Allergic Rhinitis

with obstructive rhinitis. Children’s growth should be assessed, as the combined use of intra nasal corticosteroids (INCS) and inhaled corticosteroids can reduce height at high doses. The presence of features such as conjunctivitis, nasal allergic crease, allergic salute or double creases beneath the eyes all suggest an allergic diathesis. Nasal examination is required in patients with moderate to severe AR or in those with uncontrolled symptoms despite optimal treatment. Examination should include assessment of the external appearance followed by internal examination, preferably with a nasoendoscope although an otoscope may suffice in children. Position of the nasal septum, size and colour of the inferior turbinates together with the appearance of the mucosa and the presence and nature of any secretions, polyps, bleeding, tumours, crusting or foreign bodies should be noted.

Treatment

Therapeutic options for AR include avoidance measures, nasal saline irrigation, oral antihistamines, INCS, combination INCS/antihistamine sprays, leukotriene receptor antagonists (LTRAs), and allergen immunotherapy. Other therapies that may be useful for some patients include decongestants and oral corticosteroids.

It is important to differentiate over-thecounter (OTC) and prescription therapies for AR. Nasal decongestant sprays are highly effective if used infrequently. Available options include Sudafed nasal spray (xylometazoline HCL), Otrivin (xylometazoline HCL), and Afrin (oxymetazoline HCL). Despite being available OTC, caution should be advised as incorrect use can lead to adverse effects. It is important that patients are aware that these decongestant sprays are not recommended for monotherapy in chronic AR.

First-line treatment of AR involves reduced exposure and avoidance of relevant allergens and irritants, such as house dust mites, moulds, pets and pollens, etc, that trigger the condition. Nasal saline irrigation is most effective when used for mild symptoms or before intranasal glucocorticoid

(INGC) application. INGC options include Avamys, Nasonex, and Flixonase. If symptoms remain refractory to an INGC, a second generation oral antihistamine will be prescribed.

Second-generation oral anti-histamines such as loratadine and cetirizine are first-line pharmacological treatments recommended for all patients with AR. They require once-daily dosage, are non-drowsy and are available OTC without prescription. Second-generation antihistamines offer several advantages over classical H1 antihistamines, such as lack of sedation and impairment of performance, longer duration of action, and absence of anti-cholinergic side-effects. However, loratadine is best avoided in elderly patients and patients with liver problems.

First-generation sedating antihistamines, oral antihistamines may, with caution, be used in pregnancy or in women who are breastfeeding; for example, cetirizine. such as diphenhydramine and chlorpheniramine, are also effective in relieving symptoms, however, they have been shown to negatively impact cognition and functioning, may affect the patient’s ability to drive and operate machinery and are not routinely recommended for the treatment of AR. They should not be used in patients with prostatic hypertrophy or narrow-angle glaucoma.

Other first-line therapeutic options for patients with mild persistent or moderate/ severe symptoms are INCS and they can be used alone or in combination with oral antihistamines. When used regularly and correctly, INCS effectively reduce inflammation of the nasal mucosa and improve mucosal pathology. Studies and meta-analyses have shown that INCS are superior to antihistamines and LTRAs in controlling symptoms of AR, including nasal congestion and rhinorrhoea.

INCS are not systemically absorbed. The most common adverse effects are local, including nasal irritation, stinging and epistaxis, and can usually be prevented by aiming the spray slightly away from the nasal septum. Long-term use does not damage nasal mucosa or induce glaucoma, and growth effects in children seem to be minimal. Some INCS, such as budesonide, can be safely used during pregnancy at the recommended therapeutic dose after a thorough medical evaluation.

The advantages of oral antihistamines are once-a-day administration, rapid and effective action and low cost. However, they are less effective than INCS, particularly for nasal congestion which is a common symptom of AR. Oral antihistamines are often sufficient for the treatment of mild AR, and many patients prefer oral medications to other formulations. Some

If INCS are not effective, a combination corticosteroid/antihistamine spray, such as Dymista, can be used. LTRAs should be considered when oral antihistamines, INCS, and/or combination corticosteroid/ antihistamine sprays are not well tolerated or are ineffective in controlling the symptoms of AR. For patients with AR refractory to INGCs and concomitant asthma, a trial of an LTRA, such as montelukast, is advised. If combination pharmacological therapy with oral antihistamines, INCS, combination corticosteroid/antihistamine sprays and LTRAs is not effective or is not tolerated, then allergen immunotherapy should be considered.

Immunotherapy

Allergen-specific immunotherapy (AIT) is currently the only potential treatment for allergies including AR that can modify the underlying course of the diseases. AIT is indicated for AR, allergic rhinoconjunctivitis and/or asthma when