Rhinitis%20-%20allergic%20(pediatric) Treatment
Principles of Therapy
- 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
Pharmacotherapy
Anticholinergics
- 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)
Non-Pharmacological Therapy
Allergen Avoidance
- 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 (60oC) 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
Immunotherapy
- 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