New hayfever guidelines confirm nasal steroid sprays trump antihistaminesA more recent article on allergic rhinitis steroid nasal spray vs antihistamine available. See related handout on this topic at https: Allergic rhinitis is a common chronic respiratory illness that affects quality of life, productivity, and other comorbid conditions, including asthma. Treatment should be based on the patient's age and severity of symptoms. Patients antihistaminee be advised to avoid known allergens and be educated about their condition.
Treatment of Allergic Rhinitis - American Family Physician
A more recent article on allergic rhinitis is available. See related handout on this topic at https: Allergic rhinitis is a common chronic respiratory illness that affects quality of life, productivity, and other comorbid conditions, including asthma.
Treatment should be based on the patient's age and severity of symptoms. Patients should be advised to avoid known allergens and be educated about their condition. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies e.
With the exception of cetirizine, second-generation antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less than adequate response to usual treatments. Evidence does not support the use of mite-proof impermeable covers, air filtration systems, or delayed exposure to solid foods in infancy.
Allergic rhinitis is an immunoglobulin E—mediated disease, thought to occur after exposure to indoor and outdoor allergens such as dust mites, insects, animal danders, molds, and pollens.
Symptoms include rhinorrhea, nasal congestion, obstruction, and pruritus. Table 1 lists recommended treatments based on symptoms. The initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone, with the use of second-line therapies for moderate to severe disease. Compared with first-generation antihistamines, second-generation antihistamines have a better adverse effect profile, including less sedation with the exception of cetirizine [Zyrtec].
The adverse effects and higher cost of intranasal antihistamines, as well as their decreased effectiveness compared with intranasal corticosteroids, limit their use as first- or second-line therapy for allergic rhinitis. Although safe for general use, intranasal cromolyn Nasalcrom is not considered first-line therapy for allergic rhinitis because of its decreased effectiveness at relieving the symptoms of allergic rhinitis and its inconvenient dosing schedule. Nasal saline irrigation is beneficial in treating the symptoms of chronic rhinorrhea and may be used alone or as adjuvant therapy.
Although dust mite allergies are common, studies have not found any benefit to using mite-proof impermeable mattress and pillow covers. Interventions without documented effectiveness in the prevention of allergic rhinitis include breastfeeding, delayed exposure to solid foods in infancy, and the use of air filtration systems.
For information about the SORT evidence rating system, go to https: Listed in order of treatment preference. Pharmacologic options for the treatment of allergic rhinitis include intranasal corticosteroids, oral and topical antihistamines, decongestants, intranasal cromolyn Nasalcrom , intranasal anticholinergics, and leukotriene receptor antagonists.
Inhibits the influx of inflammatory cells; onset of action is less than 30 minutes. Bitter aftertaste, burning, epistaxis, headache, nasal dryness, potential risk of systemic absorption, rhinitis medicamentosa, stinging, throat irritation.
Arrhythmias, dizziness, headache, hypertension, insomnia, nervousness, tremor, urinary retention. Inhibits histamine release; results typically noted in one week, but may take two to four weeks for full effect. Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. They act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa. Many studies have demonstrated that nasal corticosteroids are more effective than oral and intranasal antihistamines in the treatment of allergic rhinitis.
Although there is no evidence that one intranasal corticosteroid is superior to another, many of the available products have different age indications from the U. Only budesonide Rhinocort carries the FDA pregnancy category B safety rating, and only mometasone Nasonex has a delivery device that received recognition from the National Arthritis Foundation for ease of use. The adverse effects most commonly experienced with the use of intranasal corticosteroids are headache, throat irritation, epistaxis, stinging, burning, and nasal dryness.
One RCT found the rate of skeletal growth unaffected in children using mometasone for one year. Histamine is the most studied mediator in early allergic response.
It causes smooth muscle constriction, mucus secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis. They may cause substantial adverse effects, including sedation, fatigue, and impaired mental status.
These adverse effects occur because the older antihistamines are more lipid soluble and more readily cross the blood-brain barrier than second-generation antihistamines. The use of first-generation antihistamines has been associated with poor school performance, impaired driving, and an increase in automobile collisions and work injuries. Compared with first-generation antihistamines, second-generation antihistamines have a better adverse-effect profile and cause less sedation, with the exception of cetirizine Zyrtec.
Second-generation antihistamines have more complex chemical structures that decrease their movement across the blood-brain barrier, reducing central nervous system adverse effects such as sedation.
Although cetirizine is a second-generation antihistamine and a more potent histamine antagonist, it does not have the benefit of decreased sedation. As a group, the second-generation oral antihistamines are thought to stabilize and control some of the nasal and ocular symptoms, but have little effect on nasal congestion.
In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis e. Compared with oral antihistamines, intranasal antihistamines offer the advantage of delivering a higher concentration of medication to a specific targeted area, resulting in fewer adverse effects.
As a class, their onset of action occurs within 15 minutes and lasts up to four hours. Adverse effects include a bitter aftertaste, headache, nasal irritation, epistaxis, and sedation. Although intranasal antihistamines are an option in patients whose symptoms did not improve with second-generation oral antihistamines, their use as first- or second-line therapy is limited by their adverse effects and cost compared with second-generation oral antihistamines, and by their decreased effectiveness compared with intranasal corticosteroids.
Oral and topical decongestants improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness.
Duration of use for more than three to five days is usually not recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. Intranasal cromolyn is available over the counter and is thought to act by inhibiting the degranulation of mast cells.
Ipratropium Atrovent has been shown to provide relief only for excessive rhinorrhea. Advantages include that it does not cross the blood-brain barrier and is not systemically absorbed. Compliance is also an issue because it needs to be administered two or three times daily. Although the leukotriene LTD 4 receptor antagonist montelukast Singulair is FDA approved for the treatment of allergic rhinitis, a systematic review of 20 trials involving adults treated with montelukast for allergic rhinitis showed only minimal improvement which was not clinically relevant in the symptom of nasal congestion.
Although many studies have looked at the combination of an intranasal corticosteroid with an antihistamine or leukotriene receptor antagonist, most have concluded that combination therapy is no more effective than monotherapy with intranasal corticosteroids. Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments.
The greatest risk associated with immunotherapy is anaphylaxis. Although the usefulness of sublingual immunotherapy in adults with allergic rhinitis has been supported by several large trials, studies in children have met with mixed results, and the FDA has yet to approve a commercial product for sublingual use.
Recombinant DNA technology has also played a role in immunotherapy, allowing for the development of allergen-specific vaccines.
In a multicenter RCT involving adults receiving a recombinant birch pollen vaccine for 12 consecutive weeks followed by monthly injections for 15 months, patients noted statistically significant improvements in rhinosinusitis symptoms, medication use, and skin sensitivities when compared with placebo. Omalizumab Xolair , an anti-immunoglobulin E antibody, has been shown to be effective in reducing nasal symptoms and improving quality-of-life scores in patients with allergic rhinitis.
Although the precise mechanism by which acupuncture works is unclear, proponents suggest that it releases neurochemicals such as beta-endorphins, enkephalins, and serotonin, which in turn mediate the inflammatory pathways involved in allergic rhinitis. Based on RCTs looking at acupuncture as a treatment for allergic rhinitis in adults and children, there is insufficient evidence to support or refute its use.
Based on the limited data to date, probiotics cannot be endorsed as a useful alternative therapy for allergic rhinitis. Studies of probiotics gave mixed results and included 12 RCTs and one study looking at prenatal treatment. Many herb and plant-extract compounds have been studied with respect to allergic rhinitis treatment, but the effectiveness and safety of these compounds have not been established. Patients with allergic rhinitis should avoid exposure to cigarette smoke, pets, and allergens to which they have a known sensitivity.
Nasal irrigation is beneficial in the treatment of chronic rhinorrhea and may be used alone or as adjuvant therapy. Prevention has been a large focus in the study of allergic rhinitis, but few interventions have proven effective.
Already a member or subscriber? Address correspondence to Denise K. Reprints are not available from the authors. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. Prim Care Respir J. British Society for Allergy and Clinical Immunology. BSACI guidelines for the management of allergic and non-allergic rhinitis. Plaut M, Valentine MD. N Engl J Med.
The diagnosis and management of rhinitis: Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intra-nasal corticosteroids: Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis.
Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: Ann Allergy Asthma Immunol. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis.
Intranasal steroid sprays in the treatment of rhinitis: Safety of intranasal corticosteroids in acute rhinosinusitis. A review of the preclinical and clinical data of newer intra-nasal steroids used in the treatment of allergic rhinitis. Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray.
Medium and long-term growth in children receiving intranasal beclomethasone dipropionate: Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. Effects of repeated once daily dosing of three intranasal corticosteroids on basal and dynamic measures of hypothalamic-pituitary-adrenal-axis activity.
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