Treatment of Allergic Rhinitis

 


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Am Fam Physician. 2015 Dec 1;92(11):985-992.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/allergic-rhinitis.html.

  Related letter: Optimal Technique for Application of Corticosteroid Nasal Spray

Author disclosure: No relevant financial affiliations.

Allergic rhinitis is a common and chronic immunoglobulin E–mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma. Treatment should be based on the patient's age and severity of symptoms. Patients should be educated about their condition and advised to avoid known allergens. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life. More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation. Subcutaneous or sublingual immunotherapy should be considered if usual treatments do not adequately control symptoms and in patients with allergic asthma. Evidence does not support the use of mite-proof impermeable mattresses and pillow covers, breastfeeding, air filtration systems, or delayed exposure to solid foods in infancy or to pets in childhood.

Allergic rhinitis is an immunoglobulin E–mediated disease that occurs after exposure to indoor or outdoor allergens, such as dust mites, insects, animal dander, molds, and pollen. Symptoms include rhinorrhea, sneezing, and nasal congestion, obstruction, and pruritus.1

Optimal treatment includes allergen avoidance and pharmacotherapy. Targeted symptom control with immunotherapy and asthma evaluation should be considered when appropriate.2,3

Figure 1 is an algorithm for the treatment of allergic rhinitis.4

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Nasal saline irrigation is beneficial in treating the symptoms of allergic rhinitis and may be used alone or as adjuvant therapy.

B

5

Although dust mite allergies are common, studies have not found any benefit to using mite-proof impermeable mattresses or pillow covers.

A

6

Other interventions that do not have documented effectiveness in the prevention of allergic rhinitis include breastfeeding, delayed exposure to solid foods in infancy or to pets in childhood, and the use of air filtration systems.

B

2, 711

An intranasal corticosteroid alone should be the initial treatment for allergic rhinitis with symptoms affecting quality of life.

A

12, 13, 16, 1921

Compared with first-generation antihistamines, second-generation antihistamines have a better adverse effect profile and cause less sedation, with the exception of cetirizine (Zyrtec).

A

27

Because intranasal antihistamines are more expensive, less effective, and have more adverse effects than intranasal corticosteroids, they are not recommended as first-line therapy for allergic rhinitis.

C

3133

Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or want to avoid long-term medication use, and in patients with allergic asthma.

A

2, 3, 13, 16, 17, 31, 4346


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Nasal saline irrigation is beneficial in treating the symptoms of allergic rhinitis and may be used alone or as adjuvant therapy.

B

5

Although dust mite allergies are common, studies have not found any benefit to using mite-proof impermeable mattresses or pillow covers.

A

6

Other interventions that do not have documented effectiveness in the prevention of allergic rhinitis include breastfeeding, delayed exposure to solid foods in infancy or to pets in childhood, and the use of air filtration systems.

B

2, 711

An intranasal corticosteroid alone should be the initial treatment for allergic rhinitis with symptoms affecting quality of life.

A

12, 13, 16, 1921

Compared with first-generation antihistamines, second-generation antihistamines have a better adverse effect profile and cause less sedation, with the exception of cetirizine (Zyrtec).

A

27

Because intranasal antihistamines are more expensive, less effective, and have more adverse effects than intranasal corticosteroids, they are not recommended as first-line therapy for allergic rhinitis.

C

3133

Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or want to avoid long-term medication use, and in patients with allergic asthma.

A

2, 3, 13, 16, 17, 31, 4346


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual

The Authors

show all author info

DENISE K.C. SUR, MD, is a clinical professor in the Department of Family Medicine at the University of California–Los Angeles David Geffen School of Medicine....

MONICA L. PLESA, MD, is an assistant clinical professor in the Department of Family Medicine at the University of California–Los Angeles David Geffen School of Medicine.

Author disclosure: No relevant financial affiliations.

Address correspondence to Denise K.C. Sur, MD, UCLA Medical Center, Santa Monica, 1920 Colorado Ave., Santa Monica, CA 90404 (e-mail: dsur@mednet.ucla.edu). Reprints are not available from the authors.

REFERENCES

show all references

1. Nelson HS, Rachelefsky GS, Bernick J. The Allergy Report. Milwaukee, Wis.: American Academy of Allergy, Asthma, and Immunology; 2000....

2. Brozek JL, Bousquet J, Baena-Cagnani CE, et al.; Global Allergy and Asthma European Network; Grading of Recommendations Assessment, Development and Evaluation Working Group. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466–476.

3. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015;152(2):197–206.

4. Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician. 2010;81(12):1440–1446.

5. Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy. 2012;26(5):e119–e125.

6. Sheikh A, Hurwitz B, Nurmatov U, van Schayck CP. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. 2010;(7):CD001563.

7. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183–191.

8. Kramer MS, Matush L, Vanilovich I, et al.; Promotion of Breastfeeding Intervention Trial (PROBIT) Study Group. Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial. BMJ. 2007;335(7624):815.

9. Kilburn S, Lasserson TJ, McKean M. Pet allergen control measures for allergic asthma in children and adults. Cochrane Database Syst Rev. 2003;(1):CD002989.

10. Wood RA, Johnson EF, Van Natta ML, Chen PH, Eggleston PA. A placebo-controlled trial of a HEPA air cleaner in the treatment of cat allergy. Am J Respir Crit Care Med. 1998;158(1):115–120.

11. Searing DA, Leung DY. Vitamin D in atopic dermatitis, asthma and allergic diseases. Immunol Allergy Clin North Am. 2010;30(3):397–409.

12. Price D, Bond C, Bouchard J, et al. International Primary Care Respiratory Group (IPCRG) guidelines: management of allergic rhinitis. Prim Care Respir J. 2006;15(1):58–70.

13. Scadding GK, Durham SR, Mirakian R, et al.; British Society for Allergy and Clinical Immunology. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38(1):19–42.

14. Barr JG, Al-Reefy H, Fox AT, Hopkins C. Allergic rhinitis in children [published correction appears in BMJ. 2014;349:4923]. BMJ. 2014;349:g4153.

15. Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med. 2015;372(5):456–463.

16. Wallace DV, Dykewicz MS, Bernstein DI, et al.; Joint Task Force on Practice; American Academy of Allergy, Asthma & Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter [published correction appears in J Allergy Clin Immunol. 2008;122(6):1237]. J Allergy Clin Immunol. 2008;122(2 suppl):S1–S84.

17. Calderon MA, Alves B, Jacobson M, Hurwitz B, Sheikh A, Durham S. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev. 2007;(1):CD001936.

18. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63(10):1292–1300.

19. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317(7173):1624–1629.

20. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47(2):118–125.

21. Yáñez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89(5):479–484.

22. Demoly P. Safety of intranasal corticosteroids in acute rhinosinusitis. Am J Otolaryngol. 2008;29(6):403–413.

23. Lumry WR. A review of the preclinical and clinical data of newer intranasal steroids used in the treatment of allergic rhinitis [published correction appears in J Allergy Clin Immunol. 2000;105(2 pt 1):394]. J Allergy Clin Immunol. 1999;104(4 pt 1):S150–S158.

24. Sastre J, Mosges R. Local and systemic safety of intranasal corticosteroids. J Investig Allergol Clin Immunol. 2012;22(1):1–12.

25. Schenkel EJ, Skoner DP, Bronsky EA, et al. Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics. 2000;105(2):E22.

26. Mansfield LE, Mendoza CP. Medium and long-term growth in children receiving intranasal beclomethasone dipropionate: a clinical experience. South Med J. 2002;95(3):334–340.

27. Bender BG, Berning S, Dudden R, Milgrom H, Tran ZV. Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a meta-analysis. J Allergy Clin Immunol. 2003;111(4):770–776.

28. Verster JC, Volkerts ER. Antihistamines and driving ability: evidence from on-the-road driving studies during normal traffic [published corrections appear in Ann Allergy Asthma Immunol. 2004;92(6):675, and Ann Allergy Asthma Immunol. 2005;94(3):409–410]. Ann Allergy Asthma Immunol. 2004;92(3):294–303.

29. Robb G, Sultana S, Ameratunga S, Jackson R. A systematic review of epidemiological studies investigating risk factors for work-related road traffic crashes and injuries. Inj Prev. 2008;14(1):51–58.

30. Kay GG, Quig ME. Impact of sedating antihistamines on safety and productivity. Allergy Asthma Proc. 2001;22(5):281–283.

31. Tran NP, Vickery J, Blaiss MS. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3(3):148–156.

32. Corren J, Storms W, Bernstein J, Berger W, Nayak A, Sacks H; Azelastine Cetirizine Trial No. 1 (ACT 1) Study Group. Effectiveness of azelastine nasal spray compared with oral cetirizine in patients with seasonal allergic rhinitis. Clin Ther. 2005;27(5):543–553.

33. Berger WE, White MV; Rhinitis Study Group. Efficacy of azelastine nasal spray in patients with an unsatisfactory response to loratadine. Ann Allergy Asthma Immunol. 2003;91(2):205–211.

34. Jurado-Palomo J, Bobolea ID, Belver, González MT, et al. Treatment of allergic rhinitis: ARIA document, nasal lavage, antihistamines, cromones and vasoconstrictors. In: Gendeh BS, ed. Otolaryngology. New York, NY: InTech; 2012:61–82.

35. Milgrom H, Biondi R, Georgitis JW, et al. Comparison of ipratropium bromide 0.03% with beclomethasone dipropionate in the treatment of perennial rhinitis in children. Ann Allergy Asthma Immunol. 1999;83(2):105–111.

36. van Cauwenberge P, Bachert C, Passalacqua G, et al.; European Academy of Allergology and Clinical Immunology. Consensus statement on the treatment of allergic rhinitis. Allergy. 2000;55(2):116–134.

37. Juniper EF, Kline PA, Hargreave FE, Dolovich J. Comparison of beclomethasone dipropionate aqueous nasal spray, astemizole, and the combination in the prophylactic treatment of ragweed pollen-induced rhinoconjunctivitis. J Allergy Clin Immunol. 1989;83(3):627–633.

38. Barnes ML, Ward JH, Fardon TC, Lipworth BJ. Effects of levocetirizine as add-on therapy to fluticasone in seasonal allergic rhinitis. Clin Exp Allergy. 2006;36(5):676–684.

39. Di Lorenzo G, Pacor ML, Pellitteri ME, et al. Randomized placebo-controlled trial comparing fluticasone aqueous nasal spray in monotherapy, fluticasone plus cetirizine, fluticasone plus montelukast and cetirizine plus montelukast for seasonal allergic rhinitis [published correction appears in Clin Exp Allergy. 2004;34(8):1329]. Clin Exp Allergy. 2004;34(2):259–267.

40. Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2008;100(1):74–81.

41. Carr W, Bernstein J, Lieberman P, et al. A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol. 2012;129(5):1282–1289.e10.

42. Price D, Shah S, Bhatia S, et al. A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis. J Investig Allergol Clin Immunol. 2013;23(7):495–503.

43. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update [published correction appears in J Allergy Clin Immunol. 2011;127(3):840]. J Allergy Clin Immunol. 2011;127(1 suppl):S1–S55.

44. Durham SR, Yang WH, Pedersen MR, Johansen N, Rak S. Sublingual immunotherapy with once-daily grass allergen tablets: a randomized controlled trial in seasonal allergic rhinoconjunctivitis. J Allergy Clin Immunol. 2006;117(4):802–809.

45. Burks AW, Calderon MA, Casale T, et al. Update on allergy immunotherapy: American Academy of Allergy, Asthma & Immunology/European Academy of Allergy and Clinical Immunology/PRACTALL consensus report. J Allergy Clin Immunol. 2013;131(5):1288–96.e3.

46. Solelhac G, Charpin D. Management of allergic rhinitis. F1000Prime Rep. 2014;6:94.

47. Casale TB, Condemi J, LaForce C, et al.; Omalizumab Seasonal Allergic Rhinitis Trial Group. Effect of omalizumab on symptoms of seasonal allergic rhinitis: a randomized controlled trial. JAMA. 2001;286(23):2956–2967.

48. Ng DK, Chow PY, Ming SP, et al. A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Pediatrics. 2004;114(5):1242–1247.

49. Xue CC, English R, Zhang JJ, Da Costa C, Li CG. Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial. Am J Chin Med. 2002;30(1):1–11.

50. Brinkhaus B, Witt CM, Jena S, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with allergic rhinitis: a pragmatic randomized trial. Ann Allergy Asthma Immunol. 2008;101(5):535–543.

51. Roberts J, Huissoon A, Dretzke J, Wang D, Hyde C. A systematic review of the clinical effectiveness of acupuncture for allergic rhinitis. BMC Complement Altern Med. 2008;8:13.

52. Schapowal A; Petasites Study Group. Randomised controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ. 2002;324(7330):144–146.



 

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