xRead - Nonallergic Rhinitis (September 2025)

BAROODY ET AL

1443

J ALLERGY CLIN IMMUNOL PRACT VOLUME 12, NUMBER 6

Treatment of NAR

Underlying disease?

Yes

No

Treat underlying disease

Triggers?

History of nasal hyper reacƟvity (may include NARES)?

Avoidance of fragrances,

Allergen-related?

OccupaƟonal?

Drug-induced?

cigareƩe smoke, bleach, polluƟon, hot and spicy foods, someƟmes alcohol

NAPT for local allergic rhiniƟs

Treat underlying disease

Trial with saline and/or INAH

Nasal provocaƟon with occupaƟonal agent

- Predominantly rhinorrhea? Trial with ipratropium bromide spray

Start saline and INCS

Treat as AR

Avoid exposure

Stop decongestant or another causing drug (if possible)

Add INCS CombinaƟon INCS/INAH

Trial with saline and INCS

Consider capsaicin treatment

Consider surgery: Turbinate reducƟon or Vidian neurectomy

FIGURE 3. Algorithm for the evaluation of NAR. NAPT, non-allergic provocation test.

greater degradation of neuropeptides. 50,51 Glucocorticoids have also been demonstrated to reduce neurogenic plasma extravasa tion in an experimental airway model, and this could contribute to their ef fi cacy in treating NAR. 52 Use of combination agents INAHs plus INCS in NAR is very limited, despite their clinical popularity in the treatment of AR. Studies of CR, inclusive of patients with AR and NAR, indicated ef fi cacy of the combination of intranasal fl uticasone and

azelastine. 53,54 One study performed a cold, dry air challenge in an environmental exposure chamber on 30 NAR patients to investigate clinical responses and biological pathways involved using azelastine/ fl uticasone versus placebo pre- and post challenge. Treatment with azelastine/ fl uticasone demonstrated a signi fi cant reduction in the minimum nasal cross-sectional area ( P < .05), cough count ( P < .05), and substance P levels ( P < .01) compared with placebo. 29