Combination therapy Clinical experience shows that the combination of intranasal glu- cocorticoids and intranasal antihistamines is more effective than either agent alone. This has been demonstrated in patients with seasonal allergic rhinitis, although it has not been studied explic- itly in chronic nonallergic rhinitis . It is posited that the medications work better for SAR due to pathophysiology and symptomatolo- gy. ● A combination spray containing azelastine and fluticasone is available in the U.S. and is approved for adults and children six years of age and older for seasonal allergic rhinitis. The dose is one actuation per nostril, twice daily. This combination prod- uct has been studied in patients with seasonal allergic rhinitis and is superior to a single treatment with either agent alone (Leader & Geiger, 2022). ● Another combination is olopatadine and mometasone, which is approved for patients ≥12 years of age (Leader & Geiger, 2022). The dose is two sprays per nostril twice daily. Combi- nation therapy can also be achieved with two separate sprays. ● For the INGC component, many clinicians begin with full- strength dosing. Options for an intranasal antihistamine spray include: ● Azelastine 0.15%, one to two actuations per nostril twice daily, with a decreasing dose as symptoms improve. Many patients’ symptoms are controlled with once-daily dosing. Azelastine is also available in a 0.1% preparation, as well as a generic preparation that is dosed two actuations each nostril twice daily in adults and one actuation twice daily in children (De- Shazo & Kemp, 2022). ● Olopatadine hydrochloride nasal spray (0.06%) dosed two actuations twice daily in adults and children >12 and one ac- tuation twice daily for children ≤11 years (DeShazo & Kemp, 2022). Adjunctive therapies Adjunctive therapies that are helpful in some patients include oral decongestants, nasal saline sprays and irrigations, and oral anti- histamines. Studies of antileukotriene drugs and intranasal chro- mones in treating NAR are lacking. ● Oral decongestants : An oral decongestant, such as pseudoephedrine, can be added to the treatment regimen unless symptoms related to prostatic hyperplasia or hypertension preclude its use. The usual dosing of pseudoephedrine is 30 or 60 mg orally, up to three times daily on symptomatic days. Phenylephrine hydrochloride is also widely available, but it is less effective for treating rhinitis symptoms. It may not be superior to placebo at the 10-mg dose that is commonly available without a prescription. No specific studies have examined the clinical efficacy of decongestants for NAR. Such agents are employed as needed only for congestion not responsive to the use of the nasal glucocorticoid, >azelastine, or a combination of both.
● Nasal saline irrigation : Daily nasal lavage or sprays can also be useful. These interventions are beneficial for symptoms of postnasal drainage. They can be used immediately before INGCs or azelastine so that the mucosa is freshly cleansed when the medications are applied. Nasal lavage is associated with improvement in various rhinitis conditions and carries little risk if adequately performed. A large body of observational reports and one prospective controlled clinical study have found that nasal lavage is effective in NAR and chronic rhinosinusitis. In the only prospective study, the use of nasal irrigation significantly improved 23 of 30 nasal symptoms. Various over-the-counter devices, including bulb syringes and bottle sprayers, are effective, provided the system delivers an adequate volume of solution (>200 mL per side) into the nose. Nasal lavage with warmed saline can be performed as needed only, daily at baseline, or twice daily for increased symptoms. Intranasal saline sprays have also been found to be effective for symptoms of chronic NAR, including relieving postnasal drip, sneezing, and congestion. Saline sprays are somewhat less effective than larger volume nasal lavage, although they may be more convenient for some patients. ● Oral antihistamines : Clinical experience and limited data suggest that the newer, nonsedating H 1 antihistamines are less effective in NAR than in allergic rhinitis. Older, first-generation H 1 antihistamines (e.g., chlorpheniramine) have anticholinergic properties that can be helpful to some patients with persistent and bothersome postnasal drip and/or anterior rhinorrhea, despite the above therapies. However, these medications are sedating and have other disadvantages. Role of surgery Several surgical approaches have been used in patients with se- vere nonallergic rhinitis. Interventions may be helpful in patients with difficult symptoms that are refractory to multiple therapies (e.g., glucocorticoid nasal spray alone or in combination with decongestants). Before surgical options are considered, 6 to 12 months of medical management should be allowed. Studies of efficacy are lacking (DeShazo & Kemp, 2022). A turbinectomy can be performed when congestion is predom- inant. With this technique, there has been concern about the destruction and/or elimination of the mucosal surface. However, laser turbinectomy has been reported to preserve normal nasal cytology and ciliary activity. Several other surgical procedures have been tried in the past, in- cluding vidian nerve resection, electrocoagulation of the anterior ethmoidal nerve, and sphenopalatine ganglion block. None of these techniques have been shown to have long-term benefits, and the potential risks (e.g., persistent pain) must be considered carefully since they may outweigh any possible benefits.
CASE STUDIES WITH SELF-ASSESSMENT QUESTIONS
Allergic rhinitis case JP, a 39-year-old male, is looking for suggestions for treating his runny nose and clear nasal discharge. He says he experiences these symptoms annually around springtime, adding that he also suffers from irritated, itchy eyes and a sore throat. JP says the symptoms are so troublesome that they are interrupting his sleep at night, leading to daytime drowsiness. He wants an inexpensive medication that will alleviate his runny nose, if possible. JP reports no significant medical history and says he does not use other non - prescription or prescription medications. JP’s clear nasal discharge and cyclic, seasonal symptom occur - rence are characteristics consistent with allergic rhinitis (AR). Al- though not life threatening, the symptoms of AR, including watery rhinorrhea, sneezing, nasal obstruction, and nasal pruritus with or without irritation and watering of the eyes, can be particularly
bothersome and disruptive to a patient’s sleep and overall quality of life. In addition to counseling on allergen avoidance and oth- er nonpharmacologic approaches to minimize allergen exposure, consideration of nonprescriptive pharmacologic interventions to reduce symptoms and restore JP’s ability to function are warrant- ed. Based on his symptoms and disrupted sleep, recommend that he consider either monotherapy with an intranasal corticosteroid or an oral antihistamine, based on his preference. Recent evi - dence suggests that monotherapy, rather than a combination of medications from these classes, should be used to manage sea - sonal AR symptoms based on the combination’s lack of superiority in reducing symptoms. Ocular symptoms can be particularly trou- bling. An artificial tears solution or topical ketotifen could be used for persistent eye symptoms.
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