Scenario: Management | Management | Allergic rhinitis | CKS | NICE (2025)

Table of Contents
What self-management strategies should I advise? What initial drug treatments should I recommend? How should I manage treatment failure?

From age 24 months onwards.

What self-management strategies should I advise?

If a person has a diagnosis of allergic rhinitis:

  • Provide advice on sources of information and support, such as:
  • Advise the person to consider the use of nasal irrigation with saline to rinse the nasal cavity using a spray, pump, or squirt bottle, which can be purchased over-the-counter.
  • Provide advice on allergen avoidance techniques if there is a specific identified causative allergen:
    • For people with pollen allergy, advise to:
      • Avoid walking in grassy, open spaces, particularly during the early morning, early evening, and during mowing, when the pollen count is high.
      • Avoid drying washing outdoors when the pollen count is high.
      • Keep windows shut in cars and buildings when the pollen count is high.
      • Plan holidays to avoid the pollen season, where possible.
      • Shower or wash hair following high pollen exposures.
      • Consider the use of sunglasses (ideally wraparound) or nasal barriers (masks covering the nose and mouth or commercially available powders, balms or creams rubbed on the nose) when the pollen count is high.
      • Consider monitoring the pollen count using a website such as the Met Office so that avoidance measures can be used when pollen counts are high.
    • For people with confirmed house dust mite allergy following allergy testing, advise to:
      • Not fitmattresses,pillows, and duvets with house dust mite impermeable covers.
      • Usesynthetic pillows and acrylic duvets, and keepfurry toys off the bed.
      • Washall bedding and furry toys at least once a week at high temperatures.
      • Choosewooden or hard floor surfaces instead of carpets, if possible.
      • Fitblinds that can be wiped clean instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.
    • For people withconfirmed animal allergy following allergy testing, advise to:
      • Ideally not allow the animalin the house.If this is not acceptable or possible, advise restricting their presence to the kitchen.
      • Washthe animal and any surfaces they are in contact with, regularly.
    • For people with occupational allergies, advise to:
      • Avoid exposure to allergen completely where possible.
      • If elimination or complete avoidance of the allergens is not possible, reduce exposure to both known and potentially sensitizing allergens in the workplace, for example, by using latex-free gloves, wearing protective clothing, or a dust mask.
      • Ensurethat their work environment is adequately ventilated and/or relocating to lower exposure areas in the workplace.
      • Use less hazardous chemicals, if possible and appropriate.

Basis for recommendation

The recommendations on self-management strategies are based expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis[Scadding, 2017], a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK[Lipworth, 2017], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], the Cochrane systematic reviews House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review[Nurmatov, 2012]and Saline irrigation for allergic rhinitis [Head, 2018], and expert opinion in review articles on allergic rhinitis Perennial rhinitis [Saleh, 2007], Allergic rhinitis in children[Barr, 2014], and Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022], and on occupational rhinitis Occupational rhinitis: an update [Stevens, 2015].

Advice on pollen allergen avoidance
  • The recommendations on grasspollen avoidance are largely pragmaticbased on very limited evidence, but are recommended in the BSACI guideline [Scadding, 2017], which points out that allergen avoidance where possible is effective, given that people with seasonal hay fever are asymptomatic outside of the pollen season.
  • A 2023 international consensus statement reviewed the evidence for pollen avoidance strategies (such as wraparound sunglasses, nasal filters, cellulose powder applied to the nose, and pollen blocker cream) and concluded that there was some evidence for symptomatic benefit and reduced use of medication and that the lower cost strategies may be beneficial, but that more studies are needed to define this [Wise, 2023].
  • Practical tips on finding information about pollen count are based on expert opinion in a review article from the Primary Care Respiratory Society, Allergic Rhinitis: A common problem, not to be sneezed at [Stonham, 2022].
Advice on animal dander allergen avoidance
  • The 2010 revision of the ARIA guideline strongly recommends people with allergic rhinitis caused by animal dander should avoid exposure to these allergens at home, based on very low-quality evidence [Brozek et al, 2010]. Subsequent updates have been targeted at pharmacological treatments and have not addressed this issue. This approach was supported by the 2013 Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology [Roberts, 2013] and expert opinion in a narrative review article that affected people should be discouraged from having pets in the home, Perennial rhinitis [Saleh, 2007].
  • Expert opinion in an additional review narrative review article, Allergic rhinitis in children [Barr, 2014], recommends animals should be washed regularly, as should all surfaces in potential contact with animal dander .
  • A 2023 international consensus statement reviewed the evidence for allergen avoidance relating to pets and found it to be of low quality, and that pet washing has to be completed twice weekly to maintain significant reductions in allergens. Benefit to harm ratio for these measures was found to be equivocal[Wise, 2023].

What initial drug treatments should I recommend?

If a person has a diagnosis of allergic rhinitis, advise on self-management strategies and drug treatment options. Most local policies restrict prescribing for seasonal allergic rhinitis and patients are encouraged to buy treatment OTC. Generally, when the condition is long-term (such as perennial rhinitis), treatments available OTC may be prescribed in primary care. See the section on Prescribing informationfor further information.

Advise on or prescribe first-line treatment, considering patient preference, age, severity of symptoms, persistence of symptoms and the following facts:

  • First-line treatment options are intranasal corticosteroids and antihistamines (intranasal or non-sedating oral antihistamines), either alone or in combination.
  • Intranasal corticosteroids are the most effective treatment for allergic rhinitis, but patients may prefer oral medication. They may take several hours to several days to become effective. Options include intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate, which have minimal systemic absorption.
  • Intranasal antihistamines (such as azelastine) have the fastest onset of action (within minutes) but are less effective than intranasal corticosteroids.
  • The combination of an intranasal corticosteroid and an oral antihistamine is no more effective than the intranasal corticosteroid on its own. However, the combination of an intranasal corticosteroid with an intranasal antihistamine is more effective than an intranasal corticosteroid on its own.
  • Consider regularly prescribed intranasal corticosteroids for people with moderate to severe, persistent allergic rhinitis.

If allergic rhinitis is mild, intermittent, or both:

  • In children, suggest an antihistamine (intranasal or oral non-sedating antihistamine).
  • In adolescents and adults, any first-line treatment may be offered. (Intranasal or oral non-sedating antihistamine, or intranasal corticosteroid, or a combination of nasal corticosteroid with oral or intranasal antihistamine.)

If allergic rhinitis is moderate to severe (i.e. impacting on quality of life, sleep, or daily living activities) or persistent:

  • Suggest an intranasal corticosteroid or the combination of an intranasal corticosteroid with an intranasal antihistamine.
    • Advise the person that the onset of action for intranasal corticosteroids is 6–8 hours after the first dose, but the maximal effect may not be seen until after two weeks.
    • Nasal drops may be preferred if there is severe nasal obstruction.
    • Advise the person not to increase beyond the prescribed dose as there is no evidence of additional benefit, and do not switch to an alternative preparation as they all have comparable efficacy.
  • If symptoms are intermittent and there is no ongoing allergen exposure, step down treatment and stop, but if symptoms are persistent or there is ongoing exposure then continue treatment or step up if not controlled.
    • If drug treatment providesadequate symptom control, advise the personto continue treatment until they are no longer likely to be exposed to the suspected allergen.For people allergic to:
      • House dust mite and/or petsin the home — symptoms are usually present throughout the year, requiring ongoing treatment.
      • Tree pollens — treatment is usually required from early to late spring.
      • Grass pollens — treatment is usually required from late spring to early summer.
      • Weed pollens — treatment is usually required from early spring to late autumn.
        • If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the personto restart treatment two weeks before re-exposure to causative allergens.
        • If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure.
    • Advise the person to be reviewed after 2–4 weeksif symptoms persist afterinitial treatment, as management may need to be stepped up. See the section onTreatment failure and referralfor more information.

If there are additional eye symptoms:

  • Advise or prescribe antihistamine eye drops or chromone eye drops (sodium cromoglycate, nedocromil).

Basis for recommendation

These recommendations are largely based on the 2020 Next generation Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence [Bousquet, 2020b] and expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis[Scadding, 2017]. In addition, this information is supported by a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA)[Euforea, 2021a; Euforea, 2021b], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], and expert opinion in review articles on allergic rhinitis, Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Bousquet, 2020a], and Allergic rhinitis: a common problem, not to be sneezed at[Stonham, 2022].

First line treatment
  • The recommendations on considering which medication to choose come from the information used to support the 2020 Next generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence[Bousquet, 2020b].
  • The recommendations on first-line management are also based on these 2020 ARIA guidelines [Bousquet, 2020b] as well as treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) [Euforea, 2021a; Euforea, 2021b], which give specific advice for management in the paediatric population. These make minor changes from the 2017 British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis[Scadding, 2017] and build on the previous ARIA publications.
  • Information from a review of the literature in a 2023 international consensus statement suggests the use of intranasal corticosteroids may have an impact on growth in children, hence this use in children is restricted to those with more severe or persisting symptoms [Wise, 2023]. This statement advises that the lowest effective dose should be used, and growth should be monitored. The information that intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate have little systemic absorption is based on the 2017 BSACI guideline which states these should be favoured for use in children [Scadding, 2017]. This is further supported by information on the use of intranasal corticosteroids in the British National Formulary [BNF, 2023; BNFC, 2023]and a 2021 narrative review which reviewed the evidence found these second-generation nasal corticosteroids and found these second-generation products to be optimal in terms of systemic exposure as well as topical potency [Daley-Yates, 2021].
  • Information about the prescribing policy for over-the-counter medication is based on the experience of the CKS reviewers and guidance from NHS England [NHS England, 2018].
  • The current ARIA and Euforea algorithms above are based on using a visual analogue scale (VAS). The recommendations for mild here are taken from a VAS score of less than 5, and those for moderate to severe are based on those for a VAS score of 5 or more.
Advice on durations of drug treatment
  • The information on the timings of likely exposure to causative allergens is extrapolated from information in the 2008 revision of the ARIA international guideline [Bousquet, 2008]. Subsequent updates were targeted and did not include this information.
  • The recommendation to start intranasal corticosteroidstwo weeks prior to a known allergen season is based on the fact that the maximal effect of intranasal corticosteroidsmay not be seen until two weeks after starting treatment [Scadding, 2017].
Arranging review if symptoms persist
  • The recommendation to arrange review if symptoms persist after 2–4 weeks is based on an expert consensus statement, which considers a two-week trial appropriate toassess initial response to antihistamines, and a four-week trial appropriate for intranasal corticosteroids [Lipworth, 2017].

How should I manage treatment failure?

If a person has uncontrolled symptoms following initial self-management strategies and drug treatment:

  • Consider causes for treatment failure.
    • Check compliancewith self-managementstrategies, if appropriate.
    • Check compliance with initial drug treatments and/or the correct technique when using intranasal sprays or drops.
    • An alternative diagnosis or non-allergic cause for symptoms.
  • Considerstepping up treatmentif aperson has refractory symptoms while using a regularintranasal corticosteroid preparation.
    • If sudden or severe nasal congestion is a problem, consider adding in a short-term intranasal decongestant such as xylometazoline for up to 5–7 days, depending on the person's age and preparation used.
      • See the section on Intranasal decongestants inPrescribing information for more information.
    • If there is persistent watery rhinorrhoea despite a combined use of an intranasal corticosteroid and oral antihistamine, add in an intranasal anticholinergic such as ipratropium bromide in adults or young people aged 12 or older.
      • See the section on Intranasal anticholinergics inPrescribing informationfor more information.
    • If there is persistent nasal itching and sneezing, options are to add in an oral antihistamine to be used regularly rather than 'as needed', or to prescribe a combination preparation containing an intranasal antihistamine and an intranasal corticosteroid such as Dymista® (azelastine and fluticasone propionate) or Ryaltris® (olopatadine and mometasone) spray, if monotherapy with either an antihistamine or intranasal corticosteroid is ineffective.
      • See the sectionson Oral antihistamines and Combined intranasal corticosteroid and antihistamine sprays in Prescribing information for more information.
      • Note: combined use of an intranasaland oral antihistamine is not recommended.
    • If the person has ongoing symptoms and a history of asthma, consider adding a leukotriene receptor antagonist such as montelukast to an oral or intranasal antihistamine.
      • See the section on Oral leukotriene receptor antagonistsinPrescribing informationfor more information.
    • If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief, such as:
      • For adults — prednisolone 0.5 mg/kg in the morning for 5–10 days.
        • See the CKS topic onCorticosteroids - oral for more prescribing information.
      • For children —seek advice from a specialist if considering prescribing an oral corticosteroid in this situation.
  • If drug treatment providesadequate symptom control, advise the personto continue treatment until they are no longer likely to be exposed to the suspected allergen. For people allergic to:
    • House dust mites and/or pets in the home — symptoms are usually present throughout the year, requiring ongoing treatment.
    • Tree pollens — treatment is usually required from early to late spring.
    • Grass pollens — treatment is usually required from late spring to early summer.
    • Weed pollens — treatment is usually required from early spring to late autumn.
      • If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the personto restart treatment two weeks before re-exposure to causative allergens.
      • If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure.
  • Consider arranging referral for specialist assessment and management to an allergyor ear, nose, and throat (ENT) specialist if:
    • There are red flag features such as unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis, or nasal pain — arrange an urgent two-week wait referral to ENT.
    • There is predominant nasal obstruction and/or astructural abnormalitysuch as deviated nasal septum which makes intranasal drug treatmentdifficult — arrange referral to ENT.
    • There are persistent symptoms despite optimal management in primary care — consider referral to an allergy specialist for allergy testing and possible immunotherapy treatment, depending on local referral pathways and availability.
    • Allergen avoidance techniques such as house dust mite or animal dander avoidance are being considered — skin prick allergy testing to confirm the responsible allergen may be needed.
    • The person would like to consider specialist immunotherapy treatment rather than take medication long term.
    • The diagnosis is uncertain — consider referral to an allergy or ENT specialist, depending on clinical judgement.

Basis for recommendation

These recommendations are largely based on the Allergic Rhinitis and its Impact on Asthma (ARIA) international guidelines 2008 publication [Bousquet, 2008], and the 2020 targeted update Next-generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence [Bousquet, 2020b], expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis[Scadding, 2017], a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], 2021 treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) [Euforea, 2021a; Euforea, 2021b], and expert opinion in review articles on allergic rhinitis, Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Bousquet, 2020a], and Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022].

Adding in an intranasal anticholinergic
  • Ipratropium is not licensed for this indication for children under the age of 12, nor is it recommended in guidelines for children [Euforea, 2021b; Scadding, 2021; BNF, 2023].
Prescribing oral corticosteroids for severe refractory symptoms
  • The 2020 Next-generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence recommends a short 3–7 day course as an add-on option when a step-up from the combination of an intranasal corticosteroid and intranasal antihistamine is required [Bousquet, 2020b]. The 2021 European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) pocket guide for allergic rhinitis includes a short course of oral corticosteroid as an option for uncontrolled symptoms [Euforea, 2021a] without being specific about the dose or length of course.
  • The BSACI guideline notes there is no consensus in the literature on the optimal dose and duration of oral corticosteroid treatment, but suggests a dose for adults of 0.5 mg/kg in the morning, for 5–10 days. It also advises the person to continue using an intranasal corticosteroid preparation, to allow optimal intranasal cavity drug penetration [Scadding, 2017]. This guideline suggests that for children a course of 3–7 days of an oral corticosteroid may be required in severe cases but does not give any recommendation as to dose.
  • The basis for not recommending this option in primary care for children is based on the EUFOREA management algorithms in the pocket guides, which do not advise this as an option for children, and the fact that the BSACI guideline only refers to an adult-specific suggested dose regimen [Scadding, 2017; Euforea, 2021a; Euforea, 2021b]. The British National Formulary and the SPC for prednisolone do not include allergic rhinitis as a licensed indication for children and there is no suggested dose regimen for this scenario[BNF, 2023; BNFC, 2023; EMC, 2023a]. CKS concluded it would be prudent to seek advice from a specialist before prescribing a steroid to a child in this situation.
Advice on durations of drug treatment
  • The information on the timings of likely exposure to causative allergens is extrapolated from information inthe2008 ARIA international guideline [Bousquet, 2008]. Subsequent updates have been targeted and did not include this information.
  • The recommendation to start intranasal corticosteroids 2 weeks prior to a known allergen season is based on the fact that the maximal effect of intranasal corticosteroids may not be seen until 2 weeks after starting treatment [Scadding, 2017]. The British National Formulary (BNF) also advises that treatment for seasonal allergic rhinitis should begin 2–3weeks before the season commences and/or exposure to the allergen [BNF, 2023].

Immunotherapy treatment

  • Specialist immunotherapy may be appropriate for people with symptoms of allergen exposure, objective confirmation of IgE sensitivity, and persistent symptoms predominantly due to one allergen such as grass pollen or house dust mite. Treatment may be by subcutaneous injection or sublingual, and involves exposing the person to increasing amounts of an allergen to induce clinical and immunological tolerance.
    • Subcutaneous therapy may involve weekly initial dosing regimens followed by 4–6 weekly maintenance injections, usually for 3 years. Pre-seasonal immunotherapy may be effective for pollen allergy.
    • Sublingual immunotherapy may be an alternative for the treatment of allergic rhinitis due to one or more species of grass pollen and house dust mites. If tolerated, subsequent doses may be self-administered daily at home for, usually, 3 years.
    • Adverse effects are generally short-lived: subcutaneous immunotherapy may cause itching, redness, and swelling at the injection site; sublingual immunotherapy may cause oropharyngeal itching and localized swelling which typically settles with repeated dosing.
    • Immunotherapy is the only treatment that can modify disease progression, with long-term remission possible following the end of treatment. Subcutaneous immunotherapy in children with seasonal rhinitis may reduce the risk of progression to asthma, andmay prevent the development of new sensitizations.

[Brozek et al, 2010; Barr, 2014; Lipworth, 2017; Scadding, 2017; BMJ Best Practice, 2023; Wise, 2023]

Scenario: Management | Management | Allergic rhinitis | CKS | NICE (2025)
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