Allergic Rhinitis Treatment & Management
- Author: Javed Sheikh, MD; Chief Editor: Michael A Kaliner, MD more...
The management of allergic rhinitis consists of 3 major categories of treatment, (1) environmental control measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy.
Environmental control measures and allergen avoidance involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis. However, global environmental control without identification of specific triggers is inappropriate.
Pollens and outdoor molds
Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist (see Causes).
Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.
Despite all of these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal molds may be difficult.
Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure. Bed linens should be washed every 2 weeks in hot (at least 130°F) water to kill any mites present.[49, 50] Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.
Indoor environmental control measures for mold allergy focus on reduction of excessive humidity and removal of standing water. The environmental control measures for dust mites can also help reduce mold spores.
For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping it entirely out of the bedroom can be of some benefit. Cat allergen levels in the home can be reduced with high-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may be impractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.
As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.
Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoor pollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of these situations or triggers if they seem to aggravate symptoms.
Immunotherapy injections (desensitization)
A considerable body of clinical research has established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements. Success rates have been demonstrated to be as high as 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observed for 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefully consider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits of immunotherapy against the risks and benefits of the other management options.
Sublingual immunotherapy (SLIT) is currently increasing in use, particularly in Europe. Differences between SLIT and subcutaneous immunotherapy (SCIT) need further study, including research on differences in efficacy, durability, and safety.
SLIT can produce significant clinical improvement in elderly patients with allergic rhinitis caused by house dust mites (HDMs), according to a study by Bozek et al. The report looked at a group of patients aged 60-75 years with allergic rhinitis, as well as allergies to Dermatophagoides pteronyssinus and D farinae.
In 47 patients who underwent 3 years of SLIT, the total nasal symptom score fell by 44%, while in the 48 patients in the placebo group, the score dropped by just 6%. In addition, the total medication score for the SLIT patients fell by a maximum of 51%, while only an insignificant score decrease was seen in the placebo group.
Whether SLIT will be effective for non-pollen allergens as well as pollens also needs additional study. A 2012 meta-analysis of existing studies of SLIT for grass pollen reported that SCIT is more effective than SLIT in controlling symptoms and in reducing the use of allergy medications in patients with seasonal allergic rhinoconjuntivitis to grass pollen.
Indications: Immunotherapy may be considered more strongly with severe disease, poor response to other management options, and the presence of comorbid conditions or complications. Immunotherapy is often combined with pharmacotherapy and environmental control.
Administration: Administer immunotherapy with allergens to which the patient is known to be sensitive and that are present in the patient's environment (and cannot be easily avoided). The value of immunotherapy for pollens, dust mites, and cats is well established. [56, 57, 58, 59, 60] The value of immunotherapy for dogs and mold is less well established. [53, 56]
Contraindication: A number of potential contraindications to immunotherapy exist and need to be considered. Immunotherapy should only be performed by individuals who have been appropriately trained, who institute appropriate precautions, and who are equipped for potential adverse events.
SLIT immunotherapy may not be appropriate for everyone. Those affected by multiple allergens may not obtain relief of all of their symptoms by taking immunotherapy for only a single or several allergens. SLIT is more convenient in than weekly injections for individuals with limited, specific allergies that match the SL product.
In April 2014, the FDA approved an SL tablet consisting of 5 calibrated grass pollen extracts (Oralair). It contains Perennial Ryegrass (Lolium perenne), Kentucky bluegrass (Poa pratensis), Timothy grass (Phleum pratense), Orchard grass (Dactylis glomerata), and Sweet Vernal grass (Anthoxanthum odoratum).
The Oralair SL tablet needs to be initiated 4 months prior to the season for the specific allergen.
A second SL immunotherapy for Timothy grass (Grastek) was also approved in April 2014 for adults and children aged 5 years or older. It should be initiated at least 12 weeks before the start of the grass pollen season. Efficacy and safety in North America was established in a large study (n=1500) of adults and children aged 5-65 years. Results showed a 23% improvement of symptoms in the entire grass pollen season.
A third SL immunotherapy for ragweed (Ragwitek) was also approved in April 2014 for adults aged 18 years or older. Effectiveness studies included about 760 patients. Phase 3 clinical trials showed reduced rhinoconjunctivitis symptoms over the entire season by 27-43% compared with placebo. Ragwitek is approved for adults aged 18 years or older.[64, 65]
Surgical care is not indicated for allergic rhinitis but may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities. The value of turbinectomy is not established.
While the general practitioner can effectively treat most cases of straightforward allergic rhinitis, consider consultation with an allergist or immunologist for severe disease, poor response to pharmacotherapy, and the presence of comorbid conditions or complications. Consultation with other specialists also might be needed for comorbid conditions or complications. Consult with an allergy specialist when identification or clarification of specific allergic triggers is needed, when detailed counseling regarding environmental control measures is needed, when quality of life is significantly impaired, or when immunotherapy may be a consideration.
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