d) Treatment

If it is non allergic rhinitis the treatments that seem to benefit include using intranasal steroids , intranasal antihistamines, combination of the two. Also of course is avoidance of triggering factor if any is known such as the beta blockers.

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Overview — Patients with chronic NAR are generally less responsive to pharmacologic therapy than those with allergic rhinitis [7,84]. Specifically, most find oral antihistamines unhelpful [85,86]. However, two classes of medications are useful in treating the total symptom-complex of chronic nonallergic rhinitis [54,87-97]:

●Topical intranasal glucocorticoids (INGCs)

●Topical antihistamine azelastine

In addition to these agents, ipratropium bromide has been approved specifically to treat the symptom of rhinorrhea in chronic nonallergic rhinitis [98,99].

Primary therapies — Patients with mild disease may be adequately treated with either INGC or azelastine. There are no comparative studies specifically designed to compare the use of INGCs versus topical antihistamines for the treatment of NAR.

Those with moderate to severe disease tend to respond better to the combination of an INGC and azelastine [100]. (See 'Combination therapy' below.)

We generally use full-strength dosing for both agents and emphasize to patients that the medications should be used on a daily basis regardless of the presence or absence of symptoms.

Intranasal glucocorticoids — Several INGC preparations have been shown to be effective for most patients in multiple randomized controlled studies [89,90,92,101]. Multiple preparations are available (table 2).

The largest report demonstrating a positive treatment effect with INGC was a combined analysis of three double-blind, randomized, prospective, placebo-controlled studies of 983 patients with NAR with and without nasal eosinophilia (674 were classified as without nasal eosinophils) [101]. Intranasal fluticasone propionate at a dose of 200 or 400 micrograms was significantly more effective than placebo in both groups, as assessed by total nasal symptom scores for nasal obstruction, postnasal drip, and rhinorrhea.

However, not all patients with NAR respond to INGCs, and another large study showed no significant impact on symptoms [7]. A subsequent multicenter trial was performed to assess the effects of INGC therapy on a subset of patients with symptoms that were triggered predominantly by changes in weather and temperature [102]. In this randomized study, 699 patients with NAR triggered by these factors were treated with either fluticasone furoate or placebo for four weeks. There were no significant differences between the two therapies. Thus, although patients with NAR as a group derive benefit from INGCs, there are clearly important subgroups of nonresponders that require further study.

Topical antihistamine sprays — We usually begin with full-strength dosing using one of the following:

●Azelastine 0.15 percent (Astepro, containing 205 mcg per actuation), one to two actuations per nostril twice daily and decreasing the dose as symptoms improve. Many patients’ symptoms are controlled with once daily dosing.

●Azelastine is also available in a 0.1 percent preparation (Astelin, containing 137 mcg per actuation) as well as a generic preparation that is dosed two actuations each nostril twice daily in adults and one actuation twice daily in children.

●Olopatadine hydrochloride nasal spray (0.06 percent) (Patanase, containing 665 mcg per actuation) that is dosed two actuations twice daily in adults and children >12, and one actuation twice daily for children ≤11 years.

As monotherapy, azelastine has been shown to be effective in randomized controlled studies [91,103]. As an example, in two multicenter randomized open-label trials, approximately 80 to 85 percent of more than 200 subjects with chronic NAR responded favorably to azelastine [91].

The improvement in symptoms with azelastine is likely due to antiinflammatory actions. This activity includes the ability to diminish eosinophil activation and adhesion molecule expression, and suppress inflammatory cytokine generation [95,96,104]. Azelastine may also reduce neurogenic excitation from olfactory stimuli. In the previously mentioned study in which subjects with NAR were exposed to pleasant and unpleasant odors, the administration of azelastine significantly attenuated exaggerated blood flow to odor-sensitive regions of the brain as assessed by MRI [34].

Olopatadine and azelastine (0.1 percent) were compared for the treatment of NAR in a multicenter, randomized parallel group study lasting 14 days [105]. Both reduced congestion, rhinorrhea, postnasal drip, and sneezing and there were no statistically significant differences between their effects. In addition, there was no difference in the side effect profile of the two agents. In another placebo-controlled study, olopatadine reduced the response to hyperosmolar challenge in patients with prominent vasomotor symptoms [106].

Combination therapy — It has been our clinical experience that the combination of INGCs and azelastine is more effective than either agent alone, although this has not been specifically studied in chronic nonallergic rhinitis. Combination therapy can be achieved either by using two separate nasal sprays, or a combination product. A combination spray containing azelastine hydrochloride 137 mcg and fluticasone propionate 50 mcg (Dymista) became available in the US in 2012 and is approved for children older than 12 years and adults for seasonal allergic rhinitis. The dose is one actuation per nostril, twice daily. This combination product has been studied in patients with seasonal allergic rhinitis and has been shown to be superior to single treatment with either agent alone [107]. (See "Pharmacotherapy of allergic rhinitis".)