Management Allergic Rhinitis (AR)

Therapheutic consideration :
• Treatment options include:
– Enviromental control for avoidance of
allergens and triggering factors
– Pharmacotherapy
– Immunotherapy
– Patient education and follow up
 THERAPEUTIC CONSIDERATIONS

Allergen Avoidance
indicated when possible

Immunotherapy
Pharmacotherapy COSTS effectiveness
safety, effectiveness, easy specialist prescription
administration may alter the natural
course of the disease

Patient Education
always indicated
• The goal of treatment :
– To control of symptoms improvement of the
patient’s quality of life, while maintaining
function.
– Prevention of sequele : disturbed sleep,
exacerbation of asthma, eustachian tube
dysfunction with otitis media and
rhinosinusitis.
 TREAT IN A STEPWISE APPROACH
(adolescent and adults)
Diagnosis of allergic rhinitis
(history ± skin prick tests or serum specific IgE)
Allergen avoidance
Intermittent symptoms persistent symptoms
Moderate mild Moderate
Mild Severe Severe
Not in preferred order Not in preferred order Intranasal CS
• oral H1 – blocker •Oral H1 blocker
•Intranasal H1 blocker •Intranasal H1 – blocker Review the patient After 2-4 wks
•And/or decongestant
•And/or decongestant •Intranasl CS improved Failure
•(chromone)
Step-down Review diagnosis
In persistent rhinitis review the And continue Review compilance
patient after 2-4 weeks Treatment Query infections
For 1 month Or other causes

If failure: step-up Blockage

Increase Rhinorrhea add
If improved; continue for 1 month Intranasal add decongestan
CS dose ipratropium
t or oral CS
(short term)
itch/sneeze
Add H1 blocker
failure

ARIA = Allergic Rhinitis and its Impact on Asthma Surgical referral

Bousquet et al. J. Allergy Clin Immunol 2001: 08 (5 Suppl): S147
Environmental control of avoidance of
allergens and triggering factors
– Educating families about avoiding exposure to
allergens and triggering factors, about the
importance its and advised to adhere to extent
posible (Tabel 1)
 TABEL 1 Environmental Control of Allergen Exposure
Allergens Control Measures
Dust mites Encase bedding in airtight covers
Wash bedding in water at temperatures > 130°F
Remove wall-to-wall carpeting
Remove upholstered furniture

Animal dander Avoid furred pets

Keep animals out of patient’s bedroom

Cockroaches Control available food supply

Keep kitchen/bathroom surfaces dry and free of standing water
Professionally exterminate

Mold Destroy moisture-prone areas

Avoid high humidity in patient’s bedroom
Repair water leaks
Check basements, attics, and crawl spaces for standing water and mold
Pollen Keep automobile and house windows closed
Control timing of outdoor exposure
Restrict camping, hiking, and raking leaves
Drive in air-conditioned automobile
Air-condition the home
Install portable, high-efficiency particulate air filters
•Steam and saline:
Irrigation assists of rinsing allergen out of
nasal passage and help to prevent
crusting of dried nasal secretions

•Exercise
Decrease in nasal airway resistance as
result of increased sympathetic (α
adrenergic) activity
 Pharmacotherapy
• An ideal pharmacologic agent will mantain
quality of life. Have criteria:
– Proven safety and efficacy,
– Easy route of administration with rapid
absorbtion,
– Rapid onset of action with no side effects, and
– Anti allergenic activity

American Academy of allergy, asthma and immunology. The Allergy

report, April 2, 2002
 ARIA PG. Bosquet et al. j allergy clin immunol 2001 : 0815 suppl :s 147

• therapheutic agents that are indicated for

treatment of allergic rhinitis:
– Oral and intranasal antihistamin,
– Intranasal glucocorticoids,
– Oral and intranasal decongestants,
– Local chromones,
– Intranasal anticholinergics, and
– Anti leucotriens
 Treatment – Recommendations (ARIA)

Intervention Seasonal Seasonal Perennial Perennial

adults children adults children
Oral H1 A A A A
antihistamines
Intranasal H1 A A A A
antihistamines
IN steroids A A A A
IN chromones A A A
Anti-leukotrienes A
Subcutans A A A A
immunotherapy/IT
Sub Lingual IT A A A
Nasal SIT A A A
Alergen avoidance D D D D

A = RCT – meta-analysis / D = clinical experience

 ANTIHISTAMIN (AH)

• Act primarily by blocking the H1-histamine receptor. Several newer

agents also have mild anti inflammatory properties
• AH reduce symptoms of sneezing, pruritus and rhinorrhoea. Have
little or no effect on nasal congestion
• For optional results AH should be adminstered:
– Prophylactically (2-5 hours before allergen exposure)
– On regular basis if needed chronically
– Effective on as needed basis, but work best when administered in
maintenance fashion

Bernstein H, Storms : Practice parameters for allergen diagnostic testing: joint Task Force
on Practice Parameters for the Diagnosis and treatment of Asthma. Ann Allergy Asthma
Immunol 75:543-635.1995
 Antihistamines (AH)

• Three generation are available:

• The first generation (---------) cross the blood
brain barrier poor specificity for the H receptor
and interact with other receptor such as the
cholinergic receptor : sedating and drymouth
• The second generation (loratadine, cetirizine)
hyposedating or non sedating
• The third generation (fexofenadine,
desloratadine, leucocetirizine) non sedating
 Decongestants
• Used orally or as nasal sprays: symphatomimetic (α-
adrenergic receptor activation)  produce vasoconstriction
within the nasal mucosa  relieving the symptom of nasal
obstruction.

• side effects DC oral (pseudo ephedrine and phenylephrine) :

central nervous system (nervousness, insomnia, irritability,
headache) and cardiovascular (palpitation, tachycardia)
effects. In addition may elevated blood pressure, raise
intraocular pressure, and aggravate urinary obstruction

American Academy of Allergy, Asthma & Immunology. The Allergy Report. Available at:
http://www.theallergyreport.org/reportindex.html.
Accessed April 2,2002
 Decongestant
• Intranasal (ephinephrine, naphtazoline,
oksimethasolin and xylomethazoline) quick
relief and more effective.
• Side effect milder than decongestant oral
• Use for longer than 3-5 days rebound
congestion after withdrawal of drug.
• Continue to use over several months
rhinitis medicamentosa
Willsie. Improve strategies and new treatment for Allergic rhinitis. 58.JAOA. Supplement
2.Vol 102. No 6. June 2002.
 Intranasal costicosteroid
• Multiple mechanisms : vasoconstriction and
reduction of edema, suppression of cytokine
production and inhibition of inflammatory cell
influx.
• The efficacious agent for treating RA in
relieving symptoms of nasal pruritus,
rhinorrhea sneezing and congestion.

Mygind N, Nielsen LP. Hoffman H).et al : mode of acxtion of intranasal cortico

steroids.J Allergy clin Immunol 108 : S16-S25.2001
 Intranasal costicosteroid

• Prophylactic treatment before nasal

allergy challenge reduce both the early
and late phase allergy responses. Work
best when taken regularly on a daily
basis.
• Rapid onset in action (12-24 hours) 
effective when used intermittenly.
 Intranasal costicosteroid

• Pharmacologic Charateristic After intranasal

administration :
– beclomethasone dipropionate, budesonide,
flunisolide, and triamcinolone acetonide,
the resulting bioavailabilities can 50 %, but
neither
– fluticasone propionate and mometasone
furoate have low systemic availabilities
(<1%) most important in growing
children and asthma
Allen DB. Systemic effect of intranasal steroid an endocrinologist’s
perspective.J Allergy Clin Immuno.200;106 Suppl 4:179-190
 Intranasal costicosteroid

• Side effect :
- dryness and irritation of the nasal
mucous membranes in 5 % - 10 %
mild cases.
- mild epistaxis 5 %
- for mild symptoms, the dose may be
reduced, and/or saline nasal spray
should be instilled before the drug is
sprayed.
 Mast cell stabilizers
Sodium Cromoglicate
• Inhibit the release of mediator from mast cell.
• Can be useful in relieving nasal pruritis,
rhinorrhea, and sneezing; minimal effects on
congestion
• Well tolerated and most efficacious when
taken prophylactically, well in advance of
allergen exsposure.
 Intranasal Anticholinergics
• Ipratroporium Bromide reduce rhinorrhea
associated with allergic and non allergyc
rhinitis.
– Most helpful when rhinorrhea is refractory to
topical intranasal corticosteroids and/or
antihistamines. can be helpful for blocking
reflex-mediated rhinitis in people with profuse
rinorrhea.
– Side effect: drying of nasal mucosa, crusting and
epistaxis.
 Management of Allergic Rhinitis: Assessing Pharmacologic
Agents
Agent Sneezing Itching Congestion Rhinorrhea Eye Symptoms
Oral ++ ++ +/- ++ ++
antihistamine
Nasal + + +/- + -
antihistamine
Intranasal ++ ++ ++ ++ +
corticosteroid
Oral - - + - -
decongestant
Intranasal - - ++ - -
decongestant
Intranasal mast + + + + -
cell stabilizer
Topical - - - ++ -
anticholinergic

Pediatrics in Review, Vol26,No 8, August 2000

• Allergen Immunotherapy
Allergen immunotherapy induces a state of allergen-specific
T-lymphocyte tolerance. Immunotherapy should be
considered in patients who :
1. do not respond to a combination of environmental
``control measures and medications
2. experience substansial side effects with ```medications.
3. have symptoms for a significant portion
4. prefer long term modulation of their allergic
``symptoms
It must be administered by a physician who make the
decision and know about the positive and negative effects.
• Conclusions

Allergic rhinitis is often overlooked or untreated.

Allergic rhinitis in children relies on awarness of the
symptoms and signs of the disease and its
comorbidities, including asthma, sinusitis, and
otitis media.
Treatment options include environmental controls
and the use of intranasal corticosteroid,
nonsedating antihistamines, decongestant and
immunotherapy.