Rhinitis%20-%20nonallergic Treatment

• 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

• 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 1st-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, and 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 1st-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, Azelastine, 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 Azelastine

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