Journal Reading:

Allergic Rhinitis: Impact, Diagnosis, Treatment

and Management

Diana S Church, Martin K Curch, Glenis K, Clinical Pharmacist

Pharmaceutical Journal, A Royal Pharmacutical Society publication, August 9th, 2016.

Nadien (112013200)
Shienowa Andaya Sari (112015426)
Abstract
Allergic rhinitis occurs in atopic individuals who produce IgE to allergens,
such as pollen, house dustmites, animal dander and moulds.
Treatment is primarily with second generation H1 antihistamines
effective against the early symptoms
And intranasal corticosteroids reduce allergic inflammation and improve
nasal blockage.
First generation H1 antihistamines avoided because they exacerbate
the psychogenic effects of allergic rhinitis.
Respiratory Tract Mucosa
Introduction
Allergic rhinitis is a common allergic disease with increasing prevalence
(30% of individuals), particularly, but not exclusively, teenagers and young
adults.
While considered trivial disease, allergic rhinitis, in addition to the nasal
and ocular symptoms linked to impairments in information processing and
changes in attention-related cognitive processes.
However, it has been estimated that up to 90% of allergic rhinitis patients
are untreated, insufficiently treated or inappropriately treated. This has the
potential to impair patients ability to perform optimally in their daily
professional and personal life.
Pathological and psychological effects of untreated
allergic rhinitis
Allergic rhinitis generally develops during childhood
Studies have shown that these children can experience significant
impairment through multiple physical and psychological aspects. Their
symptoms, particularly a runny nose, . Nasal congestion,
The overall quality of life reduction resulting from allergic rhinitis in adults
is well established it has a detrimental effect on adult cognitive processes
(e.g. productivity at work), as well as other common attention-requiring
activities, such as driving
Mechanisms of allergic rhinitis
Mechanisms of Ocular Symptoms
Patients with allergic rhinitis may also experience ocular symptoms, primarily
reddened, itchy and watery eyes

It is now believed that these symptoms are partly the result of a naso-ocular reflex
in which allergic inflammation in the nose stimulates the trigeminal nerve with
subsequent release of neuropeptides in the tears . These neuropeptides activate
conjunctival mast cells that release histamine but cause little subsequent eosinophil
infiltration and allergic inflammation
Diagnosis of allergic rhinitis by pharmacists
Allergic rhinitis symptoms:
runny nose, itching, sneezing and nasal blockage, are similar to common cold and
can be present intermittently false suggestion of recurrent colds
More common in patients who are allergic to pollens or outdoor moulds (rather
than pets or house dust mites), which are released into the air and cause
symptoms during specific periods of time throughout the year
Taking a History from the Patient
recurrence at a particular time of year or day, or variability of symptoms, suggesting
worsening on exposure to the relevant allergen;

involvement of the eyes (itching, watering, redness, puffiness); or

predominance of itch as a symptom, which can also involve the pharynx and ears.

ergic rhinitis is more likely if there is a past or family history of allergic disease, but
can also occur as the first manifestation of allergy in a previously unaffected person.
Seasonal Considerations
Patients may be allergic to trees, plants and fungi that use the wind to disperse their
pollen or spores
Higher amounts of pollens are released during dry, warmer days when the chance
of their satisfactory dispersion is maximum
While high amounts of pollen and fungal spores are released during warmer days
compared to colder ones, house dust mite allergens are present all year round.
Seasonal Considerations
Further Testing
If in doubt, looking for the likely IgE molecules by skin prick or blood test can be
helpful guided by hstory
Random screening of multiple possible allergens is inadvisable because positive tests
do not always indicate clinical disease
Treatment
H1 - are effective in relieving histamine-induced symptoms, including itch,
antihistamines runny nose and/or sneezing

Lesser effect on nassal blockage

Effective : mild to moderate allergic rhinitis

Rapid onset Onset acute allergic rhinitis

 Treatment
Intranasal primary treatment for nasal obstruction
corticosteroids

act by reducing cytokine production thereby reducing eosinophil

recruitment

Also reduce eosinophil activation and mediator release

Leukotriene are given as tablets and may be effective in some patients but not all
receptor
antagonists
(LTRAs) reduce the effects of the leukotriene C4 (LTC4) that activated mast cells and
eosinophils secrete thereby reduce allergic inflammation

Montelukast and zafirlukast are available on medical prescription only (POM).

Leukotriene synthesis inhibitors (e.g. zileuton), are not available in the UK.
Treatment
Nasal (e.g. xylometazoline and oxymetazoline),
decongestants

are asympathetic receptor stimulants and cause constriction of the arterial vessels
delivering blood to the nasal capacitance vessels, therefore starving them of blood

May be given locally or orally. When given as nasal drops - briefly effective and rapidly
acting be used for short periods usually four to ten days

Regular use induces a decrease in the number of a-receptors in the blood vessels
rendering a reduced effectiveness with time (tolerance)

If used for longer periods- rhinitis medicamentosa, a condition characterised by nasal

congestion without rhinorrhoea or sneezing, may occur because of a reduction of blood
vessel a-receptors thus paralysing the physiological local vasoconstriction process
Treatment
Oral (e.g. pseudoephedrine)
decongestants

are only weakly effective in reducing nasal obstruction but have a

longer duration of up to six hours (with slow release preparations)

Owing to their sympathomimetic effects, they should not be used by

individuals with high blood pressure or heart problems
Treatment
Saline although relatively uncommon in UK, i
douching,

safe and inexpensive method of reducing symptoms in

children and adults with seasonal rhinitis by washing out
sticky mucus from the nose
Treatment of Ocular Symptoms

1. Intranasal are the most effective treatment for reducing nasal

inflammation and, consequently, are effective in
corticosteroids improving conjunctival symptoms

2. H1-antihistamine have a similar efficacy profile to oral antihistamines

with the advantage of a significantly faster onset of
eye drops action

3. Topical which are available as topical eye preparations, are

chromones, sodium also weakly effective. Although purported to be mast
cromoglycate or cell stabilisers, they most likely affect the inhibition
nedocromil sodium, of sensory nerve activation, thereby reducing itching
Selecting the Right Treatment
Oral antihistamines are the first-line treatment used by most patients,
doctors and pharmacists for all allergic rhinitis.

Healthcare professionals should be aware of the significant detrimental

effect of first generation antihistamines (FGAH) on cognitive processes in
all patient groups.
 Selecting the Right Treatment
Histamine acting on H1 -receptors in the brain has a
completely different function to that in the periphery
In the brain, it has an arousal effect and aids concentration and
learning

FGAHs (e.g.
chlorpheniramine, penetrate into the bind to the H1 - causing
diphenhydramine, central nervous receptors in the drowsiness and
hydroxyzine and system (CNS) brain, poor attention
ketotifen)
Selecting the Right Treatment
In Children:
exacerbate the detrimental effect of allergic rhinitis on learning ability
In teenagers:
sitting summer mock GCSE examinations, untreated allergic rhinitis
caused a 40% increased likelihood of students dropping an examination
grade. FGAHs increased this to 70%
In adults:
the detrimental effects of allergic rhinitis on quality of life and
productivity at work are exacerbated by FGAHs, even at the lowest
doses recommended by manufacturers
In elderly:
because of their anticholinergic activity, FGAHs significantly
increase the risk for development of dementia
Selecting the Right Treatment
the British and European Guidelines for both allergic rhinitis and urticaria specify that
only second generation antihistamines should be used for symptom relief, because they
penetrate less well into the brain than FGAHs and have negligible anticholinergic
effects

In UK:
cetirizine and loratadine are currently the only SGAHs - over-the-counter (OTC)
levocetirizine,desloratadine, rupatadine, fexofenadine and bilastine) - prescription-only medicines
(POM).

there are some patients who suffer sedation and psychomotor retardation, especially if
other sedatives or alcohol are taken concomitantly
Selecting the Right Treatment
Intranasal antihistamines are more effective at reducing nasal symptoms than oral
antihistamines, but do not treat extra-nasal symptoms
Corticosteroids should be used as the
therapeutic of choice for anything more than mild disease
Intranasal Steroid
most effective treatment for reducing nasal inflammation and improving conjunctival
symptoms
Management of allergic rhinitis
For patients with intermittent allergic rhinitis caused by seasonal allergens, as the
season wanes and pollen levels in the atmosphere reduce, treatment can be
gradually reduced, if the symptoms are completely controlled, and stopped once the
season is over.

Patients with persistent allergic rhinitis, such as those allergic to perennial allergens
(e.g. house dust mite, animals or indoor moulds) or those with mixed seasonal and
perennial allergies, need longer term therapy. Once complete control of symptoms
has been achieved, a gradual step down can be attempted. The treatment should be
continued for at least three to six months after complete symptom control. If
symptoms recur, the treatment should be restarted, usually for longer periods (e.g.
612 months or even for life)
Allergen avoidance
in real life situations, avoiding aeroallergens to an extent where it would
make a difference in patients symptoms is difficult to reach.
With pollen allergy, closing windows at night,
Avoiding being outside during thunderstorms can also help reduce
symptoms, because the sudden change from a dry to a wet climate causes
pollen grains to rupture and release their allergenic into smaller particles,
which can be easily inhaled into the lower airways and cause attacks of
allergic rhinitis and asthma .