Rhinitis%20-%20allergic%20(pediatric) Treatment

• A step-wise approach to treatment is recommended
• Step-down therapy as patient’s symptoms improve and step-up when symptoms worsen
• Combination/step-up therapy may be used in patients with inadequate response to monotherapy or those with severe allergic rhinitis
  • Recommendations depend on the pattern of exposure to allergens
  • For patients with moderate to severe seasonal allergic rhinitis, the following principles are applied:
    • Combination therapy of an intranasal corticosteroid with an oral antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
    • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
    • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine is preferred over monotherapy with an intranasal antihistamine
    • Leukotriene receptor antagonist or an oral antihistamine: No specific preference
    • Intranasal antihistamine or an oral antihistamine: No specific preference
  • For patients with moderate to severe perennial allergic rhinitis, the following are recommended:
    • Monotherapy with intranasal corticosteroid preferred rather than the combination of an intranasal corticosteroid with an oral antihistamine
    • Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with intranasal corticosteroid: No specific preference
    • Intranasal antihistamine or an oral antihistamine: No specific preference
  • Combination of intranasal antihistamine and intranasal steroid should be considered if antihistamine monotherapy, intranasal steroid monotherapy, or oral antihistamine and intranasal corticosteroid combination remains ineffective
  • For patients with persistent rhinorrhea on intranasal corticosteroid therapy, addition of intranasal Ipratropium may be considered

• Eg Ipratropium bromide
• Effectively controls watery rhinorrhea, no effect on sneezing and nasal congestion
• Onset of action is fast (15-30 minutes)
• Adverse effects are infrequent; if present, usually localized and mild (eg nasal dryness, irritation, epistaxis)

• First-line therapy for mild to moderate intermittent and mild persistent rhinitis
• H₁-receptor antagonists reduce nasal itching, sneezing and rhinorrhea, but are less effective for nasal congestion; also relieve ocular symptoms

• Eg Azelastine, Olopatadine, Levocabastine
• Rapid onset of action (<30 minutes) but relatively short-acting
• May be used in children with seasonal allergic rhinitis to help reduce symptoms and nasal obstruction with minimal side effects

• Eg Acrivastine, Cetirizine, Chlorpheniramine, Desloratadine, Diphenhydramine, Fexofenadine, Levocetirizine, Loratadine
• Preferred route for intermittent or persistent allergic rhinitis and may be used to prevent symptoms associated with occasional allergy exposure
• 2nd generation antihistamines are ideal as 1st-line therapy in equal preference to nasal antihistamines
• Preferred over oral leukotriene receptor antagonists for treatment of preschool children with persistent allergic rhinitis 
• Use of 1st generation antihistamines should be limited; may reduce academic ability in school children
• Onset of action occurs in <1 hour

• May be used to relieve ocular symptoms of allergic rhinitis such as pruritus and redness

• Eg Omalizumab
• Has been shown to be effective in seasonal allergic rhinitis

• Have a strong anti-inflammatory capacity and reduce nasal itching, sneezing, congestion and rhinorrhea

• Eg Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
• Most effective treatment for allergic rhinitis
• Onset of action is relatively slow (12 hours), with max efficacy after a few days
  • Ciclesonide: Onset of action is within 1 hour of use
  • Mometasone: Onset of action is within 12 hours of use
• Caution is needed due to the possible effect on growth; lowest effective dose should be used and regular height measurements are advised
• In severe cases, nasal corticosteroids should be administered before the start of allergy season as prophylaxis

• IM agents are more invasive and expensive, and are less preferred
• Oral corticosteroids are reserved for patients with refractory or severe symptoms not controlled by antihistamines or topical agents
  • Short course for 3-5 days may be helpful
• Therapy must be limited to lowest effective dose and shortest possible time

• Recommended as an alternative treatment to antihistamines and corticosteroids
• Less effective than antihistamines and nasal corticosteroids 
• An option due to its excellent safety profile
• Most efficient if used regularly prior to onset of allergic symptoms but may be considered for symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea, conjunctivitis)

• Sympathomimetic and relieves nasal congestion
• Preparations containing Ephedrine, Oxymetazoline and Xylometazoline should not be used in patients <2 years of age

• Eg Oxymetazoline, Xylometazoline
• Short courses may be used to immediately reduce severe nasal congestion
• Because of the risk of rebound congestion (rhinitis medicamentosa), use should be limited to <10 days
• Beneficial prior to instillation of nasal corticosteroids

• Eg Pseudoephedrine, Ephedrine
• Not as effective as nasal decongestant; consider the benefits versus safety concerns especially in patients <4 years of age and in patients of any age with history of cardiac arrhythmia, angina pectoris, cerebrovascular disease, uncontrolled hypertension, bladder outlet obstruction, glaucoma, hyperthyroidism, or Tourette syndrome
• No rebound congestion reported
• May be used as additional medication with antihistamine, efficacy is increased than either medication alone but with combined side effects

• Eg Montelukast
• A therapeutic option used either alone or in combination with oral antihistamines or nasal corticosteroids; not to be used as initial therapy
• May be used in children with seasonal allergic rhinitis, preschool children with persistent allergic rhinitis, and those with coexisting asthma
• Efficacy comparable to oral antihistamines and less than nasal corticosteroids

• May be used as single or adjunctive agents in reducing the symptoms and improving the quality of life
  • Can also help clear the nose before eating and sleeping
• There is no difference in radiologic or symptoms score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance
• Associated with mild side effects (eg burning, irritation, nausea)

• Identification and avoidance of trigger allergens should be an integral part of allergic rhinitis management strategy
• Removal of the allergen may result in diminished severity of the disease and decreased requirement for medications
• Identifying specific causal allergens by lab testing may encourage patients to comply with allergen avoidance instructions
• Effectiveness of avoidance will be measured by relief of the patient’s symptoms and by a decrease in the need for medications
• In the majority of cases, it is not possible to completely avoid allergens but these measures should be considered where appropriate

• Do not allow animals in the house
• If this is not possible, keep pets out of patient’s bedroom, bathe pets once or twice daily

• Major allergen found in houses
• Use allergen-impermeable covers for mattresses and pillows
• Wash sheets and blankets in hot water (60^oC) every week
• Reduce indoor humidity to around 50% (or 40-60%) (an air conditioner may reduce humidity in the summer)
• Use high efficiency particulate air filter when vacuuming or dust weekly with mask

• Avoid outdoor exposure on days when pollen counts are high
• Use of air conditioning is advisable
• Shower after outdoor activities where pollen exposure is high
• Keep doors and windows closed at home and when inside vehicles

• Discourage smoking by household members and visitors
• Minimize contact with irritants (eg perfumes, hair spray and other odors)
• Reduce growth of molds in the home by decreasing humidity and eliminating sites for mold growth

• Recommended for allergy testing-positive patients with inadequate response to pharmacologic therapy and allergen avoidance measures 

Principles of Therapy

• Repeated administration of specific allergens in patients with IgE-mediated conditions to provide protection against allergic symptoms associated with exposure to these allergens
• Only intervention that alters the natural history of allergic rhinitis
• Activates regulatory T cells, thereby altering humoral response to allergens by increasing CD8+ T cells and IL-10, and reducing IL-13 production
• Indicated for patients with the following:
  • Evidence of specific IgE antibody to allergen (positive allergy test results)
  • Any of the following:
    • Clinically diagnosed with both allergic rhinitis and asthma
    • Required medication
    • Poor response to avoidance measures
    • Adverse effects to medications
    • Prevention of asthma in allergic rhinitis patients
  • Initial dose should be performed in a medical facility by a trained personnel
  • Recommended course is usually 4-5 years

Subcutaneous Immunotherapy (SCIT)

• May be considered in children whose seasonal allergic rhinitis is triggered by pollen exposure, and perennial rhinitis due to house dust mite 
• Efficacy for allergic rhinitis is comparable to that of nasal glucocorticoids
• Limited by frequent injection on regular basis and small risk of anaphylactic reactions

Sublingual Immunotherapy (SLIT)

• Sublingual and intranasal allergen-specific immunotherapy may be considered in children with allergic rhinitis due to pollen exposure 
• A more viable treatment compared to SCIT as self-administration is encouraged with this form
• Use should be limited to those who can tolerate systemic reactions and its treatment
• Auto/self-injectable Epinephrine should be prescribed to all patients receiving SLIT
• Has been associated with mild oral and GI symptoms and less risk for anaphylaxis compared to SCIT