Alezastine is approved for individuals ≥5 years, and olopatadine is approved for individuals ≥6 years for the treatment of AR.16,22,23 A pediatric review article noted nasal antihistamine (azelastine) plus nasal fluticasone was more efficacious than NS alone.15
In children, weigh adverse effects of antihistamines against the general malaise caused by AR.3 Do not use first-generation antihistamines due to the sedation that may interfere with learning.15 Treatment with once-daily, long-acting antihistamines rather than multiple daily dosing may improve adherence in children.5 Continuous administration, rather than as needed, is optimal treatment in children.5 Cetirizine, loratadine, and levocetirizine have been studied and are effective and safe in children.3 Levocetirizine has proven safe and efficacious for children ≥2 years.24 Fexofenadine was found to be effective and safe for those ≥6 years.25
For children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones.4 Due to the safety of these agents, chromones may be used first, then antihistamines.4 Just as with nasal chromones, the need to use intraocular chromones 4 times daily may limit their use in children.4
Pregnant patients. Antihistamines do cross the placenta.5 Agents that appear to be safe for pregnant patients are chlorphenamine (first-generation), loratadine, and cetirizine.5
Leukotriene receptor antagonists: Always pair with antihistamines
As adjunctive therapy for additional symptom control, ARIA 2010 suggests oral leukotriene receptor antagonists for children and adults with seasonal AR, and for preschool children with persistent AR. These agents may also be helpful in children with concurrent asthma.15 Always pair leukotriene receptor antagonists with antihistamines. Montelukast is approved for seasonal AR in children ≥2 years and for frequent nonseasonal nasal or ocular AR symptoms in children ≥6 months.26
ARIA 2010 recommends against the use of oral leukotriene receptor antagonists in adults with persistent AR.4
Decongestants are for limited use only
For adults with severe nasal obstruction, ARIA 2010 suggests a short course (<5 days) of nasal decongestant along with other drugs.4 Limiting use of nasal decongestants to <10 days helps prevent rhinitis medicamentosa.5,27 BSACI notes nasal decongestants may be useful for eustachian tube dysfunction experienced aboard airplanes, for children with acute otitis media with middle ear pain, to relieve congestion after an upper respiratory infection, and to improve nasal patency before NS use.5 Both guidelines suggest against regular oral decongestant use.4,5
Avoid decongestants in pregnant patients.5 ARIA 2010 suggests against nasal decongestant use in preschool children.4
Chromones may help, but require multiple daily dosing
Chromones inhibit mast cell degranulation, are weakly effective for reducing nasal obstruction in AR, and have a high safety profile.3-5,28 As noted earlier, they must be used 4 times daily, which may reduce adherence—particularly in children.4
ARIA 2008 notes that disodium cromoglycate is less effective than NS or antihistamines.3 The 2010 update suggests nasal antihistamines over nasal chromones.4 For adults as well as children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones. BSACI recommends limited use of chromones for children and adults with mild symptoms.5
Nasal saline helpful as adjunct to medication
Nasal saline irrigation improves symptoms of AR, clears nasal passages, and is helpful for pregnant patients, for whom medications should be used with caution.2,3,5 Nasal irrigation using a neti pot or squeeze bottle is efficacious for chronic rhinorrhea, as solo or complementary treatment, and for children.5,16,27
Oral steroids: Use only rarely
ARIA 2010 suggests a short course of oral glucocorticosteroids for patients with AR and moderate to severe nasal or ocular symptoms not controlled with other treatments.4 BSACI notes oral steroids are rarely indicated, but that their use over 5 to 10 days may help with severe nasal congestion, symptoms uncontrolled by conventional pharmacotherapy, or before important social or work events.5 Both guidelines recommend against intramuscular steroids.4 ARIA 2008 notes oral and depot preparations of steroids affect growth in young children.3
Ipratropium when rhinorrhea is severe
Nasal ipratropium bromide, a topical anticholinergic, is helpful for excessive or refractory rhinorrhea. Consider using ipratropium with NS for patients for whom rhinorrhea is the dominant symptom.5,16,28 ARIA 2010 suggests using nasal ipratropium to treat rhinorrhea in patients with persistent AR.4
Allergen-specific immunotherapy: When other treatments fail
Allergen-specific immunotherapy (ASI) consists of repeated exposure to an allergen to induce immunomodulation, which prevents or reduces allergy symptoms and actually changes the natural course of AR. (For more on identifying the offending agent, see “Time for allergen testing?”2,5,15,18,29.) This treatment process decreases medication needs, prevents new allergen sensitization, and results in long-lasting improvement.2,5,6,30 BSACI 2011 notes that ASI is effective for adults and children with severe AR who do not respond to conventional pharmacotherapy and allergen avoidance measures.6