Allergic Rhinitis/Cold

This is the protocol for Allergic Rhinitis/Cold:

allergic rhinitis


Let’s break it down!

Allergic rhinitis and the common cold are placed in the same protocol because both primarily affect the nasal passages, and let’s be honest…. most of the time we can’t tell the difference.  Luckily for us, the treatment is about the same anyway.  A few notes about both:

Allergic Rhinitis

Also known as “Hay fever”; it occurs when your immune system overreacts to allergens in the air.  “Rhinitis” refers to “nose” (Rhin) + “inflammation” (itis).  The underlying mechanism involves IgE antibodies that attach to an allergen and subsequently result in the release of inflammatory chemicals such as histamine from mast cells. In any given year, this affects about 10-30% of people in western countries and it typically lasts longer than a cold (more than 2 weeks).  For more info, check out the Osmosis video below:


Common Cold

A viral infection of the upper respiratory tract, primarily affecting the nasal passages.  A cold can be caused by over 200 different viruses, but rhinoviruses are the most common.  On average, adults get colds 2-3 times a year while children get it about 6-8 times.  For more info, check out the Osmosis video below:

As mentioned earlier, the signs and symptoms for both allergic rhinitis and the common cold are very similar.  Rhinorrhea means nasal discharge or “runny nose”.  In allergic and viral infections, the discharge should generally be clear.  A thick, greenish-brown discharge can still occur harmlessly, but this has classically been known to be more indicative of a bacterial infection.  Pruritus or “itchiness” of the nose and eyes is also very common.

One potential complication of allergic rhinitis/cold is the development of a sinus infection, or “Sinusitis“.  This is when the infecting agent spreads to the sinuses and causes further inflammation of the mucous membranes.  Patients with sinusitis will have similar symptoms as the cold, but they will generally last longer and likely be accompanied by facial pain.  Luckily for us, most of these cases are still viral and generally involve the same workup and treatment.  However, those with severe symptoms lasting longer than ten days, and more unilateral sinus pain may have a bacterial sinus infection requiring antibiotics.  

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Fluticasone (Flonase) is a corticosteroid nasal spray that can be incredibly useful for allergic rhinitis/cold.  Like any steroid, it acts as an anti-inflammatory agent that helps decrease the swelling in the nasal passages.  It also helps relieve nasal itchiness, watery eyes, and other allergy symptoms.  Always tell your patients to blow their nose first before using the spray so that they can maximize absorption.

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Antihistamines work by inhibiting the inflammatory product histamine from binding to histamine receptors and causing an allergic response.  It doesn’t necessarily work well for a cold, but we generally give them anyway in case their symptoms are caused by allergies.  There are two different types of antihistamines: H1-antagonists and H-2 antagonists.  H-2 antagonists target the receptors in the upper gastrointestinal tract (often beneficial for heartburn), but the ones we care about for this particular patient are H1-antagonists, which specifically target the receptors on mast cells, smooth muscle, and endothelium.  

You have 4 different H1-antagonist medications to choose from.  Here are a few notes about each:

1. Diphenhydramine: a particularly strong, 1st generation antihistamine.  It works well and much faster than the other antihistamines but generally causes a sedating effect due to its ability to cross the blood-brain barrier.  Typically we wouldn’t want to give this to a soldier if they plan on continuing their mission.

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2. Cetirizine and Loratidine: both medications are 2nd generation antihistamines that provide a Non-drowsy option for allergy relief.  Much less likely to cross the blood-brain barrier.

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3. Fexofenadine: a 3rd generation antihistamine, which functions very similarly to 2nd generation antihistamines except it generally has fewer side effects and fewer interactions with other drugs.  

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Decongestants work by inducing vasoconstriction in the nasal blood vessels, thus reducing inflammation and lowering mucous production.  Works equally well for both allergic rhinitis and the common cold.  Each drug has it’s pros and cons:

1. Pseudoephedrine: Generally the best choice of the three; technically considered an amphetamine and has the potential to be abused or manipulated to make “crystal meth”.  That’s why it’s a behind the counter drug – most pharmacists in the civilian sector won’t supply any more than 720mg at a time without a prescription.  

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2. Oxymetazoline: The only nasal spray option of the three; works very quickly but can only be used for 3 days at a time due to the risk of “rebound congestion“, which is a worsening of nasal congestion.  

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3. Phenylephrine: Designed as a safer alternative to pseudoephedrine, phenylephrine functions roughly the same way.  The packaging looks similar to pseudoephedrine except for the subtle “PE” after the brand name.  Despite its similarity, several independent studies have shown that phenylephrine provides little to no benefit compared to placebo.  

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And of course, how can not tell them to drink water?  Increasing their fluid intake will help the patient loosen the mucous and make them more comfortable.   

As long as you don’t suspect a lower respiratory infection or a bacterial sinus infection, these over-the-counter medications should be enough to manage their symptoms. Most cases will resolve in 7-10 days. 

Good luck out there!



Brandon Simpson, PA-C
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