What is the recommended first-line approach for mild persistent allergic rhinitis after considering non-pharmacologic strategies?

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For mild persistent allergic rhinitis, after non-pharmacologic strategies have been considered, the recommended first-line approach is intranasal corticosteroids combined with a second-generation antihistamine, along with ongoing allergen avoidance. Intranasal corticosteroids are the most effective option for controlling nasal inflammation and all the common symptoms—congestion, runny nose, sneezing, and itching. Adding a second-generation antihistamine helps with itching and sneezing and has a favorable safety profile with minimal sedation, and using them together often provides better overall control than either alone. Maintaining allergen avoidance reduces exposure and can lessen symptom flares. In selected cases, especially when symptoms persist despite optimal medical therapy or there is clear sensitization with a high burden of disease, allergen immunotherapy may be considered as a disease-modifying option.

Antibiotics aren’t helpful since this is not an infection, systemic corticosteroids are not appropriate for mild disease due to potential side effects, and decongestants alone don’t address the underlying inflammation.