Treatment update: Allergic rhinitis

In addition to the introduction of several new pharmacologic agents, two of the most significant recent developments in the management of allergic rhi nitis have been the renewed emphasis on preventive measures, such as allerg en avoidance and immunotherapy, and the importance of performing an accurat e differential diagnosis of the disease. Recently, these evolving managemen t trends were delineated in an algorithm proposed by the Joint Task Force o n Practice Parameters in Allergy, Asthma and Immunology, which suggests tha t an initial evaluation be performed by a primary care physician. Based on findings at the initial evaluation, the patient should be treated either em pirically in the primary care setting or referred to an allergist-immunolog ist,for consultation. The allergist uses an evidence-based therapeutic appr oach based on a differential diagnosis of the type of rhinitis, which uses information derived from it detailed medical history, physical examination of the airway, and ancillary tests, particularly skin tests. Rhinitis manag ement by an allergist emphasizes a three-pronged approach that incorporates avoidance, immunotherapy, and pharmacologic therapy. However, because both avoidance and immunotherapy have their limitations, pharmacologic therapy remains the mainstay of rhinitis management, and allergists usually recomme nd that optimal first-line therapy be broad based and capable of safely all eviating the symptoms of both allergic and nonallergic disease. First gener ation oral antihistamines, topical corticosteroids and the topical antihist amine azelastine are the most broad-based treatments available. Second-gene ration oral antihistamines and leukotriene antagonists also are useful in t reating allergic rhinitis.