Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild or intermittent symptoms

1st line – intranasal corticosteroid

Back
ACUTE
|
mild or intermittent symptoms
1st line – 

intranasal corticosteroid

In patients with mild or intermittent symptoms, intranasal corticosteroids are a first-line treatment option.[67]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled.

Examples of suitable intranasal corticosteroids are provided here; however, this list is not exhaustive and many other options are available.

Primary options

beclomethasone dipropionate nasal: (42 micrograms/spray aqueous) children ≥6 years of age and adults: 42-84 micrograms (1-2 sprays) in each nostril twice daily

OR

budesonide nasal: (32 micrograms/spray) children ≥6 years of age: 32-64 micrograms (1-2 sprays) in each nostril once daily; children ≥12 years of age and adults: 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

fluticasone propionate nasal: (50 micrograms/spray) children ≥4 years of age and adults: 50-100 micrograms (1-2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) children ≥2 years of age: 50 micrograms (1 spray) in each nostril once daily; children ≥12 years of age and adults: 100 micrograms (2 sprays) in each nostril once daily

Plus – allergen avoidance

Back
ACUTE
|
mild or intermittent symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

1st line – oral antihistamine

Back
ACUTE
|
mild or intermittent symptoms
1st line – 

oral antihistamine

In patients with mild or intermittent symptoms, a nonsedating antihistamine is a first-line treatment option.[67]

Monotherapy with an intranasal corticosteroid is generally recommended because oral antihistamines are less effective.[67][81] However, many patients may prefer oral drugs. 

Oral antihistamines are effective for rhinorrhea, sneezing, and itching, but have only a modest effect on nasal congestion.[52] Cetirizine, a second-generation antihistamine, has been found to be particularly effective in AR, but may cause some mild sedation.[82] Second-generation oral antihistamines are preferred to first-generation agents because they cause less sedation, dizziness, and incoordination.[3]

Paradoxical hyperactivity with use of sedating antihistamines has been reported, particularly in children.[83]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67]

Primary options

cetirizine: children ≥6 months of age: 2.5 to 5 mg orally once daily when required; children ≥6 years of age and adults: 5-10 mg orally once daily when required

OR

desloratadine: children ≥6 months of age: 1 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 5 mg orally once daily when required

OR

fexofenadine: children ≥2 years of age: 30 mg orally twice daily when required; children ≥12 years of age and adults: 60 mg orally twice daily or 180 mg once daily when required

OR

levocetirizine: children ≥6 months of age: 1.25 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 2.5 to 5 mg orally once daily when required

OR

loratadine: children ≥2 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

Plus – allergen avoidance

Back
ACUTE
|
mild or intermittent symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

1st line – intranasal antihistamine

Back
ACUTE
|
mild or intermittent symptoms
1st line – 

intranasal antihistamine

Intranasal antihistamines (e.g., azelastine, olopatadine) are another first-line option when symptoms are intermittent and do not require daily medication.[3]

Intranasal antihistamines are particularly effective for rhinorrhea and nasal congestion, but they do not improve symptoms at non-nasal sites.[53] They have a fast onset of action after initial dosing (usually 15-30 minutes, and no later than 3 hours) and are effective over a 12-hour period.[3][67]

Intranasal antihistamines may cause sedation.

Primary options

azelastine nasal: (137 micrograms/spray) children ≥5 years of age: 137 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 137-274 micrograms (1-2 sprays) in each nostril twice daily; (205.5 micrograms/spray) children ≥6 years of age: 205.5 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 205.5 to 411 micrograms (1-2 sprays) in each nostril once to twice daily

OR

olopatadine nasal: (665 micrograms/spray) children ≥6 years of age: 665 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 1330 micrograms (2 sprays) in each nostril twice daily

Plus – allergen avoidance

Back
ACUTE
|
mild or intermittent symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

2nd line – alternative first-line monotherapy or combination therapy

Back
ACUTE
|
mild or intermittent symptoms
2nd line – 

alternative first-line monotherapy or combination therapy

The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5-7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[67]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.

Plus – allergen avoidance

Back
ACUTE
|
mild or intermittent symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

persistent and moderate to severe symptoms

1st line – intranasal corticosteroid

Back
ACUTE
|
persistent and moderate to severe symptoms
1st line – 

intranasal corticosteroid

Intranasal corticosteroids should be the first consideration if symptoms are persistent and moderate or severe.[3] They may provide additional benefit in reducing AR-associated ocular symptoms.[84][85]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled.

Examples of suitable intranasal corticosteroids are provided here; however, this list is not exhaustive and many other options are available.

Primary options

beclomethasone dipropionate nasal: (42 micrograms/spray aqueous) children ≥6 years of age and adults: 42-84 micrograms (1-2 sprays) in each nostril twice daily

OR

budesonide nasal: (32 micrograms/spray) children ≥6 years of age: 32-64 micrograms (1-2 sprays) in each nostril once daily; children ≥12 years of age and adults: 32-128 micrograms (1-4 sprays) in each nostril once daily

OR

fluticasone propionate nasal: (50 micrograms/spray) children ≥4 years of age and adults: 50-100 micrograms (1-2 sprays) in each nostril once daily

OR

mometasone nasal: (50 micrograms/spray) children ≥2 years of age: 50 micrograms (1 spray) in each nostril once daily; children ≥12 years of age and adults: 100 micrograms (2 sprays) in each nostril once daily

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

1st line – oral antihistamine

Back
ACUTE
|
persistent and moderate to severe symptoms
1st line – 

oral antihistamine

Oral antihistamines are a first-line option if symptoms are persistent and moderate or severe.

Monotherapy with an intranasal corticosteroid is generally recommended because oral antihistamines are less effective.[67][81] However, many patients may prefer oral drugs.

Oral antihistamines are effective for rhinorrhea, sneezing, and itching, but have only a modest effect on nasal congestion.[52] Cetirizine, a second-generation antihistamine, has been found to be particularly effective in AR, but may cause some mild sedation.[82] Second-generation oral antihistamines are preferred to first-generation agents because they cause less sedation, dizziness, and incoordination.[3]

Paradoxical hyperactivity with use of sedating antihistamines has been reported, particularly in children.[83]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67]

Primary options

cetirizine: children ≥6 months of age: 2.5 to 5 mg orally once daily when required; children ≥6 years of age and adults: 5-10 mg orally once daily when required

OR

desloratadine: children ≥6 months of age: 1 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 5 mg orally once daily when required

OR

fexofenadine: children ≥2 years of age: 30 mg orally twice daily when required; children ≥12 years of age and adults: 60 mg orally twice daily or 180 mg once daily when required

OR

levocetirizine: children ≥6 months of age: 1.25 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 2.5 to 5 mg orally once daily when required

OR

loratadine: children ≥2 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

1st line – intranasal antihistamine

Back
ACUTE
|
persistent and moderate to severe symptoms
1st line – 

intranasal antihistamine

Intranasal antihistamines (e.g., azelastine, olopatadine) are particularly effective for rhinorrhea and nasal congestion, but they do not improve symptoms at non-nasal sites.[53] They have a fast onset of action after initial dosing (usually 15-30 minutes, and no later than 3 hours) and are effective over a 12-hour period.[3][67]

Intranasal antihistamines may cause sedation.

Primary options

azelastine nasal: (137 micrograms/spray) children ≥5 years of age: 137 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 137-274 micrograms (1-2 sprays) in each nostril twice daily; (205.5 micrograms/spray) children ≥6 years of age: 205.5 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 205.5 to 411 micrograms (1-2 sprays) in each nostril once to twice daily

OR

olopatadine nasal: (665 micrograms/spray) children ≥6 years of age: 665 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 1330 micrograms (2 sprays) in each nostril twice daily

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

2nd line – alternative first-line monotherapy or combination therapy

Back
ACUTE
|
persistent and moderate to severe symptoms
2nd line – 

alternative first-line monotherapy or combination therapy

The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5-7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[67]

When symptoms improve, decreasing or discontinuing treatment may be considered.[3][67] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

3rd line – sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)

Back
ACUTE
|
persistent and moderate to severe symptoms
3rd line – 

sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)

Immunotherapy is the only treatment modality to potentially have a disease-modifying effect.[101] It should be targeted to include allergens that are clinically relevant to both the patient and the geographic locale.

Immunotherapy may be offered by an allergy specialist (through a shared decision-making model) to a patient who remains symptomatic despite allergen avoidance measures and pharmacotherapy.[3] Immunotherapy is also commonly used by patients either unwilling to take or unable to tolerate medications.[3]

SLIT is effective in treating AR in both adults and children.[87][89][90][91][92][93] [ Cochrane Clinical Answers logo ] It is considered to be safer than SCIT because adverse effects are usually limited to mucosal symptoms, and it is easier to administer (patient self-administers). However, SLIT may be less effective than SCIT.[93]

SLIT is more appropriately used in monosensitized patients, especially those sensitized to dust mites, grass, or ragweed.[96][97][98][99][100] For polysensitized patients, SLIT with multiple allergens is sometimes employed, although no commercially available formulation containing more than one allergen currently exists.

SLIT formulations can be employed in two different manners. One involves taking SLIT for approximately 12 weeks before and throughout the pollen season, stopping thereafter. Alternatively, SLIT can be taken daily for 3 years to provide a sustained effect for a fourth year, even after discontinuation.[101][102]

SCIT is used less frequently than SLIT. Improvement requires several months of treatment. It is generally accepted that a 1-year trial will determine who will and who will not respond to SCIT.

Local and systemic reactions to SCIT may occur.[103][104] Systemic reactions can vary from mild to life-threatening; fatal reactions after receiving an allergy vaccine are estimated to occur at a rate of 1 in 2 to 2.5 million injections.[105][106] SCIT may reduce the progression from AR to asthma when given in children ages 6 to 14 years for a minimum of 3 years.[88] Various extract manufacturers and dosing regimens exist for SCIT.

Primary options

house dust mite allergen extract: consult specialist for guidance on sublingual dose

OR

mixed grass pollens allergen extract: consult specialist for guidance on sublingual dose

OR

timothy grass pollen allergen extract: consult specialist for guidance on sublingual dose

OR

short ragweed pollen allergen extract: consult specialist for guidance on sublingual dose

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

4th line – oral corticosteroid

Back
ACUTE
|
persistent and moderate to severe symptoms
4th line – 

oral corticosteroid

If immunotherapy is not available or there is a significant wait, a short course (7 days) of an oral corticosteroid may also be considered if symptoms are severe.[67]

Primary options

prednisone: 5-60 mg/day orally

Plus – allergen avoidance

Back
ACUTE
|
persistent and moderate to severe symptoms
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.

ONGOING

usual therapy ineffective or poorly tolerated

1st line – sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)

Back
ONGOING
|
usual therapy ineffective or poorly tolerated
1st line – 

sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)

Immunotherapy is the only treatment modality to potentially have a disease-modifying effect.[101] It should be targeted to include allergens that are clinically relevant to both the patient and the geographic locale.

Immunotherapy may be offered by an allergy specialist (through a shared decision-making model) to a patient who remains symptomatic despite allergen avoidance measures and pharmacotherapy.[3] Immunotherapy is also commonly used by patients either unwilling to take or unable to tolerate medications.[3]

SLIT is effective in treating AR in adults and children.[87][89][90][91][92][93] [ Cochrane Clinical Answers logo ] It is considered to be safer than SCIT because adverse effects are usually limited to mucosal symptoms, and it is easier to administer (patient self-administers). However, SLIT may be less effective than SCIT.[93]

SLIT is more appropriately used in monosensitized patients, especially those sensitized to dust mites, grass, or ragweed.[96][97][98][99][100] For polysensitized patients, SLIT with multiple allergens is sometimes employed, although no commercially available formulation containing more than one allergen currently exists.

SLIT formulations can be employed in two different manners. One involves taking SLIT for approximately 12 weeks before and throughout the pollen season, stopping thereafter. Alternatively, SLIT can be taken daily for 3 years to provide a sustained effect for a fourth year, even after discontinuation.[101][102]

SCIT is used less frequently than SLIT. Improvement requires several months of treatment. It is generally accepted that a 1-year trial will determine who will and who will not respond to SCIT.

Local and systemic reactions to SCIT may occur.[103][104] Systemic reactions can vary from mild to life-threatening; fatal reactions after receiving an allergy vaccine are estimated to occur at a rate of 1 in 2 to 2.5 million injections.[105][106] SCIT may reduce the progression from AR to asthma when given in children ages 6 to 14 years for a minimum of 3 years.[88] Various extract manufacturers and dosing regimens exist for SCIT.

Primary options

house dust mite allergen extract: consult specialist for guidance on sublingual dose

OR

mixed grass pollens allergen extract: consult specialist for guidance on sublingual dose

OR

timothy grass pollen allergen extract: consult specialist for guidance on sublingual dose

OR

short ragweed pollen allergen extract: consult specialist for guidance on sublingual dose

Plus – allergen avoidance

Back
ONGOING
|
usual therapy ineffective or poorly tolerated
Plus – 

allergen avoidance

Treatment recommended for ALL patients in selected patient group

Allergen avoidance should be attempted by all patients with AR.

Allergy testing can be helpful in identifying the allergens of concern for a particular patient.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer