For mild, intermittent AR the first step is a non-sedating oral antihistamine and/or a decongestant for short-term use. Intranasal azelastine has a faster onset of action and is more effective than oral preparations, but is only available on prescription. It also has a bitter taste if it trickles into the throat. 

For mild-to-moderate intermittent or mild persistent symptoms, options include a non-sedating oral antihistamine and/or decongestant for short-term use, intranasal corticosteroids (INS) or an intranasal chromone. In practice, the most acceptable treatment at this stage is likely to be an INS, which reduces nasal congestion. Onset of action is six to eight hours after the first dose, but it can take up to two weeks for maximal effect so hayfever sufferers should be advised to start treatment two weeks before the start of the allergen season. 

All INS have similar clinical efficacy, but bioavailability varies considerably. Systemic absorption is negligible with mometasone furoate (recent POM to P switch), fluticasone furoate and fluticasone propionate and these preparations are favoured for children.

An intranasal chromone such as sodium cromoglicate can be used ‘as needed’ if antihistamines are contraindicated or not tolerated. If conjunctivitis is a problem then an intra-ocular chromone can be recommended for regular prophylactic use or combination decongestant/antihistamine eye drops. Wrap-around sunglasses may also be helpful.

Moderate-to-severe persistent symptoms of AR warrant referral to a GP. Such patients may require a more detailed medical assessment and be prescribed treatment with an intranasal antihistamine or leukotriene antagonist.

When to refer 

Patients should be referred to a GP when the clinical picture does not fit with allergic rhinitis or if the condition is too severe to be treated with OTC products. Referral is essential for patients with unilateral symptoms, heavily blood stained nasal discharge or pain.