Allergy: Management
Diagnosing allergic rhinitis
The American Academy of Allergy, Asthma & Immunology (AAAAI) issued practice parameters for treating rhinitis in 2008. These guidelines suggest that pharmacotherapy treatment should be individualised, and depends on a variety of factors, including1:
- The type of rhinitis—seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), or non-allergic rhinitis (NAR)
- Symptoms, their duration, and their severity
- Physical exam findings
- Comorbidities
- Age
- Patient preferences
Tailoring allergy treatment2
Nasal congestion is the primary complaint:
Treatment should include:
- Intranasal corticosteroids (INSs), e.g. Budesonide, fluticasone furoate, fluticasone propionate, or triamcinolone acetonide.
- Decongestants, e.g. Pseudoephedrine, oxymetazoline, or phenylephrine.
Mild symptoms, e.g. intermittent/episodic sneezing, nasal itching, and rhinorrhea:
Treatment should include:
- Oral antihistamines, e.g. Cetirizine, loratadine, fexofenadine, diphenhydramine, levocetirizine.
Moderate/severe symptoms:
Treatment should include:
- INSs
- Combination therapy
INSs are considered the most effective treatment for moderate, intermittent, and all stages of persistent rhinitis, and for all nasal symptoms, ocular symptoms, and sinusitis.3
The role of INSs in the treatment of AR
INSs are recognised as the most effective class for controlling symptoms of long-term anti-inflammatory treatment for AR, as they1,3:
- Relieve nasal symptoms.
- Are active in both early and late phases of the allergic cascade.
- High concentrations at receptor sites are achieved with a single dose.
According to the 2008 Rhinitis Updated Practice Parameter from the AAAAI, INSs are the most effective first-line medication class for controlling symptoms of AR.1
In the treatment of SAR, INSs have been shown to be more effective than the combined use of an antihistamine and a leukotriene (LT) antagonist.1
INSs may provide significant symptom relief for patients with SAR, whether they’re used on a regular basis or on an as-needed basis.1
Management of AR in young children
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AR in young children (<2 years of age)
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AR in young children (<2 years of age)
AR is not common in children under two years of age. Other disorders should be considered initially, such as adenoidal hypertrophy or chronic rhinosinusitis before diagnosing AR.4
Treatment options include the following:
Cromolyn sodium nasal spray:
Due to its safe profile, some parents and clinicians prefer cromolyn sodium. However, it is less effective than INCs.5
Second-generation antihistamines:
Cetirizine, loratadine, and fexofenadine are available in liquid formulations and are approved for children ≥6 months of age.6,7
Intranasal corticosteroid spray:
INCs are very effective for relieving nasal symptoms. However, it should be used for limited period (less than two weeks) due to the age-limited dose approval and the concern for potential systemic side effects (eg, adrenal suppression) in children at the higher dose.8,9
Advice on how to avoid allergies
In addition to oral antihistamines and intranasal corticosteroids, first‐line treatment for allergies also involves the avoidance of triggers that may cause an allergic reaction.10
Avoidance strategies include10:
- The use of allergen‐impermeable covers for bedding.
- Keeping relative humidity in the home below 50% to inhibit mite growth.
- Reducing pollen exposure by keeping windows closed, using air conditioning, and limiting the amount of time spent outside during peak pollen season.
- Avoiding exposure to, or ownership of, pets.
Allergy management: in summary
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.
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