Allergen immunotherapy involves the subcutaneous administra- tion of gradually increasing quantities of the patient’s relevant allergens until a dose is reached that effectively induces immuno- logic tolerance to the allergen (Small & Kim, 2011). This therapy is effective for treating allergic rhinitis caused by pollens and dust mites but has limited usefulness in treating mold and animal dan- der allergies. Typically, allergen immunotherapy is given as weekly incremental increases in dose over the course of six to eight months, followed by maintenance injections of the maximum tolerated dose every three to four weeks for three to five years. After this period, many patients experience a prolonged protective effect; therefore, con- sideration can be given to stopping therapy. Preseasonal prepa- rations that are administered on an annual basis are also available (Small & Kim, 2011). Allergen immunotherapy should be reserved for patients with optimal avoidance measures and for whom pharmacotherapy is insufficient to control symptoms or is not well tolerated. Since this form of therapy carries the risk of anaphylactic reactions, it should only be prescribed by physicians who are adequately trained in treating allergies and equipped to manage possible life-threaten- ing anaphylaxis. A simplified, stepwise algorithm for treating allergic rhinitis is provided here. Mild, intermittent allergic rhinitis can often be managed effectively with avoidance measures and oral antihistamines (Small & Kim, 2011). However, as mentioned earlier, most patients presenting with allergic rhinitis have moderate to severe symptoms and therefore may require a trial of intranasal corticosteroids and other interventions (Small & Kim, 2011). Start with step one, then proceed as needed per clinical judgment. 1. Avoid allergen. 2. Oral antihistamines. 3. Intranasal corticosteroids. 4. Combination: Intranasal corticosteroids/antihistamine spray. 5. Leukotriene receptor antagonists. 6. Allergen immunotherapy. Oral and intranasal decongestants (e.g., pseudoephedrine, phen- ylephrine) help relieve nasal congestion in patients with allergic Nonallergic rhinitis Patients with nonallergic rhinitis are largely less responsive to pharmacologic therapy than those with allergic rhinitis. In particular, most find oral antihistamines to be unhelpful. However, two classes of medications may be helpful (Leader & Geiger, 2022): There are no studies specifically comparing the two therapies. Highly symptomatic patients often respond well to combination therapy. Generally, full-strength dosing is used for both agents (Leader & Geiger, 2022). In addition to these agents, ipratropium has been approved specifically to treat the symptom of rhinorrhea in nonallergic rhinitis. ● Intranasal corticosteroids ● Intranasal antihistamines.
rhinitis. However, the side-effect profile associated with oral de - congestants (i.e., agitation, insomnia, headache, palpitations) may limit their long-term use. Furthermore, these agents are contraindicated in patients with uncontrolled hypertension and severe coronary artery disease. Prolonged use of intranasal de- congestants carries the risk of rhinitis medicamentosa (rebound nasal congestion); therefore, these agents should not be used for more than 5 to 10 days. Although not as effective as intranasal corticosteroids, sodium cromoglycate (Cromolyn) has been shown to reduce sneezing, rhinorrhea, and nasal itching and is, therefore, a reasonable thera- peutic option for some patients. The anti-IgE antibody omalizum- ab has also been shown to be effective in seasonal allergic rhinitis and asthma (Small & Kim, 2011). Surgical therapy may be helpful for select patients with rhinitis, polyposis, or chronic sinus disease that is refractory to medical treatment. Most surgical interventions can be performed under local anesthesia in an office or outpatient setting (Small & Kim, 2011). Healthcare Consideration: It is important to note that allergic rhinitis may worsen during pregnancy and necessitate pharma- cologic treatment. The benefit-to-risk ratio of pharmacological agents for allergic rhinitis must be considered before recom- mending any medical therapy to pregnant individuals. Intrana- sal sodium cromoglycate can be used as first-line therapy for allergic rhinitis in pregnancy, since no teratogenic effects have been noted in humans or animals (Small & Kim, 2011). The first-generation antihistamines may also be considered for aller - gic rhinitis in pregnancy, and, if required, chlorpheniramine and diphenhydramine should be recommended, given their lon- ger-term safety record. However, the patient should be warned of the risk of sedation with these medications. If intranasal cor- ticosteroids are required during pregnancy, beclomethasone or budesonide nasal spray should be considered first-line therapy because of its long safety record. Starting or increasing aller- gen immunotherapy during pregnancy is not recommended because of the risk of anaphylaxis to the fetus.
Figure 4: Evidence-Based Treatment for Non-allergic Rhinitis
Symptoms of nonallergic rhinitis: Rhinorrhea predom- inate
Symptoms of nonallergic rhinitis
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Primary symptoms: Con- gestion present or mixed congestion and rhinorrhea
Intranasal ipratroprium
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Intranasal steriods OR Intra- nasal antihistamines
If symptoms persist
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Intranasal ipratroprium PLUS Intranasal steriods OR Intra- nasal antihistamines
If symptoms persist
▼ Intranasal steroids AND Intra- nasal antihistamines ▼ If symptoms persist: Intrana- sal steriods PLUS Intranasal antihistamines PLUS oral decongestants
Note . Sur and Plesa, 2018.
EliteLearning.com/Pharmacy
Book Code: RPTX3024
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