MANAGEMENT OF ALLERGIC RHINITIS

What is the principle of management of AR?

Preventive therapy 

Pharmacotherapy

Immunotherapy

Global Allergic Rhinitis and its Impact on Asthma (ARIA) provides an evidence-based approach to treatment and includes quality-of-life measures useful for the evaluation of symptoms and the assessment of the response to therapy.

What preventive measures can be taken?

Specific measures to limit indoor allergen exposure may reduce the risk of sensitization and symptoms of allergic respiratory disease. 

Sealing the patient's mattress, pillow, and covers in allergen-proof encasings reduces the exposure to mite allergen. 

Bed linen and blankets should be washed every week in hot water (>54.4°C [130°F]). 

The only effective measure for avoiding animal allergens in the home is the removal of the pet. 

Avoidance of pollen and outdoor molds can be accomplished by staying in a controlled environment. 

Air conditioning allows for keeping windows and doors closed, reducing the pollen exposure. 

High-efficiency particulate air (HEPA) filters lower the counts of airborne mold spores.

How do we approach patients for pharmacotherapy?

We can categorize the patients as

Children below 2 years 

Older children and adults

Pregnant women

Breast feeding women

Older adults

How do we treat children below 2 years of age?

Usually children below 2 years do not develop AR as repeated exposures to allergen are required for a full blown picture of AR. One should always suspect adenoid hypertrophy or other anatomical abnormalities.

However, in cases where AR is diagnosed after excluding others we have treat them.

In mild cases :

Cromolyn sodium nasal spray or 

Oral antihistamines 

In severe cases:

Steroid nasal spray - 1 spray in each nostril per day but twice daily in few cases but for limited time.

How do we treat older children and adults?

In mild cases 

Oral antihistamine  or 

Antihistamine nasal spray or 

As needed or regular steroid spray or

Cromolyn sodium spray

In severe cases:  

Regular use steroid nasal spray 

In refractory cases steroid nasal spray with antihistamine spray combination(best combination) or

steroid nasal spray + oral antihistamine or

steroid nasal spray + oral antihistamine/decongestant combination.

How to treat a cae of AR with allergic conjunctivitis?

In many cases steroid nasal spray is sufficient for both.

However, adding an ophthalmic antihistamine drop is better and is effective than an oral antihistamine.

Cromolyn sodium is available in ophthalmic preparations and may also be useful as prophylactic therapy before predictable allergen exposures (ie, visiting a home with cats).

How do we treat an AR with moderate to severe asthma?

For patients with moderate-to-severe asthma that is not controlled with high doses of inhaled glucocorticoids, at least two biologic therapies for asthma also improve the symptoms of allergic rhinitis.

Omalizumab, an anti-IgE monoclonal antibody that is approved for asthma and chronic urticaria, is shown to reduce daily nasal symptoms, rescue medication use, and improve quality of life in patients with uncontrolled allergic rhinitis.

Dupilumab, an anti-interleukin (IL)-4 receptor alpha monoclonal antibody that is approved for asthma and chronic rhinosinusitis with nasal polyposis, also improves symptoms of allergic rhinitis.

How do we treat AR during pregnancy?

Non-drug approach is first choice during pregnancy in mild cases.

Oral anti-histamine - 2nd generation usually loratidine and cetirizine are preferred. No enough data on fexofenadine. If 1st generation is prescribed chlorpheramine is studied for others no sufficient data on safety during pregnancy.

In severe cases - Steroid nasal spray is very effective. Except triamcinolone all other sprays are safe. For Triamcinolone, 1 case had respiratory system abnormality.

No data on use of oral or nasal decongestants like oxymetazoline or pseudoephedrine.

Immunotherapy can be used but with caution as systemic reactions may occur.

How do we treat AR in breast feeding mother?

All patients should practice allergen avoidance. 

Nasal saline sprays or irrigation can always be tried for any nonspecific relief it can provide.

Intermittent congestion (symptoms less than four days per week) may be treated judiciously with a topical decongestant spray. 

Mild persistent symptoms (symptoms more than four days/week and more than four weeks/year) may be treated with intranasal budesonide or cromolyn and supplemented by cetirizine or loratadine.

Moderate-to-severe persistent symptoms may be treated with maintenance intranasal budesonide and/or immunotherapy injections and supplemented as needed with cetirizine or loratadine.

How do we treat AR in older adults?

Steroid nasal spray are first line therapy.

Avoid first generation antihistamine.

What is the use of normal saline?

Nasal saline sprays or irrigation with larger volumes of saline can wash allergens from the nasal passages. 

Saline can be used alone for mild symptoms or just before other topical medications, so that the mucosa is freshly cleansed when the medications are applied

What are the benefits of nasal saline irrigation?

Saline irrigates mucus and allergens from nasal mucosa

Sinuses are moisterized

Studies have shown that saline irrigation improves the cell function.

Recipe of the nasal salin solution

Add 1 to 1 and half heaping teaspoon of salt (caning salt not the table salt) and 1 teaspoon of sodium bicarbonate 1 quarter of previously boiled or sterilised water.

Use a neti-pot or 30cc syringe or water pick with an irrigation tip (preferred method), squeeze bottle, or Neti pot. Do not use a baby bulb syringe. The syringe or pick should be sterilized frequently or replaced every two to three weeks to avoid contamination and infection. 

Neti Pot

water pick with irrigation tip

Mix ingredients together, and store at room temperature. Discard after one week.

You may also make up a solution from premixed packets that are commercially prepared specifically for nasal irrigation.

The instructions

Irrigate your nose with saline one to two times per day.

If you have been told to use nasal medication, you should always use your saline solution first. The nasal medication is much more effective when sprayed onto clean nasal membranes, and the spray will reach deeper into the nose.

Pour the amount of fluid you plan to use into a clean bowl. Do not put your used syringe back into the storage container, because it contaminates your solution.

You may warm the solution slightly in the microwave, but be sure that the solution is not hot.

Bend over the sink (some people do this in the shower), and squirt the solution into each side of your nose, aiming the stream toward the back of your head, not the top of your head. The solution should flow into one nostril and out of the other, but it will not harm you if you swallow a little.

Some people experience a little burning sensation the first few times that they use buffered saline solution, but this usually goes away after they adapt to it.

Why boiled or sterilized water is used?

It is because of the risk of primary amebic meningoencephalitis which is a rar but fatal disease caused by Naegleria fowleri found in tapwater.

Which is the best pharmacotherapy for chronic use?

Steroid nasal spray is  the best for chronic therapy.

What is the mode of action?

Anti-inflammatory and immune modulation.

What are the steroid sprays available?

1st generation 

Systemic bioavailability of 10 to 50%

Beclomethasone 

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1-2 sprays in each nostril once daily.

use above 6 years.

Not available as OTC

1-2 sprays once daily. Use above 6 years. Available as OTC

In children between 6-11 years use start as 1 spray twice daily and then change to 2 spray once daily.

Flunisolide - 25mcg/spray 

Not available as OTC.

2 sprays 2-3 times/day maximum upto 4 times a day.

Indicated above 6 years

Can be used above 2 years of age 

2-5 years - 1 spray in each nostril once daily

Available as OTC.

above 6 years - 2 spray in each nostril once daily

SECOND GENERATION

<1% systemic bioavailability

NOT AVAILABLE AS OTC

either 50mcg/spray or 37 mcg/spray

50 mcg/spray above 12 years - 1 spray once daily

37 mcg/spray 

2 to 11 years: One or two sprays once daily

≥12 years: Two sprays once daily

FLUTICASONE PROPIONATE

 Available as OTC

4 to 11 years: One spray once daily

≥12 years: Two sprays once daily or one spray twice daily

Available as OTC

One or two sprays once daily; in children 2 to 11 years, start with one spray once daily

MOMETASONE

Not available as OTC

50 mcg/spray

2 to 11 years: One spray once daily

≥12 years: Two sprays once daily

Ritonavir significantly increases fluticasone serum concentrations and may result in systemic corticosteroid effects.

Use fluticasone with caution in patients receiving ketoconazole or other potent cytochrome P450 3A4 isoenzyme inhibitor

How to use steroid spray?

Proper positioning of the head can prevent the spray from draining down the throat. 

With the aqueous (nonaerosol) glucocorticoid nasal sprays, the patients should be instructed to keep their head pointed slightly downward during spraying and avoid tilting the head back. 

In addition, they should avoid pointing the spray at the septum, which can become irritated.

What is the duration of treatment?

For seasonal AR - during seasons 

For perennial and severe cases - chronic use is necessary - start with maximum dose and then taper - use alternate day when symptoms - gradually taper and stop once symptoms resolve.

What are the side effects?

Systemic side effects are less common.

Nasal perforation and epistaxis can occur.