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A 35-year-old man has a 16-year history of recurrent nasal congestion, sneezing, and rhinorrhea that begin in the early spring. He feels uncomfortable and is having difficulty concentrating at work. The patient had eczema as a child. Medical history is otherwise unremarkable. He has no allergies and takes no medications. A sister has asthma.

Vital signs, including temperature, are normal. Examination of the nose reveals a widened bridge, a horizontal nasal crease, pale nasal mucosa, and a clear mucoid discharge.

The lungs are clear to auscultation.

Which of the following is the most efficacious initial treatment?

A. Intranasal azelastine
B. Intranasal fluticasone
C. Oral fexofenadine
D. Oral pseudoephedrine

Click to see the answer



Answer: B, Intranasal fluticasone.

Educational Objective: Treat allergic rhinitis.

Critique: This patient has allergic rhinitis, for which intranasal corticosteroids are the most efficacious therapy. Intranasal corticosteroids, oral antihistamines, intranasal antihistamines, oral antihistamine/oral decongestant combination products, and intranasal cromolyn sodium are all superior to placebo. Studies have shown that intranasal corticosteroids are superior to both intranasal and oral antihistamines for relief of sneezing and nasal obstruction. Some corticosteroid preparations (for example, fluticasone) may also relieve ocular symptoms such as itching and tearing. Although intranasal corticosteroids are associated with minimal systemic bioavailability, this finding should not limit their use. Growth retardation has been reported with long-term administration of intranasal beclomethasone in children but has not been reported with use of other intranasal corticosteroid preparations. Epistaxis is the most common side effect of intranasal corticosteroids and occurs in approximately 10% of patients. However, this is not usually severe enough to warrant discontinuation of the drug. The rare side effect of nasal perforation can be avoided by using proper spray technique.

Oral second-generation (nonsedating) antihistamines (for example, fexofenadine) can either be used alone or as additional therapy for control of mild symptoms. However, the patient described here has more severe symptoms that are affecting his comfort and ability to work; therefore, intranasal corticosteroids are the preferred therapy.

Azelastine is an intranasal H1-antihistamine that improves nasal congestion but is less effective than corticosteroids in relieving other symptoms.

Oral decongestants, including pseudoephedrine, also relieve nasal congestion but not rhinorrhea, itching, or sneezing.

Other effective therapeutic agents for allergic rhinitis include oral leukotriene modifiers (to be used as add-on therapy only), topical cromolyn sodium, and nasal saline irrigation. Immunotherapy may be considered when symptoms are not well controlled by other agents. Oral corticosteroids may also be used for brief periods to relieve severe symptoms. Intranasal ipratropium bromide is generally indicated for patients with nonallergic rhinitis but can also be used for patients with allergic rhinitis associated with profuse rhinorrhea.

Key Point: Intranasal corticosteroids are superior to antihistamines for treating patients with allergic rhinitis.


Drugs for allergic disorders [erratum in Treat Guidel Med Lett. 2007;5(61):88]. Treat Guidelines Med Lett. 2007;5(60):71-80.

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