Allergic Rhinitis

Mitchell R. Lester
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Treatment of allergic rhinitis
The management of AR is analogous to that of asthma with education (trigger avoidance), symptom reliever medications (“rescue”), preventive medications (“controllers”), and immunotherapy (“immune deviation”). In addition, a similar stepwise approach and appropriate medication adjustment is essential (J Allergy Clin Immunol. 2001;108:S147. and Ann Allergy Asthma Immunol. 2011;106(2):S17-19).

Everyone should make an attempt to decrease exposure to his or her triggers of allergic rhinitis. When I speak of allergen avoidance, I speak of decreasing not eliminating exposure, as the latter is virtually impossible. Because of the ubiquity of perennial aeroallergens (dust mites, mold, and animal dander) even in schools, public transportation, and work environments, efforts for avoidance should first be directed at the home environment. Practitioners should become familiar with methods of allergen avoidance to make appropriate recommendations after testing for specific IgE is completed.

Medical treatment of AR requires follow-up visits, reassessment, and dose adjustments. The “best” regimen for a patient is the one that is most effective, best tolerated, and uses the least amount of medication necessary to accomplish those goals No single plan works best for everyone.

Second generation antihistamines (loratadine, desloratadine, fexofenadine, cetirizine, and levocetirizine) are the treatment of choice for relief of sneezing, rhinorrhea, and nasal, palatal, and ocular itch. Because these are large lipophilic molecules that do not easily cross the blood-brain barrier, second generation antihistamines are less likely to be sedating, and have fewer anticholinergic side effects than the first generation antihistamines such as diphenhydramine and hydroxyzine. They are also are longer acting. Antihistamines may not have a tremendous effect on nasal congestion for which oral decongestants (e.g., pseudoephedrine) may be necessary. Intranasal antihistamine sprays (azelastine, olopatadine) may also help relieve congestion, but some patients find the after taste unpleasant. Intranasal decongestant sprays should be used sparingly because of the risk of rhinitis medicamentosa.

Patients with mild AR may not require anything more than adequate symptom relievers. However, patients with symptoms more often than 4 days per week, for more than 4 weeks, and/or whose symptoms interfere with their quality of life (i.e., moderate or severe AR) require daily controller medications. The gold standard for preventive medications for AR are the low-dose intranasal corticosteroid sprays (INS). This large class of medications effectively manages all the symptoms of AR except palatal and ear itch, for which antihistamines might still be necessary. INS use prevents release of mediators of allergic inflammation (except leukotrienes) thereby preventing symptoms. Furthermore, they reduce nasal hyper-reactivity (analogous to bronchial hyper-reactivity of asthma) and reduce the priming effect caused after allergen exposure. By attenuating the naso-ocular reflex, INS might also contribute to control of allergic conjunctivitis.

The INS are intended for regular/daily use and are extraordinarily safe. They have negligible if any of systemic side effects. The most common adverse effects are local drying, irritation, and epistaxis that are reduced by aiming the spray laterally, not medially during application. Nonetheless, many patients do not prefer this useful class of medications because of intolerable side effects, aversion to nasal sprays, or steroid phobias.

The leukotriene receptor antagonists (LTRAs) are an alternative to INS for symptom prevention, especially in those resistant to use or intolerant of INS or for whom the INS are ineffective. Although montelukast and related medications generally do not work as well in as many people as the INS, there are patients for whom LTRAs provide outstanding or even complete relief of symptoms by blocking the leukotriene pathway. One can only speculate that in those patients, the leukotriene mediators are a primary cause of allergic inflammation. The LTRAs are well tolerated and with the exception of previous adverse reaction there is no contraindication to their use.

The medical regimen should be stepped up or down as indicated depending on the degree of control. Patients with seasonal worsening may need annual seasonal adjustments.

Allergen immunotherapy (AIT) is a highly effective and potentially curative treatment option for AR. By altering the immune response to aeroallergens from a TH2 to a TH0 or T reg response, most patients achieve tolerance to allergens and ultimately require little or no daily controller medications.

All patients with moderate or severe AR should be considered for AIT as long as they have allergen-specific IgE that correlates with their symptom pattern. Of great importance, those with poor symptom control despite using controller medications and who are trying to avoid their triggers should be encouraged to start AIT. I also think patient preference must be considered. Even those with easily controlled symptoms may prefer AIT to the use of medications.

The natural history of the patient’s disease should also be considered when discussing AIT. Is the patient improving or worsening over time? Patients with AR are at risk of progression of disease with the development of new sensitivities and development of asthma. AIT is known to decrease the likelihood of progression of disease by at least 50%. Certainly, those who have started to worsen should consider AIT. Patients with intense occupational exposures to indoor or outdoor allergens should also consider AIT.

However, AIT is not for everyone. While there is a dearth of head-to-head studies, subcutaneous AIT (SCIT) appears to be more effective than sublingual AIT (SLIT) for seasonal allergens and is comparable to or more effective than SLIT for perennial aeroallergens. SCIT must be administered in a medical setting with capacity to treat anaphylaxis in the rare event of a significant systemic reaction to the injections. SLIT appears to have less of a risk for systemic reactions, but it is not risk-free. While SLIT is administered at home, SCIT requires many visits to the allergist's office and should not be offered to those who cannot commit the time necessary for it to be effective. In the United States, only grass, ragweed, and dust mites have been approved for SLIT in tablet form.

AIT doses should not be increased during pregnancy but AIT should not be stopped because of pregnancy. Patients with poorly controlled asthma or fragile cardiovascular disease are at greater risk of systemic AIT reactions and those on beta-blockers may not respond as well to epinephrine if it is needed to treat a severe AIT reaction.

Guidelines for the care of AR provide considerations for consultation with an allergist. Patients with moderate-severe AR might benefit from consultation, but those with an incomplete response to medications or comorbid conditions should be referred. If allergic triggers need to be identified or AIT is a consideration, the allergist will be useful. Patients suspected of having a structural abnormity contributing to symptoms might benefit from ear, nose throat consultation.

AR is a highly prevalent disease that has significant impact on quality of life and negatively affects the daily activities of the majority of patients. It is often under-appreciated as a source of misery for its sufferers and its comorbidities are often not related to the baseline disease.
Many highly effective and inexpensive treatment options are available for AR, giving us the ability to alleviate the misery it causes. Practitioners should be aware of treatment alternatives, adjusting the medical regimen as needed to provide much needed relief.

References
Allergic Rhinitis Allergic Rhinitis 09/06/2018
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