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Managing Seasonal Allergic Rhinitis with Medications

Information sourced from NEJM Journal Watch:

Managing Seasonal Allergic Rhinitis with Medications

Updated guidelines from the 2017 Joint Task Force on Practice Parameters recommend initial treatment with an intranasal corticosteroid alone.

Sponsoring Organizations: American Academy of Allergy, Asthma, and Immunology (AAAAI); American College of Allergy, Asthma, and Immunology (ACAAI)

Target Audience: Primary care providers, otolaryngologists, allergists, and pulmonologists


Seasonal allergic rhinitis affects as many as 14% of adults in the U.S. Most patients either self-treat or see primary care clinicians; only a minority of patients see allergists. Patients and physicians alike often express confusion about the best medication or combination of medications to use. This update of a 2008 guideline from the AAAAI and ACAAI provides specific guidance on pharmacologic treatment for seasonal allergic rhinitis, including for initial therapy.

Key Recommendations

  • For initial treatment in adolescents and adults (age, ≥12), monotherapy with an intranasal corticosteroid is preferred; combining it with an oral antihistamine confers no additional benefit.

  • For initial treatment in patients older than 14, an intranasal corticosteroid should be chosen over a leukotriene-receptor antagonist such as montelukast.

  • For moderate-to-severe allergic rhinitis, adding an intranasal antihistamine to an intranasal corticosteroid can be beneficial.


Patients tend to prefer oral medications over nasal sprays, but if an intranasal corticosteroid is used regularly, it is the most effective medication for addressing all allergic rhinitis symptoms, with no need to add an oral antihistamine. However, because many patients seem to feel better while taking oral antihistamines, I suggest using them only as needed and stressing daily use of their nasal steroid. For patients with mild nasal symptoms (especially mild itching, rhinorrhea, or sneezing) or systemic itching or urticaria, an oral antihistamine is appropriate first-line therapy. For patients whose allergic rhinitis is not controlled adequately with intranasal corticosteroids alone or who have severe symptoms and want quicker onset of action, intranasal antihistamines such as azelastine can be added to their nasal steroid, albeit at the expense of dysgeusia.

David J. Amrol, MD reviewing Wallace DV et al. Ann Intern Med 2017 Nov 28.


Wallace DV et al. Pharmacologic treatment of seasonal allergic rhinitis: Synopsis of guidance from the 2017 Joint Task Force on Practice Parameters. Ann Intern Med 2017 Nov 28; [e-pub].

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