First-line treatments for allergic rhinitis in primary care include intranasal corticosteroids and antihistamines, which can be intranasal or oral non-sedating antihistamines, used either alone or in combination.
Intranasal corticosteroids, such as mometasone furoate, fluticasone furoate, or fluticasone propionate, are the most effective treatments and have minimal systemic absorption.
Intranasal antihistamines (e.g., azelastine) act faster but are less effective than intranasal corticosteroids.
The combination of an intranasal corticosteroid with an intranasal antihistamine is more effective than an intranasal corticosteroid alone, whereas combining an intranasal corticosteroid with an oral antihistamine does not increase effectiveness beyond the corticosteroid alone.
For mild or intermittent allergic rhinitis, children are suggested to use either intranasal or oral non-sedating antihistamines, and adolescents and adults may choose any first-line treatment option.
For moderate to severe or persistent allergic rhinitis, intranasal corticosteroids alone or combined with intranasal antihistamines are recommended.
Nasal drops may be preferred for patients with severe nasal obstruction.
Patients should be informed that intranasal corticosteroids take 6–8 hours to begin action but may require up to two weeks for maximal effect.
Regarding environmental controls and allergen avoidance:
- For pollen allergies: Avoid grassy/open areas during high pollen times, keep windows shut in cars/buildings, avoid drying washing outdoors when pollen counts are high, monitor pollen counts (e.g., via Met Office), shower after exposure, consider wraparound sunglasses or nasal barriers like masks or creams, and plan holidays outside pollen season if possible.
- For confirmed house dust mite allergy: Use impermeable covers on bedding, use synthetic pillows and acrylic duvets, wash bedding and soft toys weekly at high temperatures, avoid carpets by opting for wooden/hard floors, prefer blinds over curtains, and regularly clean surfaces with a damp cloth.
- For confirmed animal allergy: Ideally, do not allow animals indoors; if this is not possible, restrict animals to certain areas (like the kitchen) and wash animals and contact surfaces regularly.
- For occupational allergies: Avoid allergens completely if possible; if not, reduce exposure using personal protective equipment, ensure good ventilation, relocate to lower exposure areas, or use less hazardous substances.
Nasal irrigation with saline is also advised as a self-management strategy.
Drug treatment should continue while exposure to allergens persists, with restarting intranasal corticosteroids recommended two weeks prior to allergy season where exposure timing is known.