Allergic rhinitis (AR) is an inflammatory disease of the nasal mucosa. The typical symptoms are rhinorrhea, sneezing, nasal congestion, nasal pruritus which could extend to eyes, and also redness and lacrimation in many patients. In this article Dr. Manuj Jain (ENT Surgeon), guides on “How to manage Allergic Rhinitis”.
Allergic rhinitis (AR) is an inflammatory disease of the nasal mucosa. The typical symptoms are rhinorrhea, sneezing, nasal congestion, nasal pruritus which could extend to eyes, and also redness and lacrimation in many patients. AR can lead to many other consequent diseases including Obstructive Sleep Apnea Syndrome (OSAS) syndrome, rhinosinusitis, asthma, conjunctivitis, and otitis media, and could affect the social life, school outcomes, work production. (1)
The burden of allergic rhinitis is enormous, constituting about 55% of all allergies. About 20-30% of Indian population suffers from at least one allergic disease. Reported incidence of allergic rhinitis in India also ranges between 20% and 30 % (2), (3).
While many patients downplay rhinitis symptoms as an inconvenience rather than a disease, the economic burden is quite significant. The disease has a direct impact in the form of hospital admission and stay and an indirect impact in the form of work leaves. It is estimated that productivity decreases by US$600 per affected employee per year, which is a greater loss than asthma, diabetes, and coronary heart disease. (4)
AR is an immunoglobulin E−mediated inflammatory reaction in the nasal mucosa caused by inhaled allergens, such as pollen, mold, or animal dander. The allergic response occurs in 2 phases—early and late.
The early (or acute) phase of an allergic reaction, which develops within minutes of exposure and causes AR symptoms include sneezing, nasal pruritus (itching), upper airway obstruction (congestion or blockage), rhinorrhea (clear nasal discharge), and itchy or watery eyes.
The late response is associated with chronic inflammation and includes the same symptoms seen in the early-phase response, with nasal congestion becoming the primary symptom due to mucosal edema. These symptoms begin 6 to 12 hours after allergen exposure, peaking at 12 to 24 hours.
There are 2 symptom patterns of AR, seasonal (also known as hay fever, or intermittent) and perennial (or persistent). Seasonal allergic rhinitis (SAR) symptoms are usually easily identifiable and directly associated with seasonal allergen exposure, such as tree, grass, and weed pollens, or fungi.
Perennial allergic rhinitis (PAR) symptoms occur for up to 75% of the year, are present for >4 days per week and for >4 weeks, and are less easy to identify because they overlap with symptoms seen in sinusitis, respiratory infections, and other types of rhinitis. Symptoms are often caused by nonseasonal allergens, such as dust mites, animal dander, or mold. (5)
Monozygotic twins show a concordance of 45-60% in the development of allergic rhinitis, and dizygotic twins have a concordance rate of about 25%. These data point to a genetic link. (6)
How to Manage Allergic Rhinitis?
According to ARIA guidelines, the standard care in the treatment of AR includes antihistamines, nasal decongestants or/and corticosteroids, cromones, antileucotrienics (if asthma coexists), and specific immunotherapy (7)
There are many options for the treatment of AR, both nonpharmacologic and pharmacologic. A number of medications are also available over the counter (OTC) without a prescription, and product selection should be based on patient factors, including their symptoms and medical history. The goal of treatment is to reduce or eliminate current symptoms while preventing future attacks and long-term complications. Appropriate treatment selection should allow for minimal adverse effects and enable the patient to maintain a normal lifestyle.
Three approaches of AR management include allergen avoidance, pharmacotherapy, and immunotherapy. Nonpharmacologic interventions, such as allergen avoidance, can reduce or eliminate AR symptoms and the amount of pharmacotherapy needed for symptom control. Allergen avoidance is a practical option when allergens have been identified, either by the patient or by allergy testing. Patients can take steps to reduce exposure to triggers based on the specific allergen, whether it is pollen, mold, or animal dander. Allergen avoidance should be part of an overall treatment strategy that includes pharmacotherapy. (5)
Precautions can be taken against dust mites. Carpet removal, removal of soft toys from the bedroom, using allergen-impermeable bedding covers for the mattress and pillow, vacuuming with a high-efficiency particulate air (HEPA) filter, and washing bedclothes and bed sheets in hot water (60℃) are helpful. Any single method alone is unlikely to provide benefit, and patient should be encouraged to use multiple interventions. For those with animal allergies, ideally, removal of the pet from the home would be best along with careful vacuuming of all carpets, upholstered furniture, and mattresses.
Environmental moisture control can improve mold levels. Using pesticides and meticulous control of food debris can decrease cockroach environmental allergens. However, it may take over 6 months to remove residual cockroach allergen. (8)
Histamine activates the H1 receptor on a distinct set of neurons to produce the sensation of itching. This leads to sneezing, nose rubbing, and the “allergic salute”. The newer second-generation agents have both anti-allergic and anti-inflammatory properties.
The first generation H1 antihistamines such as diphenhydramine, chlorpheniramine, brompheniramine and hydroxyzine are also referred to as the sedating antihistamines. These agents are effective at controlling rhinorrhea, sneezing and pruritus associated with allergic rhinitis. Unfortunately, these agents cross the blood-brain barrier thus producing undesirable side effects such as central nervous system depression, sedation leading to impaired performance at home, work and school and cardiotoxicity.
The second-generation antihistamines developed in the early 1980’s, have improved H1 receptor selectivity, absent or decreased sedation, faster onset and longer duration of action and fewer adverse effects. Their half-lives are longer (12-24 hours) compared to the first generation (4-12 hours).14 Of the second generation H1-antagonists, fexofenadine has no sedating effects even at higher than recommended doses. Loratadine and desloratadine are non-sedating at recommended doses but may cause sedation at higher doses. Cetirizine, and its purified enantiomer levocetirizine, have more sedation potential than other second generation H1-antagonists (9) (10).
Topical H1-antihistamines (azelastine, olopatadine) provided faster onset of action (less than 15 minutes) and similar to greater efficacy compared to oral preparations in regard to rhinitis and conjunctivitis.
Some patients may complain of a bitter taste, and intranasal H1-antagonists are less effective than intranasal steroids. In a direct comparison trial between azelastine nasal spray versus oral cetirizine, azelastine was found to have a significant improvement in nasal symptom scores for the specific symptoms of sneezing and nasal congestion over cetirizine (11).
In addition to oral H1-antihistamines, intranasal corticosteroids are a mainstay of treatment. They are the most effective medications for controlling all rhinitis symptoms. Their onset of action is from 3-12 hours. They are generally safe, and there is little evidence to support suppression of the hypothalamic-pituitary-adrenal axis with prolonged use. Side effects are generally mild (crusting, dryness, and minor epistaxis). They can be minimized by proper nasal spray technique. Septal perforation has only been described anecdotally.
Systemic corticosteroids should be considered a last resort treatment option, but they may be necessary for severe or intractable symptoms. Steroids should never be injected into the turbinates. Recommendations on short courses oral steroids differ from 5-7 days1 to no more than 3 weeks.2
Decongestants are also available in oral and topical formulations. They are effective in relieving congestion. However, studies of H1-antihistamine in combination with oral decongestants failed to show improved benefit compared to either alone. Side effects include insomnia, anorexia, irritability, and rarely elevated blood pressure. Oral decongestants should be avoided in children less the 1-year of age, adults over 60 years of age, and any patient with a cardiac condition. The main side effect of topical decongestants is the development of rhinitis medicamentosa. Maximum duration for use of oral decongestant nasal drops is 5-7days.
Intranasal formulations of cromolyn and nedocromil have been used to treat allergic rhinitis but are less effective than topical corticosteroids. Although the exact mechanism is unknown, they work mainly by inhibiting mast cell activation. There may even be an inhibitory effect on neural signals involved in rhinitis.2 Overall, they are safe with minimal to no side effects.1,2
The anticholinergic ipratropium bromide is available in a nasal form and blocks the parasympathetic signaling that leads to watery rhinorrhea, and it has been shown effective in controlling this particular symptom. There are little to no side effects. Guidelines state it does not decrease sneezing or nasal obstruction, but one study in children showed improvement in rhinorrhea, congestion, and sneezing although to a lesser degree than intranasal steroids.
Leukotriene receptor antagonists have been shown to be effective controlling allergic rhinitis, and they are comparably effective with oral antihistamines. After 2 weeks of therapy, montelukast progressively decreased symptoms scores, but still to a lesser degree than intranasal fluticasone (12).For patients whose symptoms are not controlled with intranasal corticosteroids, adding montelukast did not offer any further benefit (13).
The anti-IgE antibody omalizumab may be efficacious, but it has not been shown to be superior to current allergic rhinitis treatments. Additionally, its high cost limits it use as a standard treatment.
Taken as a whole, intranasal corticosteroids seem to be the most effective in controlling nasal symptoms. The next most effective are oral and intranasal antihistamines.
Subcutaneous immunotherapy (SCIT) has been shown to be effective in treating allergic rhinitis in patients with identifiable IgE mediated symptom triggers. It has some advantages over the above-mentioned treatments. Effects can be sustained for years, and it may prevent the development of new allergen sensitivities or even asthma. It is effective for not only control of allergic rhinitis but also of allergic conjunctivitis and allergen induced asthma. In regard to specific inhaled allergens, evidence supports immunotherapy for pollens, animal dander, and dust mite. Large local reactions at the injection site are the most common adverse reaction. The risk of severe systemic reactions during subcutaneous immunotherapy is rare but present in less than 1% of those receiving standard immunotherapy. It is advised that patients receive immunotherapy injections in a setting with staff and equipment that can handle anaphylaxis, and that patients be observed for 30 minutes after each injection. Other disadvantages include injection discomfort, the frequency of shot visits, and the total cost. However, immunotherapy is the only treatment that can modify the disease. When the direct costs of symptomatically managed allergic rhinitis are compared to the cost of immunotherapy, the values are virtually the same. When indirect costs are factored in, immunotherapy may be much more economical.
Subcutaneously is the most common way to deliver immunotherapy, but sublingual immunotherapy (SLIT) is also used. SLIT has been reported to cause oral itching and gastrointestinal side effects, but in most studies, these rates seem to be the same as those observed in the placebo arm. There is a lack of standardization in SLIT with timothy grass pollen extracts being the only commercially available therapy (Grazax by ALK-Abelló Hørsholm. Denmark), and there are no SLIT therapies approved for the US by Food and Drug Administration. Advantages of SLIT include an extremely low risk of anaphylaxis and the ability to begin therapy at the maintenance dose without a build-up phase. SLIT is not as well established as SCIT, and further investigation is required to determine the optimal dose and patient selection (15, 16)
Allergic rhinitis is a predominant disease of the modern world with extensive use of fossil fuels for daily travel, unchecked and fast-growing construction, lack of green belt, and most of all lack of immunity in the growing children due to the eating habits and lack of exposure to the outer world in their formative years being some of the reasons.
AR requires thorough examination and proper categorization following which customized approach to tackle each patient must be made rather than casual prescription of OTC drugs both on part of the patient as well as the treating physician.
Care must be taken to diagnose patients of AR early and start them on a proper treatment plan so that they do not land into complications like Bronchial Asthma and skin disorders.
About the Author
Dr. Manuj Jain
Dr. Manuj Jain is a tireless dynamic ENT surgeon with an active practice at both Delhi and Gurgaon, born and raised in Delhi. Dr. Jain has a deep connection to his hometown. Trained under the most prominent ENT surgeons in our country. He is known for his holistic approach towards his patients in his professional practice and keeps himself updated with the latest trends and developments in the field of ENT through journals, attending & conducting workshops and CME’s.
Graduated from KIMSDU, Karad and holds the postgraduate degree from NBE from the prestigious Balabhai NANAVATI HOSPITAL, MUMBAI/ MAX NANAVATI SUPERSECIALITY HOSPITAL, MUMBAI. Went on to train in ADVANCED ENT in MUMBAI, HISSAR, DELHI & JAIPUR. Completed his fellowship in minimal access endoscopic surgery and anterior skull base surgery from JAIN ENT HOSPITAL, JAIPUR under the guidance of the most prominent ENT surgeon of the modern era- Dr. SATISH JAIN.
His areas of interest include endoscopic surgeries for Ear, Nose and Throat along with treatment of Allergic cough/ Nasobronchial Allergies/Asthma, Snoring disorders, Facial aesthetic surgery (RHINOPLASTY), and vertigo/imbalance disorders. Believes in professional conduct with his patients yet having an interactive relationship with the patients in helping them provide the best possible treatment and care to his patients.
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