Treatment update: allergic rhinitis

In addition to the introduction of several new pharmacologic agents, two of the most significant recent developments in the management of allergic rhinitis have been the renewed emphasis on preventive measures, such as allergen avoidance and immunotherapy, and the importance of performing an accurate differential diagnosis of the disease. Recently, these evolving management trends were delineated in an algorithm proposed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, which suggests that an initial evaluation be performed by a primary care physician. Based on findings at the initial evaluation, the patient should be treated either empirically in the primary care setting or referred to an allergist-immunologist for consultation. The allergist uses an evidence-based therapeutic approach based on a differential diagnosis of the type of rhinitis, which uses information derived from a detailed medical history, physical examination of the airway, and ancillary tests, particularly skin tests. Rhinitis management by an allergist emphasizes a three-pronged approach that incorporates avoidance, immunotherapy, and pharmacologic therapy. However, because both avoidance and immunotherapy have their limitations, pharmacologic therapy remains the mainstay of rhinitis management, and allergists usually recommend that optimal first-line therapy be broad based and capable of safely alleviating the symptoms of both allergic and nonallergic disease. First generation oral antihistamines, topical corticosteroids and the topical antihistamine azelastine are the most broad-based treatments available. Second-generation oral antihistamines and leukotriene antagonists also are useful in treating allergic rhinitis.