Allergic Rhinitis Treatment & Management

Updated: May 18, 2018
  • Author: Javed Sheikh, MD; Chief Editor: Michael A Kaliner, MD  more...
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Treatment

Medical Care

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. [54] 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.

Indoor allergens

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. [55] Bed linens should be washed every 2 weeks in hot (at least 130°F) water to kill any mites present. [56, 57] 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. [58]

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. [59] 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.

Occupational allergens

As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.

Nonspecific triggers

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.

Pharmacotherapy

See Medication.

Immunotherapy (desensitization)

Injections

A considerable body of clinical research has established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements. [60] 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.

  • 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. [61, 62, 63, 64, 65] The value of immunotherapy for dogs and mold is less well established. [60, 61]

  • 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.

Sublingual

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. [66]

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. [66]  In addition, the house dust mite (HDM) SLIT decreases the risk of asthma exacerbation in adults with house dust mite allergy-related asthma. [67]

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). [68]

The Oralair SL tablet needs to be initiated 4 months prior to the season for the specific allergen and is approved for patients 10–65 years of age.

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. [69] 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. [70]

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. [71, 72]

A sublingual (SL) house dust mite immunotherapy (Odactra) was approved by the FDA in 2017. It is a standardized allergen extract indicated as daily SL immunotherapy for allergic rhinitis, with or without conjunctivitis, confirmed by in vitro testing for IgE antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites, or skin testing to licensed house dust mite allergen extracts.

The first dose must be given in a healthcare setting under the supervision of a physician with experience in diagnosis and treatment of allergic diseases. Patient monitoring for signs or symptoms of a severe systemic or local allergic reaction is required following administration. Life-threatening allergic reactions are described in a boxed warning within the prescribing information. The boxed warning also includes the need to prescribe autoinjectable epinephrine for the patient to have while using HDM immunotherapy.

Approval was based on a double-blind, multicenter trial (n = 1482) in adolescents and adults with HDM allergic rhinitis with or without conjunctivitis (AR/C). Over a 52-week period, HDM immunotherapy improved rhinoconjunctivitis score and visual analog scale-assessed AR/C symptoms (P <0.001).<ref>73</ref>

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 couple allergens. SLIT is more convenient than weekly injections in those with with limited, specific allergies that match the SL product. Whether SLIT will be effective for non-pollen allergens other than dust mites 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 rhinoconjunctivitis to grass pollen. [74]

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Surgical Care

Surgical care may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities.

Turbinoplasty may be effective for persistent allergic rhinitis when refractory to intranasal steroids and antihistamines. [75] Radiofrequency turbinoplasty has been shown to improve nasal congestion subjectively and objectively through rhinomanometry more than intranasal steroids even after 12 months from surgery. [76] Intranasal steroids in conjunction with turbinoplasty shows greater efficacy in controlling allergic rhinitis compared with intranasal steroids alone. [77] However, radiofrequency reduction of inferior turbinates seems to provide only temporary relief since patients have worsening symptoms by 5 years post operatively. [78, 79]

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Consultations

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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