eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Allergic Rhinitis: Treatment & Medication

Author: Jack M Becker, MD, Clinical Associate Professor of Pediatrics, Drexel University School of Medicine
Contributor Information and Disclosures

Updated: Jul 13, 2009

Treatment

Medical Care

Treatment of allergic rhinitis (AR) can be divided into 3 categories: avoidance of allergens or environmental controls, medications, and allergen-specific immunotherapy (allergy shots).

• Use of environmental controls is not adequately explored in most patients. For many patients, the removal of the trigger can have a dramatic effect. Difficulty arises when the trigger needs to be identified and eliminated. Eliminating the trigger may be simple if removal of a feather pillow or blanket is involved; however, it can be very difficult if a family pet needs to be removed. Although avoiding outdoor pollens is impossible, the patient can reduce exposure to pollens to attenuate symptoms.
• Identification and elimination is easiest for dust mite allergens.
  • Feathered bedding should be removed and replaced with a fiber-filled product encased by dust mite–proof encasings. Such encasings can be purchased at the local stores or via mail orders. These encasings should be zip-locked and cover all surface areas.
  • A bed pad that is placed on top is not helpful and may be another source of dust mite infestation.
  • Less expensive plastic encasings may leak allergens through needle holes or between zipper teeth; therefore, more expensive dust mite–proof covers are preferable.
  • The pillow must be covered; this is even more crucial than covering the bed mattress itself because the pillow is where the patient's head usually spends most of the night. Box springs usually do not need to be covered.
  • Care should be taken to be sure the encasings are dust mite–proof. Some products may claim to be an allergy cover but may not provide the proper protection for dust mite. Also hypoallergenic bedding usually refers to the fact that the bedding is not made of feathers and does not necessarily mean that it is dust mite–proof.
• Pollen is more difficult to avoid because daily activities must be altered to do so.
  • The patient is best advised to remain indoors with air-conditioning during the period of the highest pollen counts of the day. Commonly, remaining indoors is not possible because of activities, and many schools are not air-conditioned.
  • An easy intervention is to keep the windows closed, which is easily accomplished in air-conditioned homes and must be done throughout the year. Windows tend to be opened most frequently during fall and spring in moderate climates, but these seasons are the worst possible times for open windows for patients with pollen allergy. If windows must be open, open them during the day and close them at night. Many pollen counts are highest during the night, especially for molds and trees.
  • Another intervention is to obtain a window filter or filter fan, which allows air, but not pollen, to enter the room.
  • Advise patients to wash head to toe and to change clothing upon coming in from the outdoors during high pollen season. Avoid hanging cloths outdoors to dry.
• The most difficult trigger to avoid is the family pet. Ideally, the pet should be removed from the home, but removal is the option, not the rule. Some helpful manipulations include removing the pet from the patient's bedroom and play area, using air cleaners in these areas and, occasionally, frequently sponge-bathing the pet (once per week). Even when these interventions are performed, many patients continue to experience symptoms. Other therapies are necessary in these patients; however, some patients choose to live with the source of offending allergens.
• See Medication for a discussion of medications and allergen-specific immunotherapy (ie, allergy shots). A recent study concluded that specific immunotherapy can be recommended for treatment because it is effective in reducing symptoms.⁶

Surgical Care

• No routine surgical care is needed.
• Some patients may be seen by ear, nose, and throat (ENT) specialists, and turbinectomies may be performed to provide some relief. This is an extreme measure and is reserved for patients in whom all other therapies have failed.
• Rarely, in adults, if nasal polyps do not respond to topical nasal steroids, surgical removal may be necessary, although the polyps often grow back.

Consultations

• Primary care physicians can attend to most patients.
• Patients in whom diagnosis or treatment is more difficult may require consultation with a specialist. This usually starts with an allergist, who performs a complete allergy evaluation, including diagnostic tests. Therapy is instituted, which is a combination of environmental manipulations, medications and, in some patients, allergen-specific immunotherapy.
• If medical therapies do not produce an adequate result, referral to an ENT specialist should be indicated for possible surgical intervention.

Diet

• Dietary restrictions do not help because allergic rhinitis is not triggered by foods.

Activity

• No limitations are placed on activity.
• For some pollens, patients with allergic rhinitis benefit from avoiding the outdoors during peak pollen periods of the day. This time varies according to pollens and location. Geographic location and distance from the source have an impact. Patients who are miles away from the source have different peak pollen times than patients near the source.

Medication

Many groups of medications are used for allergic rhinitis (AR), including antihistamines, corticosteroids, decongestants, saline, sodium cromolyn, and antileukotrienes. These can be further subdivided into intranasal and oral therapies. Intranasal administration has the advantage of directly affecting the site of action, and, in general, intranasal medications have fewer adverse effects and no systemic effects. The main advantage of oral therapy is ease of use. Some patients resist using intranasal medications.

Allergen-specific immunotherapy is an alternative form of therapy that has several advantages. Most importantly, it is the only form of therapy that can cure allergy symptoms. Allergen-specific immunotherapy must be customized to the patient's individual allergies and involves weekly injections of increasing concentrations of an allergen until the maintenance dose is reached and a monthly injection of the maintenance dose for several years. The process usually does not produce clinical results in the first 6 months but results are seen afterwards. The recommended course is usually 4-5 years. Allergen-specific immunotherapy has been demonstrated to be more cost effective and improves the patient's quality of life more efficiently than standard allergy medications.

Sublingual immunotherapy is also available in some parts of the United States as well as other countries of the world.⁷ In this form of therapy, small amounts of the allergen are placed under the tongue on a daily basis. The 2 main advantages are that no injections are necessary and that it can be administered at home. The efficacy rate is about 20-30% in countries outside of the United States. Currently, it is not approved by the US Food and Drug Administration (FDA), and the formulation that is presently used has not been shown to be effective for this use. The formulations that have been tested in other countries are not available in the United States. This form of treatment is controversial.

The position from the National Allergy Organization is that the therapy may show promise but is not ready for widespread use. A recent study concluded that 5-grass-pollen sublingual immunotherapy tablets reduced symptom scores and medication use in children and adolescents with grass pollen–related allergic rhinitis.⁸

Saline nasal irrigation is effective in approximately 50% of patients with allergic rhinitis. Irrigation assists the body's natural function of rinsing allergens out of nasal passages. Tap water cannot be used because it is hypotonic and causes edema, leading to greater congestion.

Oral antihistamines

Antihistamines are classified in several ways, including sedating and nonsedating, newer and older, and first- and second-generation antihistamines (most widely accepted classification). First-generation antihistamines are primarily over the counter and are included in many combination products for cough, colds, and allergies. These include brompheniramine (Dimetapp), chlorpheniramine (Atrohist), and diphenhydramine (Benadryl). Loratadine (Claritin) and cetirizine (Zyrtec) are now available over the counter without a prescription. Second-generation antihistamines include desloratadine (Clarinex), fexofenadine (Allegra), and levocetirizine dihydrochloride (XYZAL), which require a prescription.

Cetirizine (Zyrtec)

Low-sedating second-generation medication with fewer adverse effects than first-generation medications. Selectively inhibits peripheral histamine H1 receptors. Available as syr (5 mg/5 mL) and 5- or 10-mg tab.

Levocetirizine (Xyzal)

Histamine H1-receptor antagonist. Active enantiomer of cetirizine. Peak plasma levels are reached within 1 h, and half-life is about 8 h. Available as a 5-mg breakable (scored) tab. Indicated for seasonal and perennial AR

Loratadine (Claritin)

Nonsedating second-generation antihistamine. Fewer adverse effects than with first-generation medications. Selectively inhibits peripheral histamine H1 receptors. Available as tab, disintegrating tab (Reditab), syr (5 mg/5 mL), or combined with pseudoephedrine in 12- or 24-h preparations. The only one that is presently available without a prescription

Desloratadine (Clarinex)

Nonsedating second-generation antihistamine. Fewer adverse effects than with first-generation antihistamines. Selectively inhibits peripheral histamine H1 receptors. Relieves nasal congestion and systemic effects of seasonal allergies. Long-acting tricyclic histamine antagonist selective for H1-receptor. Major metabolite of loratadine, which, after ingestion, is extensively metabolized to active metabolite 3-hydroxydesloratadine. Available as tabs, syr (0.5 mg/mL), or PO disintegrating Reditabs (2.5 and 5 mg).

Fexofenadine (Allegra)

Nonsedating second-generation medication with fewer adverse effects than first-generation medications. Competes with histamine for H1 receptors in GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Available in qd and bid preparations. Also available combined with pseudoephedrine.

Intranasal antihistamines

These agents are an alternative to oral antihistamines to treat allergic rhinitis. Currently, azelastine is the only agent available in the United States.

Azelastine (Astelin)

An effective antihistamine delivered via the intranasal route. Mechanism is similar to PO antihistamines. Systemic absorption occurs and may cause sedation, headache, and nasal burning.

Intranasal corticosteroids

This class of medications is most effective. Intranasal corticosteroids are potent anti-inflammatory agents shown to decrease allergic rhinitis symptoms in more than 90% of patients. Presently, 9 medications are available in this class, and all are essentially equivalent in efficacy, although few head-to-head studies have been performed. Mometasone (Nasonex) and fluticasone furoate (Veramyst) have been demonstrated to have a somewhat faster onset of action; however, after one week, no difference is found between medications. Most can be used on a once-daily basis, and all have a similar safety profile. Nasonex is the only medication that did not show an affect on growth at one year. Veramyst did not show a growth affect in a 2-week study that is designed to evaluate for growth affects. A longer study began in late 2007.

Beclomethasone (Beconase, Vancenase)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.

Budesonide (Rhinocort Aqua)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.

Ciclesonide (Omnaris)

Corticosteroid nasal spray indicated for AR. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg.

Flunisolide (Nasalide, Nasarel)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.

Fluticasone propionate (Flonase)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.

Fluticasone furoate (Veramyst)

Intranasal corticosteroid. Indicated for seasonal and perennial allergic rhinitis. Relieves nasal symptoms associated with allergic rhinitis. Has also demonstrated improvement in allergic eye symptoms. Contains 27.5 mcg/spray.

Mometasone (Nasonex)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation. Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells).

Triamcinolone (Nasacort AQ)

May decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation.

Intranasal decongestants

Decongestants are effective for short-term symptom control. They decrease nasal discharge and congestion and are available without a prescription. The 2 medications in this group are oxymetazoline hydrochloride (Afrin) and ipratropium bromide (Atrovent). Oxymetazoline hydrochloride is an addictive medication that is effective in shrinking nasal membranes and is not recommended for long-term use. Use of oxymetazoline hydrochloride for more than 7-10 d is habit forming. Patients can be addicted for years at a time. Addiction is termed rhinitis medicamentosa. Ipratropium bromide can be used for a prolonged period of time.

Ipratropium bromide 0.03% or 0.06% (Atrovent)

Anticholinergic used for reducing rhinorrhea in patients with AR or vasomotor rhinitis. An excellent medication for decreasing rhinitis. Nonaddictive and lasts for 12 hours. Does not shrink the nasal mucosa, but inhibits secretion that causes rhinitis. Used alone or in conjunction with other medications.

Intranasal mast cell stabilizers

These are effective therapy for AR in approximately 70-80% of patients. They produce mast cell stabilization and antiallergic effects by inhibiting mast cell degranulation. They have no direct anti-inflammatory or antihistaminic effects and minimal bronchodilator effects. They are effective for prophylaxis. They also clean out antigens mechanically, similar to saline. These products are now available over the counter.

Cromolyn sodium (Nasalcrom)

Used on a daily basis for seasonal or perennial AR. Significant effect may not be seen for 4-7 d. Administer just before exposure in patients with isolated and predictable periods of exposure (eg, animal allergy, occupational allergy). Generally less effective than nasal corticosteroids. Protective effect lasts 4-8 h; thus, frequent dosing is necessary. If desired, may be used with other medicines, including other allergy medicines.

Antileukotrienes

Montelukast has been approved as monotherapy for allergic rhinitis. It has been shown to be most effective in patients in whom significant congestion is a primary complaint. It has also been shown to work as adjunctive therapy with present second-generation antihistamines to provide greater relief of symptoms than antihistamines alone. It is beneficial in patients with symptoms in whom present antihistamines are not adequate. A study has shown a combination with cetirizine is as effective as an intranasal corticosteroid. Antileukotriene can also be added to the treatment plan in patients receiving antihistamines and intranasal therapy.

Montelukast (Singulair)

Inhibits airway cysteinyl leukotriene receptors. Because these receptors are found throughout the airway, the medication can mediate the effect in the upper and lower airway.

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