Understanding the updated Allergic Rhinitis Guidelines 

By Purvi Parikh, MD

Short of living in a bubble, most people find exposure to environmental allergens extremely difficult to avoid, especially in the spring when pollen and mold spores swirl through the air and hitch rides into our homes on clothes and pets. To ease the resulting allergy symptoms, we often turn to medications. But which are most effective?

You can listen to ads on TV, read labels in the pharmacy or talk with your friends to help you decide – but physicians like to turn to what’s been proven in clinical studies. The difficulty there is keeping up with new developments, so periodically a team of experts evaluate recent research and summarize the results in published guidelines.

Comprehensive allergic rhinitis guidelines published 10 years ago were recently updated. The guidelines are written for doctors, but the findings are helpful for patients as well.

1 Corticosteroid nasal sprays are the first choice for treating allergic rhinitis and often give added relief to eye, throat and ear symptoms. They are extremely effective, widely available, relatively inexpensive and don’t have a lot of side effects. For best results, corticosteroid nasal sprays should be taken daily, beginning seven days before your allergy season begins and lasting throughout.

2 Patients who don’t find relief from a corticosteroid nasal spray may benefit from a antihistamine nasal spray, which works faster than oral antihistamines and treat sneezy, itchy, runny nose symptoms. The guidelines recommend using both corticosteroid and antihistamine nasal sprays over antihistamines alone, but this would be a cost-versus-benefit decision. You can take two separate nasal sprays or use a medication that combines both ingredients in one device.

3 For patients unable or unwilling to use a nasal spray, the next choice is a nondrowsy second-generation antihistamine: cetirizine (Zyrtec), levocetirizine (Xyzal), fexofenadine (Allegra) or loratadine (Claritin). These antihistamines cause fewer side effects such as drowsiness than first-generation diphenhydramine (Benadryl).

4 More is not better. For most people, there’s no extra benefit from taking an antihistamine pill along with a nasal spray, unless your doctor advises it.

5 Leukotriene modifiers, like montelukast (Singulair), are another option for those opposed to nasal sprays. The guidelines say corticosteroid nasal sprays are more effective, but some – especially those using montelukast for asthma – may find allergy relief. Talk with your doctor about montelukast’s side effects, which may include behavioral changes such as depression, mood swings and suicidal thoughts in some patients.

6 Intranasal cromolyn sodium is less effective than corticosteroid nasal sprays, but it can be useful for prevention and treatment of allergic rhinitis and is associated with minimal side effects.

7 Allergen immunotherapy should be considered for patients whose allergies have been identified. Allergy shots can build resistance to a wide range of allergens; in addition, immunotherapy tablets target grass, ragweed and dust mites. This is the closest thing we have to an allergy cure – immunotherapy helps decrease severity of symptoms by making your immune system less allergic.

If allergies are disrupting your life, it’s time to see a board-certified allergist and undergo testing to find out exactly what you’re allergic to and develop a long-term treatment plan.


Purvi Parikh, MD, is a board-certified allergist and immunologist in New York City. She is a member of the Board of Directors for the Advocacy Council of the American College of Allergy, Asthma & Immunology.