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15 Fitzgerald Health Education Associates, Inc., August 2015 fhea.com something in their nose. In some cases they report a burning sensation, or that the nasal spray does not re- lieve congestion as expected or causes sores in the nose and nosebleeds. Teaching patients proper tech- nique and keeping the nasal mucosa healthy and cleared of mucus reduces burning, bad taste, sores, bleeding, and irritation. Finally, using an appropriate overall treatment plan that addresses the severity of the patients' allergic rhinitis with the least amount of medication will enhance adherence and, more impor- tant, help patients obtain relief and control of their symptoms ( See Developing a Plan.). Steffi, a 29-year-old woman, complains of frequent nasal itching, sneezing, runny nose, and nasal congestion. Symptoms began when the trees started blooming 5 months ago, and though her symptoms have improved somewhat, they have largely persisted. Runny nose and itching are the most bothersome symptoms. She has limited herself to indoor activities to prevent increased symptoms, but she wants to participate in outdoor activities again. Her current medications include loratadine (Claritin) 10 mg every morning and diphenhydramine (Benadryl) 25 mg every night. Steffi's symptoms are persistent, more than mild in severity, and are affecting her quality of life. She is cur- rently on both a first- and second-generation antihista- mine, and they are not controlling her symptoms. In- tranasal corticosteroids are superior to antihistamines in controlling overall allergic rhinitis symptoms, partic- ularly if symptoms are moderate-to-severe and/or per- sistent, as is the case for Steffi. An antihistamine is also needed to relieve itching and rhinorrhea. A reasonable management plan would be to change to a different second-generation antihistamine daily, add an in- tranasal corticosteroid daily, and consider adding a leukotriene modifier to Steffi's regimen. Developing a Plan Allergic rhinitis medications can be combined in a vari- ety of ways in order to achieve relief and control symp- toms. When developing the pharmacologic plan for al- lergic rhinitis, consider the severity and persistence of Allergy & Asthma Consult Table 3: Joint Task Force on Practice Parameters Guidelines for the Pharmacologic Management of Allergic Rhinitis First-generation Not recommended; caution about antihistamine (oral) side effects Second-generation First-line therapy for reducing itching, antihistamine (oral) sneezing, and runny nose. Added benefit in reducing allergic conjunctivitis symptoms. Limited benefit in nasal congestion; combination medication will be needed for more severe persistent symptoms, most importantly an intranasal corticosteroid. Intranasal Consider first-line for allergic or antihistamine non-allergic rhinitis. Benefit in reducing congestion. Intranasal First-line therapy, especially for corticosteroid moderate-to-severe rhinitis, chronic rhinitis, and nasal congestion. The most effective medication class in controlling symptoms. Leukotriene Beneficial alone or in combination modifier with antihistamine. Additional benefit with asthma. Decongestant Consider with antihistamine to reduce (oral) congestion. Safety issues. Subcutaneous Indicated if treatment is insufficient, immunotherapy symptoms severe or protracted, and to prevent progression and development of comorbidities (ie, asthma). Source: Joint Task Force on Practice Parameters for Allergy and Immunology. 2 C ontinued from page 13