Rhinitis - Allergic Điều trị

Evaluation

• Mild intermittent allergic rhinitis
• Moderate-severe intermittent allergic rhinitis
• Mild persistent allergic rhinitis
• Moderate-severe persistent allergic rhinitis 

• ≥5: Uncontrolled (VAS score of 5 suggests moderate-severe allergic rhinitis)
• ≥2 to <5: Partially controlled
• <2: Well-controlled

Principles of therapy

Treatment is based on the duration and severity of symptoms. A stepwise approach to treatment is recommended for adolescents and adults. Step down therapy as the patient’s symptoms improve and step up when the symptoms worsen. 

Similar therapeutic principles are applied in children; however, care should be taken to avoid the adverse effects of certain classes of drugs in the pediatric population. Drugs used for rhinitis are usually administered either orally or intranasally. 

Combination or step-up therapy is recommended for patients with disease progression after monotherapy or those with severe allergic rhinitis. Recommendations depend on the pattern of exposure to allergens.

• Combination therapy of an intranasal corticosteroid with an oral antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Combination therapy of an intranasal corticosteroid with an intranasal antihistamine is preferred over monotherapy with an intranasal antihistamine
• Leukotriene receptor antagonist or an oral antihistamine: No specific preference
• Intranasal antihistamine or an oral antihistamine: No specific preference 

• Monotherapy with intranasal corticosteroid is preferred rather than the combination of an intranasal corticosteroid with an oral antihistamine
• For combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Intranasal antihistamine or an oral antihistamine: No specific preference 

Pharmacological therapy

Anticholinergics

Example drug: Ipratropium bromide

Anticholinergics work by blocking the muscarinic receptors of the seromucinous glands. They effectively control watery rhinorrhea but do not affect sneezing or nasal congestion, which precludes their use as a first-line medication. They may be used together with intranasal corticosteroids or antihistamines in patients in whom rhinorrhea is the predominant symptom, or in whom rhinorrhea does not respond well to the other medications. 

Antihistamines

H₁-receptor antagonists reduce nasal itching, sneezing, and rhinorrhea, but are less effective for nasal obstruction. They are considered as first-line treatment for mild-moderate intermittent and mild persistent rhinitis. They are added to intranasal corticosteroids for moderate-severe persistent rhinitis with eye symptoms uncontrolled by intranasal corticosteroid monotherapy. 

Nasal Antihistamines 

Example drugs: Azelastine, Levocabastine, Olopatadine

Nasal antihistamines have a rapid onset of action (<15-30 minutes). They are recommended in patients with seasonal, perennial, or episodic allergic rhinitis. They are also recommended as a first-line option for patients with intermittent allergic rhinitis. They are the preferred treatment for allergic rhinitis when compared to intranasal cromones. They are associated with a significant effect on nasal congestion. 

They are considered effective at the site of administration and may be used for mild, organ-limited disease or as an “as required” medication used together with a continuous one. They are as effective as oral antihistamines but they require twice-daily dosing. 

Oral Antihistamines 

Oral antihistamines have the advantage of relieving other allergic symptoms of other sites (eg conjunctivitis) along with nasal symptoms. They may be used to prevent symptoms associated with occasional allergy exposure. They are preferred over leukotriene receptor antagonists (LTRA) in patients with moderate-severe perennial allergic rhinitis. 

Second-generation antihistamines are preferred over intranasal antihistamines. The use of first-generation antihistamines should be limited as they may reduce academic ability in school children and may produce performance impairment in adults while driving. They have an onset of action that occurs within 1 hour. 

Second-generation Oral Antihistamines

Example drugs: Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, Mequitazine, Rupatadine

Second-generation oral antihistamines should be considered as a first-choice treatment and are preferred over first-generation oral antihistamines. They have less undesirable central nervous system (CNS) and fewer anticholinergic effects compared to first-generation antihistamines. They have little or no sedative effect at the recommended dosages. 

First-generation Oral Antihistamines 

Example drugs: Chlorpheniramine, Clemastine, Diphenhydramine 

The use of first-generation antihistamines is limited by their sedative and anticholinergic side effects and short half-life. They may further impair cognitive functioning and school performance in children.

Intraocular Antihistamines 
Intraocular antihistamines may be used in patients with symptoms of ocular involvement (eg conjunctivitis).

Anti-Immunoglobulin E Antibody

Example drug: Omalizumab 

Omalizumab has been shown to be effective in reducing nasal symptoms and improving quality of life in patients with seasonal allergic rhinitis. 

Corticosteroids

Corticosteroids have a strong anti-inflammatory capacity by reducing cytokine and chemokine release. 

Intranasal Corticosteroids

Example drugs: Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone 

Intranasal corticosteroids are more efficacious than oral or topical nasal antihistamines in relieving symptoms of allergic rhinitis, especially nasal obstruction. 

They are considered first-line treatment in patients with moderate-severe and/or persistent symptoms. They are preferred over intranasal and oral antihistamines in patients with moderate-severe perennial or seasonal allergic rhinitis. Monotherapy with intranasal steroids is preferred over a combination with oral antihistamines for patients with perennial allergic rhinitis. Combination therapy with intranasal antihistamines is more effective than monotherapy with intranasal steroids in patients with moderate-severe disease. 

In severe cases, nasal corticosteroids should be started 2 weeks before the start of the pollen season, then given regularly. 

The onset of action takes a few hours (6-12 hours) to a few days, with maximum efficacy developing after two weeks. Aqueous preparations are preferred because they are less irritating to the nasal mucosa. Studies have shown reassuring safety data of Fluticasone, Mometasone, and Ciclesonide use on the long-term growth of children. They are generally not associated with clinically significant systemic side effects if given in recommended doses. 

Systemic Corticosteroids 

Systemic corticosteroids may be used in rare conditions in severe patients unresponsive to other treatments and are intolerant to intranasal corticosteroids. Prednisolone or Methylprednisolone should be administered in a short period of time (5-7 days). 

Cromones (Nasal)

Nasal cromones are less effective than antihistamines and intranasal corticosteroids. Compliance is often poor because of the need for frequent administration. They may be considered in symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea) to be given prior to allergen exposure. Intraocular cromones may be considered for the management of ocular symptoms (eg conjunctivitis). 

Cromones have an excellent safety profile that may make them a suitable option for children and pregnant women.

Decongestants

Decongestants promote vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa. 

Nasal Decongestants 

Example drugs: Oxymetazoline, Xylometazoline 

Nasal decongestants are very effective in relieving nasal obstruction and rhinorrhea. Because of the risk of rebound vasodilation (rhinitis medicamentosa) and atrophic rhinitis with prolonged use, their use should be limited to 3-5 days. Short courses may be used to immediately reduce severe nasal obstruction while giving other medications for allergic rhinitis (eg intranasal corticosteroid-decongestant combination). They may be added to intranasal corticosteroid or intranasal corticosteroid/antihistamine combination therapy for four weeks in patients with persistent nasal congestion. 

Oral Decongestants

Example drugs: Ephedrine, Pseudoephedrine  

Oral decongestants have a weaker effect on nasal obstruction than topical preparations but do not cause rebound vasodilatation. They help relieve nasal obstruction, rhinorrhea, and ocular symptoms. Their use may be considered in patients with severe allergic rhinitis who are unresponsive to oral antihistamines and intranasal corticosteroids. Their use should be limited due to known adverse effects (insomnia, agitation, palpitation). 

Leukotriene Receptor Antagonists (LTRA)

Example drugs: Montelukast, Pranlukast, Zafirlukast  

The efficacy of LTRA is similar to oral antihistamines for patients with seasonal allergic rhinitis. They help relieve sneezing and rhinorrhea and reduce eosinophilic infiltration and nasal secretion. It is a therapeutic option used either alone or in combination with antihistamines but should not be used as initial therapy. It should only be considered in patients with treatment failure or intolerance to first-line therapy. They are also preferred in patients with coexisting asthma. There is a reduction in beta-agonist use with the administration of Montelukast. 

Saline Solutions

Saline solutions may be used as single or adjunctive agents in reducing the symptoms of allergic rhinitis. There is no difference in the radiologic or symptomatic score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance.

Immunotherapy

• Patient’s preference
• Adherence to therapy
• Required medications
• Adverse effects to medications
• Poor response to avoidance measures
• Prevention of asthma in allergic rhinitis patients
• Clinically diagnosed with both allergic rhinitis and asthma

Subcutaneous Immunotherapy (SCIT) 

The indications of SCIT include inadequate control with medications, patient refusal to receive pharmacotherapy or to undergo treatment on a long-term basis, and intolerable or unacceptable adverse effects from medications. 

It should be considered in patients with seasonal allergic rhinitis due to pollens and perennial allergic rhinitis triggered by house dust mites. The efficacy of SCIT for allergic rhinitis is comparable to that of nasal glucocorticoids. However, it is limited by frequent injections on a regular basis and the small risk of an anaphylactic reaction. 

Sublingual Immunotherapy (SLIT)

SLIT should be considered in patients with allergic rhinitis triggered by house dust mites and grass or ragweed pollen, regardless of whether the patient has asthma. It is considered a more viable treatment compared to SCIT as self-administration is encouraged with this form. Its use should be limited to those who can tolerate systemic reactions and its treatment. It has been associated with mild oral and gastrointestinal (GI) symptoms; however, it has less risk for anaphylaxis compared to SCIT. 

Lifestyle Modification

Allergen Avoidance 

The first step to symptom control is the identification and avoidance of the trigger allergens. Identifying the specific causal allergens by skin testing or laboratory testing may encourage patients to comply with allergen avoidance instructions. The effectiveness of avoidance will be measured by relieving the patient’s symptoms and decreasing the need for medications. 

Elimination of the allergen results in diminished severity of the disease and decreased requirement for medications. In most cases, it is not possible to completely avoid allergens, but these measures should be considered where appropriate. 

House Dust Mites 

House dust mites are the major allergen found in houses. Advise patients to wash sheets and blankets in hot water (60°C) and to vacuum-clean beds every week. It is advised to use anti-mite covers on mattresses, beds, and pillows, and clean furniture in the bedroom with damp rags. For indoors, the use of an exhaust circulation-type cleaner is recommended.

Pollen 

Advise patients to avoid going outdoors on days when pollen counts are high. Advise patients to wear a mask and use glasses during heavy pollen dispersal period, avoid wearing woolen coats, and avoid activities which can increase exposure to allergens (eg mowing grass). Inform the patient to shake the dust off (eg suit and hair) before entering the house, shower after outdoor activities where pollen exposure is high, keep doors and windows closed at home and when inside cars, and use air conditioning. 

Pets 

Advise patients to not allow animals in the house. If this is not possible, exclude pets from the bedroom or keep them out of the door. Inform patients to clean the rooms and improve ventilation. 

Others 

Discourage smoking by patients (active smoking), household members, and visitors (passive smoking). Advise patients to minimize contact with irritants (eg perfumes, hair spray and other odors, air pollution from traffic). Advise patients to reduce the growth of molds in the home by decreasing humidity or dampness and eliminating sites for mold growth. 

Patient Education

Surgery

Inferior Turbinate Reduction

Inferior turbinate reduction may be offered to patients with nasal airway obstruction and hypertrophic inferior turbinates who are unresponsive to pharmacological therapy. It should be reserved for patients with persistent allergic rhinitis.