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13 Fitzgerald Health Education Associates, Inc., August 2015 fhea.com a useful resource for NPs caring for pa- tients with allergic rhinitis ( Table 3 ). 2 The guidelines recommend intranasal corticosteroids as a first-line treatment because of their superior efficacy in re- lieving overall allergic rhinitis symp- toms, especially moderate-to-severe symptoms, chronic symptoms, and nasal congestion. Second-generation antihistamines are a first-line treat- ment for the relief of itching, sneezing, and runny nose unless the patient has nasal congestion, has moderate or se- vere symptoms, and/or if symptoms are persistent. In- tranasal corticosteroids would be the first-line treat- ment for those symptoms, and the oral antihistamine second-line. First-generation antihistamines are not rec- ommended because of their adverse side-effect profile and the effectiveness and longer duration of action of the second-generation antihistamines. The most effective therapy to relieve overall allergic rhinitis symptoms, moderate-to-severe rhinitis, and congestion is an intranasal corticosteroid. Lori's current use of cetirizine is not going to give her the relief she wants from congestion and sinus pressure because an- tihistamines have limited benefit in relieving conges- tion. A combination approach using medications from different pharmacologic classes should provide more relief and control Lori's symptoms. One combination approach is to add an intranasal corticosteroid to Lori's current sec- ond-generation antihistamine. Anoth- er option is to add an intranasal corti- costeroid and change to a different second-generation antihistamine. Consider adding a leukotriene modifi- er and/or an oral decongestant to the intranasal corticosteroid and second- generation antihistamine, depending on the severity of the symptoms. Devon, a 9-year-old boy, has had nasal congestion for years. His mother reports that he has been snoring lately. He was evaluated by an ear, nose, and throat specialist, who recommended that Devon use a nasal spray. However, his mother reports that Devon does not like nasal sprays and will not use them. The most effective therapy for congestion related to al- lergic rhinitis and the medication recommended in the Joint Task Force rhinitis guidelines is an intranasal cor- ticosteroid. 2 However, for a variety of reasons, some patients are highly reluctant to use a nasal spray. You should not give up on the possibility that a patient may change his or her mind about using a nasal spray! Find out why your patients do not like nasal sprays. Of- ten patients are reluctant to use nasal sprays because they do not like the taste or they do not want to put Allergy & Asthma Consult Table 2: Effects of Pharmacologic Therapies on Allergic Rhinitis Symptoms 2 Sneezing Itching Runny Nose Ocular Congestion Antihistamine (oral) ++ +++ ++ ++ +/– Antihistamine (nasal) ++ ++ ++ +/– + Intranasal corticosteroid +++ ++ +++ ++ +++ Leukotriene modifier +/– +/– + + + Source: Joint Task Force on Practice Parameters for Allergy and Immunology. 2 Incorporating evidence- based guidelines into the decision- making process is important when developing the treatment plan for allergic rhinitis. Continued from page 11 Continued on page 15