Rhinitis%20-%20allergic Treatment

• Treatment of allergic rhinitis is based on the duration and severity of symptoms
• A step-wise approach to treatment is recommended for adolescents and adults
• Step down therapy as patient’s symptoms improve and step up when symptoms worsen
• Similar therapeutic principles are applied in children; however, care should be taken to avoid the adverse effects of certain classes of drugs in the pediatric population
• Drugs used for rhinitis are usually administered either orally or intranasally
• Combination or step-up therapy is recommended for patients with disease progression after 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 histamine
    • 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

Anticholinergics

• Eg Ipratropium bromide
• Block the muscarinic receptors of the seromucinous glands
• Effectively controls watery rhinorrhea but does not affect sneezing or nasal congestion, which precludes its use as a 1st-line medication
• May be used together with intranasal corticosteroids or antihistamines in patients in whom rhinorrhea is the predominant symptom, or in whom rhinorrhea does not respond well to the other medications

Antihistamines

• H₁-receptor antagonists reduce nasal itching, sneezing and rhinorrhea, but are less effective for nasal obstruction
• 1st-line treatment for mild-moderate intermittent and mild persistent rhinitis
• Added to intranasal corticosteroids for moderate-severe persistent rhinitis with eye symptoms uncontrolled by intranasal corticosteroid monotherapy

Nasal Antihistamines

• Eg Azelastine, Levocabastine, Olopatadine
• Rapid onset of action (<15-30 minutes)
• Recommended in patients with seasonal, perennial, or episodic allergic rhinitis
• Recommended 1st-line option for patients with intermittent allergic rhinitis
• Preferred treatment for allergic rhinitis when compared to intranasal cromones
• Associated with clinically significant effect on nasal congestion
• Effective at the site of administration
• May be used for mild, organ-limited disease or as an “as required” medication used together with a continuous one
• As effective as oral antihistamines but require twice-daily dosing

Oral Antihistamines

• Have the advantage of relieving other allergic symptoms of other sites (eg conjunctivitis) along with nasal symptoms
• May be used to prevent symptoms associated with occasional allergy exposure
• Preferred over leukotriene receptor antagonists (LTRA) in patients with moderate-severe perennial allergic rhinitis
• 2nd-generation antihistamines are preferred over intranasal antihistamines
• Use of 1st-generation antihistamines should be limited; may reduce academic ability in school children and may produce performance impairment in adults while driving
• Onset of action occurs within 1 hour

Second-generation Oral Antihistamines

• Eg Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, Mequitazine, Rupatadine
• Should be considered as a 1st-choice treatment
• Preferred over 1st generation oral antihistamines
• Have less undesirable CNS and fewer anticholinergic effects compared to 1st-generation antihistamines
• Have little or no sedative effect at the recommended dosages

First-generation Oral Antihistamines

• Eg Chlorpheniramine, Clemastine, Diphenhydramine
• Use is limited by sedative and anticholinergic side effects and short half-life
• May further impair cognitive functioning and school performance in children

Intraocular Antihistamines

• May be used in patients with symptoms of ocular involvement (eg conjunctivitis)

Anti-Immunoglobulin E Antibody

• Eg Omalizumab
• Has been shown to be effective in reducing nasal symptoms and improving quality of life in patients with seasonal allergic rhinitis

Corticosteroids

• Have a strong anti-inflammatory capacity by reducing cytokine and chemokine release

Intranasal Corticosteroids

• Eg Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
• More efficacious than oral or topical nasal antihistamines in relieving symptoms of allergic rhinitis, especially nasal obstruction
• Considered as 1st-line treatment in patients with moderate-severe and/or persistent symptoms
  • Preferred over intranasal and oral antihistamines in patients with moderate-severe perennial or seasonal allergic rhinitis
  • Monotherapy with intranasal steroids is preferred over combination with oral antihistamines for patients with perennial allergic rhinitis
  • Combination therapy with intranasal antihistamines is more effective than monotherapy with intranasal steroids in patients with moderate-severe disease
• Onset of action takes a few hours (6-12 hours) to a few days, with maximum efficacy developing after 2 weeks
• Aqueous preparations are preferred because they are less irritating to the nasal mucosa
• Studies have shown reassuring safety data of Fluticasone, Mometasone and Ciclesonide use on long-term growth of children
  
  • Generally not associated with clinically significant systemic side effects if given in recommended doses 
• In severe cases, nasal corticosteroids should be started 2 weeks before the start of the pollen season, then given regularly

Systemic Corticosteroids

• May be used in rare conditions in severe patients unresponsive to other treatments and intolerant to intranasal corticosteroid
• Prednisolone/Methylprednisolone should be administered in a short period of time (5-7 days)

Cromones (Nasal)

• Less effective than antihistamines and intranasal corticosteroids
• Compliance is often poor because of the need for frequent administration
• May be considered in symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea) to be given prior to allergen exposure
  • Intraocular cromones may be considered for the management of ocular symptoms (eg conjunctivitis)
• Excellent safety profile make it a suitable option for children and pregnant women

Decongestants

• Promote vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa

Nasal Decongestants

• Eg Oxymetazoline, Xylometazoline
• Very effective in relieving nasal obstruction and rhinorrhea
• Because of the risk of rebound vasodilation (rhinitis medicamentosa) and atrophic rhinitis with prolonged use, their use should be limited to 3-5 days
• Short courses may be used to immediately reduce severe nasal obstruction while giving other medications for allergic rhinitis (eg intranasal corticosteroid-decongestant combination)
• May be added to intranasal corticosteroid or intranasal corticosteroid/antihistamine combination therapy for 4 weeks in patients with persistent nasal congestion

Oral Decongestants

• Eg Ephedrine, Pseudoephedrine
• Weaker effect on nasal obstruction than topical preparations but do not cause rebound vasodilatation
• Help relieve nasal obstruction, rhinorrhea and ocular symptoms
• Use may be considered in patients with severe allergic rhinitis who are unresponsive to oral antihistamines and intranasal corticosteroids
• Use should be limited due to known adverse effects (insomnia, agitation, palpitation)

Leukotriene Receptor Antagonists (LTRA)

• Eg Montelukast, Pranlukast, Zafirlukast
• Efficacy similar to oral antihistamines for patients with seasonal allergic rhinitis
• Help relieve sneezing and rhinorrhea and reduce eosinophilic infiltration and nasal secretion
• Therapeutic option used either alone or in combination with antihistamines; not to be used as initial therapy
  • Should only be considered in patients with treatment failure or intolerance to 1st-line therapy
• Preferred in patients with coexisting asthma
  
  • There is a reduction in beta-agonist use with administration of Montelukast

Saline Solutions

• May be used as single or adjunctive agents in reducing the symptoms of allergic rhinitis
• There is no difference in radiologic or symptomatic score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance

Allergen Avoidance

• The 1st step to symptom control is identification and avoidance of the trigger allergens
• Identifying specific causal allergens by skin testing or laboratory 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
• Elimination of the allergen results in diminished severity of the disease and decreased requirement for medications 
• In the majority of cases, it is not possible to completely avoid allergens but these measures should be considered where appropriate

House Dust Mites

• Major allergen found in houses
• Wash sheets and blankets in hot water (60°C) every week
• Use anti-mite covers in mattresses, beds and pillows
• Vacuum-clean beds each week
• For indoors, use of exhaust circulation-type cleaner is recommended
• Clean furniture in the bedroom with damp rags

Pollen

• Avoid going outdoors on days when pollen counts are high
• Wear a mask and use glasses during heavy pollen dispersal period
• Avoid wearing woolen coats
• Avoid activities which can increase exposure to allergens (eg mowing grass)
• Shake the dust off (eg suit and hair) before entering the house
• Shower after outdoor activities where pollen exposure is high
• Keep doors and windows closed at home and when inside cars
• Use air conditioning

Pets

• Do not allow animals in the house
• If this is not possible, exclude pets from bedroom or keep out of doors
• Clean the rooms and improve the ventilation

Others

• Discourage smoking by patient (active smoking), household members and visitors (passive smoking)
• Minimize contact with irritants (eg perfumes, hair spray and other odors, air pollution from traffic)
• Reduce growth of molds in the home by decreasing humidity or dampness and eliminating sites for mold growth

• Recommended for patients with moderate or severe persistent allergic rhinitis with inadequate response to usual pharmacologic therapy and allergen avoidance measures under the supervision of a specialist or allergist

Principles of Therapy

• Repeated administration of specific allergens to patients with IgE-mediated conditions to provide protection against allergic symptoms associated with exposure to these allergens
  • Most effective if secondary to pollen, dust mites and animal dander; less effective if due to mold
• Specific immunotherapy is effective when optimally administered
• Only treatment that may cause long-term remission of rhinitis (3-5 years)
• Initial dose should be performed in a medical facility by a trained personnel
• Recommended course is usually 4-5 years
• Immunotherapy may be given to children and adults who have the following factors:
  • Evidence of specific IgE antibody to allergen
  • Any of the following:
    • Patient’s preference
    • Adherence to therapy
    • Required medications
    • Adverse effects to medications
    • Poor response to avoidance measures
    • Prevention of asthma in allergic rhinitis patients
    • Clinically diagnosed with both allergic rhinitis and asthma

Subcutaneous Immunotherapy (SCIT)

• Indications:
  • Inadequate control with medications
  • Patient refusal to receive pharmacotherapy or to undergo treatment on a long-term basis
  • Intolerable or unacceptable adverse effects from medications
• Should be considered in patients with seasonal allergic rhinitis due to pollens and perennial allergic rhinitis triggered by house dust mites
• Efficacy for allergic rhinitis is comparable to that of nasal glucocorticoids 
• Limited by frequent injections on regular basis and small risk of anaphylactic reaction

Sublingual Immunotherapy (SLIT)

• Should be considered in patients with allergic rhinitis triggered by house dust mites and grass or ragweed pollen, regardless if patient has asthma 
• 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
• Has been associated with mild oral and gastrointestinal symptoms and less risk for anaphylaxis compared to SCIT