Management

Healthcare professtional

    

A guideline-based approach to allergic rhinitis (AR) treatment

Diagnosis of allergic rhinitis

ARIA AR treatment algorithm1

The management of AR should be tailored according to the severity of the disease, co-morbidities, treatment availability and affordability, and the patient’s preference.1

Treatment of allergic rhinitis

Simplified AR treatment algorithm

Although each treatment option will help to reduce a person’s AR symptoms, clinicians should tailor the treatment option. Each of the following scenarios would have different considerations2:

  1. Person with nasal congestion as the primary complaint
  2. Person with intermittent or episodic nasal AR symptoms
  3. Person with mild AR symptoms
  4. Person with moderate to severe AR symptoms

Recommendations from the AAAAI (American Academy of Allergy Asthma & Immunology)

  • The American Academy of Allergy, Asthma & Immunology (AAAAI) issued practice parameters for treating rhinitis in 2008. These guidelines suggest that pharmacotherapy treatment should be individualized and depends on a variety of factors, including3:
    • Type of rhinitis—seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), or Nonallergic rhinitis (NAR)
    • Symptoms, their duration, and their severity
    • Physical exam findings
    • Comorbidities
    • Age
    • Patient preferences

Overall, the AAAAI recognizes that INCSs are an effective class for controlling symptoms of long-term treatment for AR.3

Current Canadian guidelines recommend INCSs as a first-line treatment for moderate to severe allergic rhinitis.4

Pharmacological options

Allergy medicine types

The most commonly used medications in the treatment of AR are5:

Although each treatment option will help to reduce a person’s AR symptoms, clinicians should tailor the treatment option. Each of the following scenarios would have different considerations2:

  • Person with nasal congestion as the primary complaint
  • Person with intermittent or episodic nasal AR symptoms
  • Person with mild AR symptoms
  • Person with moderate to severe AR symptoms

  • MOA of intranasal corticosteroids (INCSs)

    Some INCSs are now available OTC, are often used as first-line treatment for patients with mild persistent or moderate-to-severe symptoms, work locally in the nasal mucosa to block multiple inflammatory substances and mediators involved in both phases of the allergic cascade, including histamine, cytokines, leukotrienes, chemokines, prostaglandins, and tryptase.3,4

    INCSs3,4:

    • Suppress the impact of both early and late phases of the inflammation process, therefore relieving the initial and persistent symptoms they cause
    • Provide relief of nasal congestion and itching, runny nose and sneezing, and itchy, watery eyes

    Patients may not fully understand how intranasal sprays work. People commonly use INCSs incorrectly, or expect that the INCS spray will work faster than it does. Many patients expect instant success with an INCS, but it could take up to a few days to get the full effect.6

    It is important to explain this to patients to help set their expectations. Opening the conversation about this can be as easy as asking a simple question to gauge their knowledge. INCSs are recognized as an effective class for controlling symptoms of AR.1,3,7,8

    INCSs7,9:

    • Relieve nasal symptoms
    • Active in both early and late phases of the allergic cascade
    • High concentrations at receptor sites achieved with a single dose

    Since optimal clinical response is determined by the proper application of the nasal spray, patients should be counseled on the appropriate use of applicator devices.6

  • MOA of decongestants

    Decongestants work by stimulating receptors on blood vessels, causing vasoconstriction and shrinking of the nasal turbinates. Vasoconstriction alleviates nasal mucosa inflammation resulting in opening of the nasal passages for the patient to breathe better. It also allows the sinuses to drain, thereby further reducing nasal congestion. Decongestants are also known for rebound congestion effect, thus should be used for a short Duration (i.e., up to 3 days).10

  • MOA of Chromones/chromoglycates

    Chromones reduce symptoms of allergic rhinitis by stabilizing the mast cells, thereby blocking the release of histamine and other mediators of immunity, rather than blocking H1-histamine receptors.11

  • MOA of anti-leukotrienes

    Anti-leukotrienes block the action of leukotrienes, which cause tightening of airway muscles and production of excess mucus and fluid, reducing nasal secretions.10

  • MOA of antihistamines

    Antihistamines work by binding to the H1 receptor, therefore inhibiting histamine (one of the many mediators of the inflammatory response) from binding to the H1 receptor. This interferes with the body’s response when exposed to an allergen, thus preventing symptoms such as wheezing, sneezing, coughing, itchy nose and eyes, runny nose, and shortness of breath.4,12

  • MOA of anticholinergics

    Act by inhibiting activation of the nasal mucosal glands, thereby reducing secretions associated with parasympathetic stimulation. Used directly in the nose to relieve runny nose and have no associated systemic side effects. Can cause nose bleeds, nasal dryness, crusting, nasal congestion, dry mouth, or sore throat. They do not relieve sneezing and do not provide complete relief.13

INCSs are considered an effective treatment for mild-persistent and moderate-severe allergic rhinitis and to help manage all nasal symptoms, ocular symptoms, polyposis, and sinusitis.7

 

Common side effects of INCSs include nasal irritation and stinging, and epistaxis.4,6 INCSs demonstrate low systemic absorption. Some cases of immunosuppression and effect on growth in the pediatric population has been reported in literature with the use of INCSs.6,14,15

The role of INCSs in the treatment of AR: According to the algorithms pharmacological options

According to the 2008 Rhinitis Updated Practice Parameter from the AAAAI, INCSs are an effective first-line medication class for controlling symptoms of AR.3

INCSs may provide significant symptom relief for patients with SAR, whether they’re used on a regular basis or on an as-needed basis, however continuous use may be more effective than as-needed use.3

Canadian guidelines currently mirror American and Global guidelines for treatment of AR recommending INCSs as a first-line treatment for moderate to severe allergic rhinitis.4

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