Allergic Rhinitis

Allergic rhinitis is a symptomatic disorder of the nose, induced by allergen exposure resulting in IgE-mediated inflammation of the nasal membranes. In Singapore, the prevalence of allergic rhinitis is estimated to be more than 30%, with most cases occurring among the paediatric and young adult population¹.

This Care Protocol focuses on the management of patients diagnosed with allergic rhinitis (AR).

Clinical Approach [2,3,4,5]

Recommended considerations when taking history for diagnosis:

1. Cardinal symptoms: sneezing, nasal obstruction, rhinorrhoea, and itching of the nose
2. Diagnosis is made clinically when ≥ 2 symptoms are present for ≥ 2 consecutive days for > 1 hour on most days
3. Assess for exposure to common allergens: house dust mite (predominant), pets, rodents, cockroaches, indoor mould
4. Assess for exposure to non-allergenic irritants: tobacco smoke (both first-hand and second-hand exposure)
5. Check for family and personal history of atopy, such as asthma, eczema or allergic conjunctivitis

Physical examinations suggestive of AR

General / facial examination	Mouth breathing Nasal itching or presence of a transverse supratip nasal crease Allergic shiners (dark discolouration around the lower eyelids) Periorbital oedema
Ear examination	Possible tympanic membrane retraction or middle ear fluid
Nasal examination (anterior rhinoscopy)	Inferior turbinate hypertrophy Congested or oedematous nasal mucosa Pale discolouration of the mucosa (e.g. grey / purplish-bluish)
Eye examination	Conjunctival erythema Chemosis (conjunctival swelling)

Classification and Severity of Allergic Rhinitis (ARIA 2008 and 2016)^3,4

Frequency

1. Intermittent – Symptoms are present < 4 days per week or for < 4 weeks
2. Persistent – Symptoms are present ≥ 4 days per week and for ≥ 4 weeks

Severity

1. Mild – Individual does not report any of the symptoms listed below for "moderate-severe"
2. Moderate/severe – ≥ 1 of following symptoms present:

a. Sleep disturbance
b. Impairment of school or work function
c. Impairment of daily activities, leisure, and/or sports activities
d. Troublesome symptoms

Visual Analogue Scale (VAS) for AR Symptom Severity (Next Generation ARIA 2019)⁵

VAS may be helpful to establish a baseline level of symptom severity. It can then be used to monitor ongoing symptom control and inform treatment adjustments.

Complications of AR^3,4,5

1. Rhinosinusitis
2. Nasal polyps
3. Adenoid hypertrophy
4. Eustachian tube dysfunction
5. Otitis media with effusion
6. Chronic cough

Red Flag symptoms

1. Persistent unilateral symptoms
2. Nasal obstruction without other symptoms
3. Mucopurulent rhinorrhoea
4. Posterior rhinorrhoea with thick mucus and/or no anterior rhinorrhoea
5. Severe facial or orbital pain
6. Recurrent or persistent epistaxis (particularly if unilateral or severe)
7. Anosmia

Differential diagnosis of allergic rhinitis^3,4,5

Management [1,2,3]

1. Recommended Care Components for Allergic Rhinitis

Recommended Care Components

Minimum Frequency

Remarks

Education on Allergen Avoidance:

At diagnosis; thereafter, as clinically indicated

Patient education regarding disease course and measures to control exposure to allergens.

Allergen testing is not routinely indicated

Smoking Assessment

Annually for smokers; once-off for non-smokers, unless there is a change in smoking habit

Assessment on smoking habits (estimated sticks/day; zero for non- or ex-smoker) and smoking cessation counselling.

2. Pharmacological*

Principles of pharmacological treatment (refers to Para 3 under Management section) are the same in children as in adults with allergic rhinitis, but dosages should be adjusted, and care should be taken to avoid the side effects involving impairment of growth and cognitive development, particularly when using intranasal corticosteroids for long durations.
Pharmacotherapy should be continued until symptoms resolve, after which treatment review and step-down can be considered. If AR symptoms recur, pharmacotherapy should be restarted on the previous effective dose.
Three classes of medications are recommended as initial treatment options. These include:

a. Intranasal corticosteroids (INCS)

b. Second generation or later oral antihistamines (OAH)

c. Combination INCS + Intranasal antihistamines (INCS + INAH)

Intranasal corticosteroids (INCS)

INCS are more efficacious in overall symptom control than OAH, especially for nasal congestion.
Second-generation INCS (e.g. mometasone furoate) with lower bioavailability (<1%) are preferred.
INCS takes 1-2 weeks to achieve maximal effect
Intranasal technique counselling should be performed to optimise treatment outcomes and mitigate risk of local side effects

Once symptoms are adequately controlled, INCS dose can be stepped down at 2 to 4 weekly intervals to the lowest effective dose. Some patients can reduce the use of intranasal corticosteroids sprays gradually and maintain symptom control with every other day or as-needed use. Alternatively, refer to INCS accompanying product information leaflets (PILs) for details on starting dose and dosing adjustments.

Antihistamines

Oral and intranasal H1-antihistamines are recommended for the treatment of allergic rhinitis and conjunctivitis in adults and children.
In terms of oral antihistamines, the second- and third-generation agents are minimally sedating and are preferred over first-generation agents because they are equally potent with fewer central nervous system effects.
Intranasal antihistamines, when added to INCS, is more efficacious than INCS alone and should be considered as a step-up treatment option when monotherapy with INCS is inadequate.

Intranasal corticosteroids and intranasal antihistamine combination

INCS+INAH combination shows the greatest efficacy and most rapid onset of action compared to INCS or OAH monotherapy. For patients with AR on INCS monotherapy, INCS+INAH combination is often recommended as a step-up option.

Adjunctive pharmacotherapy for treatment of AR

Decongestants

Oral and intranasal decongestants may be used for severe nasal obstruction.
Oral decongestants have limited effectiveness in relieving AR symptoms beyond nasal congestion and are associated with an increased risk of adverse effects. Their utility is primarily in short-term combination with oral antihistamines (OAH), where the pairing offers broader symptom relief encompassing rhinorrhoea, nasal congestion, nasal itching, and sneezing. Intranasal decongestants, on the other hand, may be used in combination with INCS or OAH for persistent nasal congestion. However, it should not be used for more than 5 days due to risk of rhinitis medicamentosa (rebound nasal congestion).

Intranasal saline

Intranasal saline irrigation is a safe and effective adjunct for AR management that improves nasal symptoms and quality of life, with added benefit when combined with INCS and OAH.

Leukotriene Receptor Antagonist (LTRAs)

Leukotriene receptor antagonists (e.g. montelukast) provide inferior symptom control compared with the recommended first-line therapies for AR. It may be considered as a treatment option in patients with concomitant asthma over 6 years of age.
Restrict use to patients with inadequate response or are intolerant to alternative therapies.
Before starting the medication, patients should be counselled regarding the neuropsychiatric risk of montelukast.

4. Consideration for Specialist Referral

a. Persistent symptoms affecting quality of life, despite compliance to treatment
b. Red flag symptoms (see above – Clinical Approach section)
c. Associated atopy/asthma requiring specialist evaluation (for example, evaluation of allergies by allergy specialist with consideration for skin test/specific immunotherapy)
d. Children under 2 years of age (allergic rhinitis is uncommon in this age group)

Data Submission

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* is mandatory and required for the Healthier SG Annual Service Fee payments.

Diagnosis

1. Diagnosis*

2. CDMP Condition(s)*

3. Diagnosis Year

Smoking History

1. Date of smoking assessment

2. Smoking status [Never smoker, Ex-smoker, Current smoker]*

3. Year started smoking (if Current smoker is selected under Smoking status)

4. No. of sticks smoked/day (if Current smoker is selected under Smoking status)*

5. State of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation, (iv) Action, OR (v) Maintenance

6. Fagerstrom Test Score: (0-2) very low dependence, (3-4) low dependence, (5-7) moderate-high dependence, (8-10) very high dependence

Financing

CHAS/PG/MG cardholders who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications sold within the stipulated price caps.

References

1. Agency for Care Effectiveness. Allergic Rhinitis (ACG) – Diagnosis and Management. Ministry of Health, Singapore; [2026].

2. Wong QYA, Lim JJ, Ng JY, et al. The burden of allergic rhinitis is undermanaged in a large proportion of Chinese young adults from Singapore. World Allergy Organization Journal. 2024;17(9)

3. MOH Chronic Disease Management Programme (CDMP) Handbook, 2024

4. Brożek JL, Bousquet J, Agache I, Agarwal A. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol. 2017 Oct;140(4):950-958. doi: 10.1016/j.jaci.2017.03.050. Epub 2017 Jun 8. PMID: 28602936.

5. Bousquet J, Khaltaev N, Cruz AA, Denburg J. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008 Apr;63 Suppl 86:8-160. doi: 10.1111/j.1398-9995.2007.01620.x. PMID: 18331513.

6. Liu X, Wang Y, Charn TC, Koh LT, Teo NW, Ong YK, Thong MK, Bachert C, Pfaar O, Schünemann HJ, Bedbrook A, Czarlewski W, Bousquet J. Next-Generation Allergic Rhinitis Care in Singapore: 2019 ARIA Care Pathways. Ann Acad Med Singap. 2020 Nov;49(11):885-896. doi: 10.47102/annals-acadmedsg.202076. PMID: 33381782.

7. Shankari, P.K., Suresh, S. & Begum, R.F. Efficacy of intranasal fluticasone propionate and budesonide in management of allergic rhinitis—a prospective comparative study. Egypt J Otolaryngol 37, 123 (2021).

Frequently Asked Questions (FAQs)

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Answer to common questions asked by General Practitioners (GPs) on the clinical conditions. 