Rhinitis%20-%20nonallergic Treatment
Principles of Therapy
- If possible, treatment should be aimed at the underlying causative physiology of NAR
- No single medication or individual medication class can treat the entire spectrum of symptoms
- Treatment response may be less satisfactory than in allergic rhinitis
Pharmacotherapy
- Block the muscarinic receptors of the seromucinous glands
- Ipratropium is ideal for patients who present with watery rhinorrhea as the main symptom
- Have no activity against sneezing, itching or nasal congestion
- H1-receptor antagonists reduce nasal itching, sneezing and rhinorrhea, but are less effective for nasal obstruction
- Intranasal antihistamines may be offered as first-line monotherapy option for patients with NAR
- May have limited benefit in NAR unless symptoms result from histamine release
- Oral antihistamines may be used as adjunctive therapy in some patients (eg patients with NARES); topical antihistamines have shown better efficacy for NAR
- Azelastine, Olopatadine, or a combination of Azelastine and Fluticasone can reduce symptoms for over a year
- Reduce airway hyperresponsiveness, amount and activity of inflammatory mediators, and allow relaxation of smooth muscle
- Decrease sneezing, pruritus, rhinorrhea and nasal obstruction
- May be offered as a first-line treatment for symptoms of NAR
- Onset of action is relatively slow (6-12 hours), with maximum efficacy developing after 2-3 weeks
- Better response is achieved with continuous use rather than with as-required use
- Patient should be maintained on the lowest dose which achieves symptom control
- Aqueous preparations are preferred because they are less irritating to the nasal mucosa
- Intranasal corticosteroids with low bioavailability is suggested since it has been shown to have no effect on growth
- Provoke vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa
- Very effective in relieving nasal obstruction
- Because of the risk of rebound vasodilation (rhinitis medicamentosa) and atrophic rhinitis with prolonged use, use should be limited to <10 days
- May be used for short term, intermittent or episodic therapy of nasal congestion
- Have weaker effect on nasal obstruction than topical preparations, but do not cause rebound vasodilatation
- May be given to patients with nasal congestion unresponsive to intranasal corticosteroids, intranasal antihistamine, or a combination of both
- For patients with inflammatory NAR that have not responded to anti-inflammatory therapy and combination therapy, an Aspirin challenge can be done followed by desensitization if positive
Nasal Saline Irrigation
- Nasal lavage or saline spray is useful for postnasal drainage symptoms
- Cleanses nasal mucosa when used before intranasal corticosteroids or intranasal antihistamine
Other Investigational Agents
- Some studies show benefit of Capsaicin, Ribomunyl and Silver nitrate for rhinitis symptoms
- Capsaicin and Silver nitrate may be used for vasomotor rhinitis and Ribomunyl for infectious rhinitis
- Topical Capsaicin desensitization reduces symptoms for several months