The use of antihistamines and intranasal steroids are complicated by conflicting recommendations concerning when it is appropriate to use either, or both. Managed care organizations make their own rules regarding which type of medication can be used by the use of formulary limitations.

The Rule of Two is used for determining the presence of inflammation in the lower airways and establishing guidelines for rescue (acute relief) and controller (preventive) medications. Patients and practitioners have learned to use this simple concept for asthma management. The Rule of Four uses similar guidelines for nasal rescue (decongestant/antihistamines) and controller (intranasal steroid) medications. If a nasal rescue medication (decongestant/antihistamine) is being used four or more days per week, nasal inflammation is increasing and a controller medication (intranasal steroid) is needed. Once control is achieved (rescue medication need is less than four days per week), the controller can be reduced slowly to the lowest dose that maintains control.

The Rule of Four provides a simple rationale for patient medication self-management using an already accepted guideline for inflammation treatment. Practitioners can readily teach the Rule of Four guidelines because of their familiarity with the Rule of Two.

The overall effect of the Rule of Four is to provide better patient understanding of medication management and a decrease in cost for medications.