daily.

Max: 220ug/day

 BID= twice daily

 

*Not a listed benefit of the Saskatchewan Drug Plan. Pharmacists may prescribe & assessment fee may be claimed.

∅ Not a listed benefit of the Saskatchewan Drug Plan. Pharmacists may prescribe but no fee can be claimed. 

 These products are OTC. If you choose this product for a patient, you cannot bill an assessment fee. 

Provide verbal and printed instructions on use of INCS:

  • Use of saline spray to clean nose prior to corticosteroid if the nose is crusted or contains mucus.
  • An unobstructed airway is necessary for optimal effect. Use of an intranasal decongestant spray prior to the intranasal corticosteroid for first 2–3 days of therapy may be recommended to improve deposition of the corticosteroid.
  • Gently shake the bottle prior to using. Many products require priming before first use & if they haven't been used in > 2 weeks. 
  • Spray should be directed away from the nasal septum to avoid irritation.
  • Sniff gently after spraying to pull it into the higher parts of the nose. Avoid a strong sniff as this will draw medication down into the throat.
  • Holding the other nostril closed with a finger may improve ability to draw the spray into the upper nose.
  • Spit out medicine that drains into the throat.

Assess benefit after 2 weeks

  • Symptomatic relief within 1-2 days; may take up to 2 weeks for maximum benefit. (For INCS)
  • If not effective
    • assess compliance and administration technique.
    • if being used appropriately refer to appropriate healthcare provider for further evaluation of condition.
  • If partially effective, consider adding antihistamine; reassess in 1 -2 weeks.
  • If symptoms are controlled, consider tapering to maintenance dose. If the patient requires year-round therapy, refer to their primary care provider.

Assess for adverse effects

  • Drowsiness (if using an antihistamine): Instruct patient to take at bedtime, or switch to less sedating agent, or switch to an INCS.
  • Frequent nose bleeds: ensure patient is directing spray away from septum.
  • Persistent nasal irritation: switch to a different INCS, or add a moisturizing nasal gel or spray.
  • Change in vision: refer to appropriate healthcare practitioner (glaucoma, cataracts).
Generic Name
Beclomethasone
50ug/dose AQUEOUS NASAL SPRAY
Budesonide
64ug/dose NASAL SPRAY
100ug/dose NASAL SPRAY
100ug/dose POWDER FOR INHALATION
Ciclesonide
50ug/dose METERED DOSE NASAL SPRAY
Fluticasone Furoate*
27.5ug/dose NASAL SPRAY
Fluticasone Propionate ∅
50ug/dose NASAL SPRAY    
(OTC only indicated in ≥ 18yo, otherwise RX) 
Mometasone Furoate 
50ug/dose AQUEOUS NASAL SPRAY
Triamcinolone Acetonide ∅
55ug/dose AQUEOUS NASAL SPRAY
(OTC product only indicated in ≥ 12 yo, otherwise Rx) 

*Not a listed benefit of the Saskatchewan Drug Plan. Pharmacists may prescribe & assessment fee may be claimed.

∅ Not a listed benefit of the Saskatchewan Drug Plan. Pharmacists may prescribe but no fee can be claimed. 

 These products are OTC. If you choose this product for a patient, you cannot bill an assessment fee.   

Reminder: INCS fall under the MAC pricing policy of the Saskatchewan Drug Plan.

  • pseudoDIN: 00951090
    • May bill 4 claims per 365 days per patient

  • May prescribe sufficient quantity for patient's allergy season (but only one assessment fee applicable).
    • Ensure patient is having adequate response before giving refills.
    • If the patient requires year-round therapy, must refer to their primary care provider.

  • Only products with an official indication from Health Canada for allergic rhinitis are considered for these guidelines. Only the active ingredients in the "products" section are approved for pharmacist prescribing
    • Note: Some Fluticasone propionate & Triamcinolone acetate products are now available OTC. You may prescribe these, however, they are not eligible for billing the assessment fee.
    • INCS fall under the MAC pricing policy of the Saskatchewan Drug Plan.
    • Fluticasone furoate is not a listed benefit of the Saskatchewan Drug Plan.
  1. Keith P. Allergic Rhinitis.  In RxTx - CTC online. Available at www.e-therapeutics.ca (by subscription).
  2. Kendrick J. Allergic Rhinitis. In RxTx - CTMA. Available at www.e-therapeutics.ca  (by subscription).
  3. Sheikh J. Allergic Rhinitis. In Emedicine. Available at  http://emedicine.medscape.com/article/134825-overview (free access).
  4. C-Health. Allergic Rhinitis Fact Sheet. Available at www.chealth.canoe.com (free access).
  5. Intranasal corticosteroids chart. RxFiles Charts. Available at www.rxfiles.ca .
  6. Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1-43. (American guidelines).  Available at http://www.ncbi.nlm.nih.gov/pubmed/25644617.
  7. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clinic Immunol  2008;122:S1-84  (American guidelines). Available at www.aaaai.org  (free access).
  8. deShazo R, Kemp S. Pharmacotherapy of allergic rhinitis. In UpToDate online. Available at  www.uptodate.com (by subscription).
  9. Allergic rhinitis. In Dynamed online. Available at www.dynamed.com (by subscription).
  10. Allergic Rhinitis Practical guide for allergy and immunology Canada 2018 Allergy, Asthma & Clinical Immunology. Available at https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0280-7

No part of this work may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the copyright holder. For copyright permission requests, please contact druginfo@usask.ca.

Prepared by medSask.
Reviewed by Dr. L. Sandomirsky, Family Physician and Dr. J. Taylor, Professor, College of Pharmacy and Nutrition,
Funded by the Saskatchewan College of Pharmacy Professionals
Posted May 2010, Updated May 2017