Allergic rhinitis: What’s best for your patient?
The algorithm and recommendations provided here can help you take an evidence-based approach to your patient’s allergic rhinitis.
The summary that follows provides a more detailed look at the recommendations, with a review of the pathophysiology of AR (“Phases of allergic rhinitis”2,3,5,8,13-15).
The early phase of allergic rhinitis (AR) occurs within minutes of allergen exposure. Mast cell degranulation releases histamine and other inflammatory mediators that cause sneezing, pruritus, rhinorrhea, and nasal congestion.3,8,13 The late phase, beginning at 4 hours and peaking 6 to 12 hours after exposure, is believed to be due to recruitment of circulating leukocytes—particularly eosinophils. Leukocyte activation causes additional inflammatory mediators to be released, which primarily causes nasal congestion—often the most bothersome symptom of AR.2,5,8,13,14 Other presenting symptoms may include feeling “fuzzy” or tired, chronic viral infections, sniffing, eye rubbing, blinking, congested voice, snoring, or dark skin beneath the eyes (allergic shiners).15
Of note: This summary preserves the terminology used in ARIA 2010. Specifically, the ARIA guideline uses the term suggest for conditional recommendations and recommend for strong recommendations.4 That same language is used here.
Nasal steroids: First-line Tx for moderate to severe symptoms
BSACI indicates that nasal steroids (NS) are the treatment of choice for moderate to severe persistent AR (symptoms lasting >4 days per week or >4 weeks per year).5 ARIA 2010 suggests NS as first-line treatment rather than oral antihistamines for adults and children with seasonal (related to outdoor allergens such as pollens or molds) and persistent AR.4 ARIA 2008 finds NS are the most effective treatment for children.3 Steroids reduce inflammation by decreasing inflammatory cell migration and inhibiting cytokine release.16 They are the most effective monotherapy for all symptoms of AR, including nasal congestion, which antihistamines do not treat effectively.13,16 NS also treat ocular symptoms of allergy effectively.15,17
The ARIA 2010 guideline also recommends using NS rather than nasal antihistamines and leukotriene receptor antagonists.4 Combination therapy (eg, NS with the addition of nasal antihistamines) is an option for severe or persistent AR, but it appears to be no more effective than monotherapy with NS.16 A 2010 Cochrane review determined there is insufficient evidence for or against the use of oral antihistamines plus NS vs NS alone in children with AR.7 Intermittent steroid use may be beneficial in children.5
Steroids begin working 6 to 8 hours after the first dose, although symptom reduction may take days and maximal effect up to 2 weeks.5 Treatment failure may be due to poor technique that can cause local adverse effects (ie, dryness, irritation, epistaxis). Technique-related failure occurs in up to 10% of users.5,15 Educating patients and families about correct technique with steroid spray may decrease nonadherence due to irritation and epistaxis.18 Tell them to shake the bottle well, look down, aim the nozzle toward the outside wall of the nostril using the opposite hand, and spray while sniffing lightly.5
Any steroid is appropriate for adults. For children ≥2 years of age, consider fluticasone propionate, mometasone furoate, or triamcinolone acetonide.3 These medications have lower systemic bioavailability and a decreased risk of such adverse effects as hypothalamic-pituitary-adrenal axis suppression and growth retardation.15 Budesonide is appropriate for those ≥6 years.19-21 Avoid regular use of betamethasone, which has high bioavailability, for >1 year in children, as it may decrease their growth rate.3 Beclomethasone, fluticasone, and budesonide have been used widely and safely for pregnant women with asthma.5
Antihistamines are first-line Tx for mild symptoms
ARIA 2010 recommends new-generation oral nonsedating antihistamines that do not affect cytochrome P450 for mild AR,4 such as cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine. First-generation antihistamines can reduce symptoms, but are not first-line treatment as they cause sedation, fatigue, decreased cognitive function, and reduced academic and work performance.3-5 ARIA 2010 further suggests choosing oral antihistamines over oral leukotriene receptor antagonists in patients with seasonal AR and in preschool children with persistent AR.4
BSACI recommends oral or topical antihistamines as first-line treatment for mild to moderate symptoms lasting <4 days per week or <4 weeks per year and moderate persistent AR.5 When steroids alone do not control moderate to severe persistent AR, BSACI recommends adding oral or topical antihistamines.5 Oral and topical antihistamines decrease histamine-related symptoms of itching, rhinorrhea, and sneezing, but do not significantly decrease nasal congestion.15
Nasal antihistamines (levocabastine, azelastine) have a rapid onset of action and few adverse effects.3 ARIA 2010 suggests nasal antihistamines over nasal chromones (inhibitors of mast cell degranulation) and notes that the need to use chromones 4 times daily may limit adherence.4 The same guidelines suggest nasal antihistamine use for children and adults with seasonal AR and suggest not using nasal antihistamines for patients with persistent AR until more data on efficacy and safety are available.4
