Kennebec Region Health Alliance

1. Avoidance of Triggers
   The most common allergic triggers for rhinitis include pollen, fungi, dust mites, animal dander and cockroach feces.
   Highly pollen allergic individuals should limit exposure to the outdoors when high pollen season counts are present.
   Reduction of indoor fungal exposure involves removal of moisture sources, replacement of contaminated materials, and the use of dilute bleach solutions on nonporous surfaces.
   Clinically effective dust mite avoidance requires humidity control, dust mite covers for bedding, and HEPA vacuuming of carpeting.
   Avoidance is the most effective way to manage animal sensitivity.
   The best treatment for rhinitis triggered by irritants, such as tobacco smoke and fragrances is avoidance.
2. If avoidance of triggers is not possible or does not work pharmacology therapy is then recommended.
   1. Oral Antihistamines
      Second or third generation oral Antihistamines such as Loratadine, Cetirizine, and Fexofenadine are preferred over first-generation Antihistamines for treatment of allergic rhinitis.
      Nonsedating antihistamines are Fexofenadine, Loratadine and Desoratadine.
   2. Intranasal Antihistamines
      Should be considered as first line treatment for allergic and nonallergic rhinitis.
      Equal or superior to oral second-generation antihistamines for treatment of seasonal allergic rhinitis.
      May cause sedation.
      Generally less effective than intranasal Steroids for treatment of allergic rhinitis.
   3. Oral Decongestants
      Pseudoephedrine is the only recommended over-the-counter decongestant. Phenylephrine is not efficacious.
   4. Topical Decongestants
      May be used for up to 5 days for temporary relief of congestion. Risk of rebound nasal congestion is minimal with short term use.
   5. Intranasal Steroids
      Intranasal Steroids are the most effective medication class for controlling symptoms of allergic rhinitis.
      Intranasal Steroids have been shown to be more effective than the combined use of Antihistamines and Leukotriene antagonists in treating seasonal allergic rhinitis.
      Intranasal Steroids can be drying to nasal passages and cause nasal bleeding. Instruct patients to spray them away from the nasal septum and to discontinue use of them if they have nasal bleeding.
   6. Oral Steroids
      A short course of oral Steroids 5-7 days, may be appropriate for severe or intractable nasal symptoms.
      Single administration of parenteral Corticosteroids is discouraged.
   7. Oral Leukotriene receptor antagonists
      The use of an antagonist, such as Montelukast, alone or in combination with Antihistamines has been proven to be useful in the treatment of allergic rhinitis.
   8. Nasal saline
      There is evidence that topical saline is beneficial in the treatment of chronic rhinorrhea and rhinosinusitis when used solely, or as an adjunct treatment.
3. Referral to allergy
   1. Patients are not receiving appropriate symptom control from a combination of the above therapies.
   2. They do not wish to take medications and would prefer immunotherapy.
   3. They wish to identify their allergens through further testing.

When making referral to allergist, please include any pertinent clinical information concerning possible allergy triggers as well as all previous therapies tried prior to referral.