Treatment options for the management of perennial allergic rhinitis, with a focus on intranasal corticosteroids.Abstract: Perennial allergic rhinitis Allergic Rhinitis Definition
Allergic rhinitis, more commonly referred to as hay fever, is an inflammation of the nasal passages caused by allergic reaction to airborne substances. (PAR) can have a significant impact on a patient's quality of life. While allergen allergen /al·ler·gen/ (al´er-jen) an antigenic substance capable of producing immediate hypersensitivity (allergy).allergen´ic
pollen allergen avoidance is the first line of management for PAR, complete avoidance is difficult. Therapeutic options available for PAR include intranasal in·tra·na·sal
Within the nose. corticosteroids Corticosteroids Definition
Corticosteroids are group of natural and synthetic analogues of the hormones secreted by the hypothalamic-anterior pituitary-adrenocortical (HPA) axis, more commonly referred to as the pituitary gland. (INS INS
1. Immigration and Naturalization Service
2. International News Service
Noun 1. INS ), [H.sub.1]-antihistamines, decongestants Decongestants Definition
Decongestants are medicines used to relieve nasal congestion (stuffy nose).
A congested or stuffy nose is a common symptom of colds and allergies. and local chromones, as well as immunotherapy. For mild symptoms, INS and antihistamines Antihistamines Definition
Antihistamines are drugs that block the action of histamine (a compound released in allergic inflammatory reactions) at the H1 are the standard of care, whereas for moderate-to-severe PAR, INS are the preferred therapy due to their proven efficacy. Patient quality of life and therapy preference play a role in maintaining adherence to treatment adherence to treatment Compliance Therapeutics The following of a recommended course of treatment by taking all prescribed medications for the length of time necessary .
Key Words: perennial allergic rhinitis, avoidance, intranasal corticosteroids, antihistamines
Allergic rhinitis (AR) is the most prevalent chronic allergic disease. It is thought that up to 10% of adults and 40% of children in the US are affected by AR. (1) As such, AR is one of the most common reasons for visits to primary care practitioners, (2) who play a key role in the management of the disease.
The economic burden associated with AR is substantial. In 1996, the estimated total cost of AR in the US was $6 billion. (3) While the symptoms caused by AR are not life threatening, they can significantly impact on patient quality of life (4); the disease reduces productivity at work, (5) impairs concentration (6) and reduces learning ability in children. (7) AR is often associated with a number of comorbidities, including sinusitis sinusitis
Inflammation of the sinuses. Acute sinusitis, usually due to infections such as the common cold, causes localized pain and tenderness, nasal obstruction and discharge, and malaise. , asthma and otitis media Otitis Media Definition
Otitis media is an infection of the middle ear space, behind the eardrum (tympanic membrane). It is characterized by pain, dizziness, and partial loss of hearing. . (8-12) Poorly controlled AR can exacerbate these conditions, adding greatly to the morbidity and economic burden of the disease. (2)
Effective management can prevent the adverse events of perennial AR (PAR), restore patient quality of life, avoid exacerbation of comorbid pathologies and reduce economic burden. This article reviews the current recommendations for the diagnosis and management of PAR, providing a practical overview for the primary care practitioner.
Classification and Diagnosis of Perennial Allergic Rhinitis
AR has traditionally been divided into AR that occurs seasonally due to outdoor allergens such as pollen, and AR that occurs perennially due to indoor allergens such as dust mites and pet dander dander /dan·der/ (dan´der) small scales from the hair or feathers of animals, which may be a cause of allergy in sensitive persons.
n. . (13) However, these definitions are a poor reflection of real life, (14) with some pollens occurring perennially (15) and some symptoms of perennial allergies not being present continuously. Therefore, the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines reclassify Verb 1. reclassify - classify anew, change the previous classification; "The zoologists had to reclassify the mollusks after they found new species"
class, classify, sort out, assort, sort, separate - arrange or order by classes or categories; "How would you AR into intermittent and persistent AR, based on symptom timing and frequency (Table). (11) Both intermittent and persistent AR can be subdivided based on the severity of patient symptoms into mild or moderate-to-severe. The traditional nomenclatures of seasonal and perennial AR are retained herein to allow a direct discussion of published data.
AR clinically presents as some or all of the following symptoms: rhinorrhea, sneezing To verbally tell somebody about a new and interesting Web site. See viral marketing. , nasal congestion nasal congestion ENT Difficulty in nasal breathing, due to an ↑ vascular thickness of nasal mucosa. See Nasal stuffiness. , itching of the nose and palate, and ocular symptoms (itchy, watery eyes). Seasonal allergic rhinitis seasonal allergic rhinitis,
n See hay fever.
seasonal allergic rhinitis Allergic rhinitis in which Sx wax and wane as a function of environmental pollen. See Allergic rhinitis. can be easy to diagnose due to the rapid onset of symptoms when the patient is exposed to pollen. (16) For example, the ragweed ragweed, any plant of the genus Ambrosia, coarse, weedy herbs belonging to the family Asteraceae (aster family), most of which are native to America. They have inconspicuous greenish flowers and soft subdivided leaves. pollen season occurs during the fall in the northern latitudes of the US; AR symptoms occurring during this period may be caused by ragweed pollen. Conversely, diagnosing PAR can be difficult, as diagnostic criteria can overlap with those of some non-AR diseases such as sinusitis and vasomotor rhinitis vasomotor rhinitis
Congestion of nasal mucosa without infection or allergy.
vasomotor rhinitis ENT Rhinitis characterized by intermittent episodic sneezing, rhinorrhea, and congestion of nasal mucosa, attributed to . (16) Furthermore, occupational rhinitis Rhinitis Definition
Rhinitis is inflammation of the mucous lining of the nose.
Rhinitis is a nonspecific term that covers infections, allergies, and other disorders whose common feature is the location of their symptoms. can result from both allergic and nonallergic causes. (17) For example, animal dander animal dander See Dander. found in laboratory environments may result in AR, whereas irritants such as wood dust, detergents, dyes and other industrial chemicals can cause non-AR. (18) Diagnosis should focus on symptoms, triggers, seasonal variation, allergies, medical history and current treatments. (17) Accurate diagnosis is paramount, as effective therapies for AR may not be so effective at treating nonallergic rhinitis. (19)
The causative allergens of PAR commonly include house-dust mites, indoor molds, cockroaches cockroaches
insects which may carry Salmonella spp. in their gut and play a part in the spread of the disease. and animal dander. (11) The prevalence of the trigger allergen dictates the incidence of a patient's symptoms; the identification of the trigger allergen is an important aspect in the diagnosis of PAR. A thorough clinical history will provide clues as to the probable trigger. Patients should be carefully questioned regarding possible allergens present at home, work or school. Typically, the causative allergens of PAR are ubiquitous and present all year round.
Percutaneous or intradermal intradermal /in·tra·der·mal/ (-der´mal)
1. within the dermis.
Within or between the layers of the skin. skin testing and immunoglobulin E immunoglobulin E
n. Abbr. IgE
The class of antibodies produced in the lungs, skin, and mucous membranes and responsible for allergic reactions. (IgE) testing (assessed by radioallergosorbent testing [CAP-RAST]) are commonly used by qualified personnel to confirm sensitivity to a particular allergen. Skin testing introduces the allergen into the skin and results in a wheal wheal (hwel) a localized area of edema on the body surface, often attended with severe itching and usually evanescent; it is the typical lesion of urticaria.
n. and flare reaction after 15 minutes, (20) whereas CAP-RAST testing is an in vitro in vitro /in vi·tro/ (in ve´tro) [L.] within a glass; observable in a test tube; in an artificial environment.
In an artificial environment outside a living organism. test that involves the binding of a specific allergen to specific IgE in serum. Antibodies are used to quantify the amount of specific IgE bound to the allergens. (21,22) The significance of a positive result during these tests must be considered in conjunction with a suggestive clinical history. (23)
Mechanisms of Perennial Allergic Rhinitis
The pathology of AR can be divided into early and late-phase reactions. Early-phase symptoms occur within minutes of allergen exposure and are characterized by rhinorrhea, nasal obstruction nasal obstruction,
n a narrowing of the nasal cavity, which reduces breathing capacity. Caused by an irregular septum, nasal polyps, foreign bodies, or enlarged turbinates. , sneezing and pruritus pruritus /pru·ri·tus/ (proo-ri´tus) itching.prurit´ic
pruritus a´ni intense chronic itching in the anal region.
pruritus hiema´lis xerotic eczema. . (24) Immunoglobulin E-mediated activation of mast cells Mast cells
A type of immune system cell that is found in the lining of the nasal passages and eyelids, displays a type of antibody called immunoglobulin type E (IgE) on its cell surface, and participates in the allergic response by releasing histamine from and basophils release mediators, such as histamine and leukotriene leukotriene /leu·ko·tri·ene/ (-tri´en) any of a group of biologically active compounds derived from arachidonic acid that function as regulators of allergic and inflammatory reactions. , which activate their respective receptors and induce the symptoms of AR. Histamine is probably the major mediator of the early-phase reaction. (25) Both mast cells and T cells T cells
A type of white blood cell produced in the thymus gland. T cells are an important part of the immune system. Infants born with an underdeveloped or absent thymus do not have a normal level of T cells in their blood. also release cytokines Cytokines
Chemicals made by the cells that act on other cells to stimulate or inhibit their function. Cytokines that stimulate growth are called "growth factors. such as interleukins, that induce IgE synthesis. (26)
Approximately 30 to 40% of patients develop a late-phase reaction occurring 4 to 5 hours after the initial allergen exposure (25) characterized by nasal obstruction. (25) Cytokines and chemokines, such as interleukin (IL)-8, as well as the mediators released by the early-phase reaction, help recruit and activate inflammatory cells, such as eosinophils Eosinophils
A leukocyte with coarse, round granules present.
Mentioned in: Histiocytosis X
eosinophils , (27) which themselves release mediators. Symptoms are therefore perpetuated, with persistent AR sufferers existing in a continual state of eosinophilia eosinophilia /eo·sin·o·phil·ia/ (e?o-sin?o-fil´e-ah) abnormally increased eosinophils in the blood.
An increase in the number of eosinophils in the blood. and increased mediator release. (28)
Management of Perennial Allergic Rhinitis
A review of MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. was performed to assess pharmacologic treatment options using the terms 'perennial allergic rhinitis', 'allergen avoidance', 'intranasal corticosteroids', 'antihistamines', 'decongestants' and 'chromones', as well as individual drug names.
Allergen avoidance is the first line of management for PAR. Reducing the allergens in a patient's immediate environment can have a significant impact on symptom frequency and severity. (29) A range of measures can be employed, depending on the allergen involved. Aggressive cleaning of the home, effective filtering of the air, hot washing of bedding, replacement of carpets with hard flooring and regular wet-wiping of surfaces are general measures that eradicate most allergens. Despite rigorous cleaning, many allergens persist for extended periods of time and are easily transferred between environments. The total exclusion of an allergen from the environment is difficult. If the causative allergen is occupational, allergen avoidance may be unrealistic. Therefore, treatment to control the symptoms of PAR is frequently required.
Mites. Several specific mite-avoidance measures have been investigated in clinical studies, with varying outcomes. For example, tightly woven mattress coverings have been shown to effectively exclude both cat and house-dust mite allergens. (30) In addition, randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. , controlled studies have shown that the use of dust-mite impermeable impermeable /im·per·me·a·ble/ (-per´me-ah-b'l) not permitting passage, as of fluid.
Impossible to permeate; not permitting passage. mattress covers and other specific environmental controls can result in children being less likely to develop sensitization sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun)
1. administration of an antigen to induce a primary immune response.
2. exposure to allergen that results in the development of hypersensitivity. to dust mites (31) and in reductions in nasal symptoms. (32) Another study indicated that impermeable bedding covers significantly reduced the level of exposure to mite allergens, although corresponding improvements in the clinical symptoms of AR were not noted. (33)
Animals. For animal allergy, removing the animal from the home is the first option though this may cause distress to the patient and their family. High-efficiency particulate air (HEPA HEPA
1. high-efficiency particulate air
2. high-efficiency particulate arresting )-filtered vacuum cleaners have been shown to reduce the concentration and particle size of airborne cat allergens. (34) The effect allergen reduction had on symptoms was not assessed in this study. A further study indicated that despite the combination of a HEPA room air cleaner, the use of mattress and pillow covers and cat exclusion from the bedroom, no effect on disease activity was noted. (35) Therefore, while allergen avoidance can be useful, some avoidance measures may not always be enough as a single approach, and multiple avoidance measures may be needed.
For PAR, a number of treatment options can be considered. For patients with mild symptoms, [H.sub.1]-receptor antagonists in oral and nasal formulations, INS, local chromones and oral and intranasal decongestants are recommended. Intranasal anticholinergic anticholinergic /an·ti·cho·lin·er·gic/ (-ko?lin-er´jik) parasympatholytic; blocking the passage of impulses through the parasympathetic nerves; also, an agent that so acts.
n. agents are also recommended for cases where rhinorrhea is the main symptom. (11) Antileukotrienes, such as montelukast montelukast /mon·te·lu·kast/ (mon?te-loo´kast) a leukotriene antagonist used as the sodium salt in prophylaxis and chronic treatment of asthma.
n. , have recently been approved for the treatment of nasal congestion due to AR. (36) In moderate-to-severe PAR, INS are first-line therapy. (11,37-39) Agents can be used individually or in combination to provide optimal symptom relief depending on symptoms.
Six aqueous INS formulations are currently licensed for the treatment of adult and pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. PAR in the US: beclomethasone dipropionate bec·lo·meth·a·sone di·pro·pi·o·nate
A corticosteroid usually used as an inhalant to treat asthma.
beclomethasone dipropionate (bek´l (BDP BDP Botswana Democratic Party
BDP Bund Der Pfadfinderinnen und Pfadfinder (German Scouts)
BDP Boogie Down Productions
BDP Bandwidth Delay Product
BDP Beclomethasone Dipropionate
BDP Business Development Program ), budesonide, flunisolide, fluticasone propionate fluticasone propionate (fltik´ (FP), mometasone furoate mometasone furoate Asmanex®, Nasonex®, Twisthaler® Therapeutics An inhaled steroid used for seasonal allergic rhinitis and asthma (MF) and triamcinolone acetonide triamcinolone acetonide (topical) (as´tō´nīd),
n brand names: (TAA TAA - Track Average Amplitude ).
Mechanism of Action
While the precise mechanism of action of corticosteroids has yet to be fully elucidated, they are known to have a profound impact on the inflammatory response, suppressing many elements of the allergic inflammatory cascade. By binding to the glucocorticoid receptor of nasal epithelial cells Epithelial cells
Cells that form a thin surface coating on the outside of a body structure.
Mentioned in: Corneal Transplantation , corticosteroids modulate the expression of a number of genes that play a pivotal role in the inflammatory response. (40) Among other functions, corticosteroids have been shown to reduce eosinophil eosinophil /eo·sin·o·phil/ (e?o-sin´o-fil) a granular leukocyte having a nucleus with two lobes connected by a thread of chromatin, and cytoplasm containing coarse, round granules of uniform size. infiltration and survival (41,42) and to suppress the expression of the cytokines IL-3, IL-4, IL-5 and IL-13, (43) dramatically reducing the infiltration of inflammatory cells into the nasal mucosa nasal mucosa,
n See mucosa. . Corticosteroids also reduce the release of several chemical mediators of inflammation, including histamine, (44) tryptase (45) and leukotrienes Leukotrienes
A class of small molecules produced by cells in response to allergen exposure; they contribute to allergy and asthma symptoms.
Mentioned in: Leukotriene Inhibitors
leukotrienes , (46) although these effects may be due to a reduction in the overall number of inflammatory cells in the epithelium.
Safety of Intranasal Corticosteroids
The adverse events arising from the long-term use of systemic corticosteroids Corticosteroids, Systemic Definition
Corticosteroids are a group of drugs which are chemically related to the hormones produced by the adrenal glands as a response to adrenocorticotropic hormone (ACTH), but excluding the sex hormones that are produced , such as skin-thinning, osteoporosis and Cushing syndrome Cushing syndrome
Disorder named for Harvey Williams Cushing, caused by adrenal cortex overactivity. If caused by a pituitary gland tumour, it is called Cushing disease. , are well known. (11) However, INS and systemic corticosteroids should not be classified together as they exhibit differing adverse-event profiles. Local application of corticosteroids allows the use of lower doses that are associated with lower risks of adverse events. In addition, the improved pharmacokinetic profile and, hence, reduced bioavailability bioavailability /bio·avail·a·bil·i·ty/ (bi?o-ah-val?ah-bil´i-te) the degree to which a drug or other substance becomes available to the target tissue after administration.
n. of the newer INS agents, further reduces the risk of systemic effects.
Local adverse events. Local adverse events associated with INS are generally minor and easily managed; the most common adverse events include irritation of the nasal epithelium, minor nosebleeds and headaches. These adverse events can usually be managed, although if they persist, switching to another agent or delivery device often eliminates the problem. (11) Septal septal /sep·tal/ (sep´tal) pertaining to a septum.
Of or relating to a septum or septa. perforation per·fo·ra·tion
1. The act of perforating or the state of being perforated.
2. An abnormal opening in a hollow organ or viscus, as one made by rupture or injury.
A hole. is an extremely rare adverse event of INS therapy that may largely be avoided by correct administration. (47) Patients should be advised to direct the spray away from the septum septum /sep·tum/ (sep´tum) pl. sep´ta [L.] a dividing wall or partition.
alveolar septum interalveolar s. to minimize any risk of septal perforation. (48)
Systemic adverse events. Suppression of the hypothalamic-pituitary-adrenal (HPA (1) (High Performance Addressing) Refers to a variety of earlier addressing techniques that improved the quality of a passive matrix (LCD) screen.
(2) (High Power A ) axis is a well-characterized adverse event of systemic corticosteroids. However, a number of clinical studies have shown that TAA, MF and FP have little or no effect on the HPA axis. (49,50) A preliminary study found no evidence of HPA-axis suppression with both FP 200 [micro]g once daily and TAA 220 [micro]g once daily when used in combination with the same agents administered at clinically recommended dosages for inhaled administration (FP 1760 [micro]g daily and TAA 1600 [micro]g daily). (51) It is advisable to use the lowest corticosteroid corticosteroid /cor·ti·co·ster·oid/ (-ster´oid) any of the steroids elaborated by the adrenal cortex (excluding the sex hormones) or any synthetic equivalents; divided into two major groups, the glucocorticoids and dose possible to control allergic disease because of a potential additive effect of intranasal and inhaled corticosteroids.
Concerns have also been raised over the effect of long-term INS therapy on linear growth in young children, (52) with one study suggesting that long-term use of BDP reduced growth in children. (53) The weight of evidence from data collected in recent years suggests that INS therapy has no significant long-term effect on normal growth in children. For example, a 1-year trial of MF 100 [micro]g once daily showed no evidence of growth suppression or impaired bone metabolism in children with PAR. (54) Similarly, a study of FP 100 [micro]g administered twice daily for 1 year to children aged 1 to 3 years showed no significant effect on growth. (55) Another 1-year study in children aged 6 to 14 years also demonstrated no significant effect of TAA treatment on growth velocity. (56) Finally, a comparative study of TAA 110 [micro]g and 220 [micro]g once daily and FP 200 [micro]g in children showed no significant statistical difference in mean growth velocity compared with placebo. (57)
Despite marked differences in the pharmacokinetic properties of the currently available INS formulations, all have proven efficacy in controlling the symptoms of PAR. (58) Furthermore, several head-to-head and comparative studies have indicated no clinical differences in efficacy between INS agents. For example, one study compared the efficacy of MF and FP at treating PAR in a 3-month, double-blind, double-dummy, placebo-controlled trial. Both agents were significantly (P < 0.01) superior to placebo at reducing nasal symptoms. There was no statistically significant difference between the two agents. (59) In a similar trial comparing TAA and FP, both agents were found to be equally effective in reducing total nasal symptom score from baseline (3.17 [+ or -] 0.18 and 3.15 [+ or -] 0.19, respectively). (60)
Quality of Life
PAR can have a strong negative impact on patient quality of life. A study of health-related quality of life found that patients with PAR reported more pain, felt less healthy, had poorer mental health and felt less able to function effectively than healthy volunteers. (61) INS agents have been shown to have benefits in patient health-related quality of life. (62) For example, a placebo-controlled, multicenter, randomized, double-blind study in patients with PAR found that TAA 220 [micro]g once daily significantly (P = 0.04) improved health-related quality of life, as assessed using the Rhinoconjunctivitis Quality of Life Questionnaire. Improvement in quality of life directly correlated with reductions in nasal symptoms. (63) A similar trial compared the effects of budesonide and FP on quality of life in patients with AR. (64) Both agents significantly (P < 0.05) improved patient quality of life as measured by the Rhinoconjunctivitis Quality of Life Questionnaire when compared with placebo. Greater improvements in patient quality of life were seen with budesonide than FP. (64) A study concerning nocturnal symptoms only found that TAA 220 [micro]g once daily for 3 weeks significantly improved (P < 0.001) nocturnal symptoms compared with baseline (65) as measured by the Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire and Pittsburgh Sleep Quality Index.
Successful treatment of PAR requires good long-term patient adherence. (66) Patient education and involvement is crucial to maintaining good treatment compliance, and patient preference for certain aspects of INS treatment, including convenience of administration, sensation during and after administration, irritation upon administration, and INS odor and taste, is thought to play a significant role in maintaining adherence to a therapeutic regimen. (67,68) A number of studies have compared patient preference for MF, FP and TAA; however, these have included the old MF formulation, before the current alcohol-free formulation was available. Therefore, the comparisons with the old formulation are no longer relevant.
For example, a multicenter, randomized, double-blind, crossover study comparing patient assessments of the sensory attributes of MF (old formulation), FP and TAA, found that TAA was rated as having little or no odor, a milder, more pleasant taste and a less drying effect on the throat than FP (P [less than or equal to] 0.05). (67) During the same trial, a greater proportion of patients indicated that they would be more compliant with medication if they were prescribed TAA over FP. (67) An earlier study also demonstrated preference for TAA over FP and BDP when rated for odor or taste. (69) Patient preference has also been shown for budesonide over FP (70) and the new MF formulation over FP based on sensory attributes. (71)
[H.sub.1]-receptor antagonists are a mainstay treatment for patients with mild-to-moderate PAR, and can be classified into first- and second-generation agents. First-generation antihistamines have been effective treatments for symptoms of AR, but are known to cause adverse events due to their lack of selectivity, resulting in anticholinergic effects such as dry mouth, tachycardia tachycardia: see arrhythmia.
Heart rate over 100 (as high as 240) beats per minute. When it is a normal response to exercise or stress, it is no danger to healthy people, but when it originates elsewhere, it is an arrhythmia. , urinary retention and gastrointestinal disturbances. (72) Further adverse events are caused by the ability of the first-generation agents to cross the blood-brain barrier, resulting in sedation and impairment of psychomotor psychomotor /psy·cho·mo·tor/ (si?ko-mo´ter) pertaining to motor effects of cerebral or psychic activity.
1. and cognitive function. (73) Nasal antihistamines such as levocabastine, azelastine and antazoline, however, have almost no associated adverse events, targeting only the organs to which they are administered. (74) Nasal antihistamines are of particular benefit to children whose symptoms are limited to the eyes or the nose. (75)
Second-generation antihistamines, such as cetirizine, loratadine, desloratadine and fexofenadine, are also effective at controlling the main symptoms of mild-to-moderate PAR, (76-79) but are more selective for the [H.sub.1]-receptor than their first-generation predecessors and have a lower tendency to cross the blood-brain barrier. (80) Due to their improved safety profile, a recent consensus report recommended that second-generation antihistamines should be used instead of the first-generation agents in all patients with AR. (80)
Second-generation oral antihistamines generally have a fast onset of action onset of action Pharmacology The length of time needed for a medicine to become effective. See Therapeutic drug monitoring. (1-3 h) (81,82) and are convenient to use due to their once-daily formulations. However, compared with INS, oral antihistamines are less effective against nasal congestion. Therefore, in persistent or moderate-to-severe PAR, antihistamines are often used concurrently with an INS or a decongestant decongestant /de·con·ges·tant/ (de?kon-jes´tint)
1. tending to reduce congestion or swelling.
2. an agent that so acts.
Oral and Intranasal Decongestants
Decongestants may also be used to relieve nasal congestion. For patients with moderate-to-severe nasal congestion, decongestants are used as add-on therapies to INS. (11) While the intranasal agents are faster than the oral formulations, the duration of treatment is limited to less than 10 days to prevent rhinitis medicamentosa (11); intranasal decongestants are not used as long-term therapy except during severe symptoms. The adverse events associated with oral decongestants are dose-dependent and include irritability, dizziness, headaches, tremor and insomnia. Care should be taken when giving oral decongestants to susceptible patients such as pregnant women and the elderly.
Combinations of oral decongestants with second-generation oral antihistamines are also available. There are limited published studies on the use of such combinations in PAR, but they have been shown to be more effective at treating the whole range of symptoms in patients with seasonal AR, compared with the individual monotherapies. (83-86)
Intranasal chromones are considered to be less effective than other treatment options, with a short-lasting effect. (11) Although typically associated with the treatment of seasonal AR, chromones can be used for the treatment of mild PAR symptoms, especially in children, due to their excellent safety profile. However, compliance is generally poor due to twice-/three times-daily dosing.
Allergen immunotherapy can be an effective method of treating PAR. (11) Patients whose AR cannot be controlled by avoidance measures and pharmacologic treatments and who need to avoid potential adverse events associated with pharmacologic treatments are good candidates for receiving immunotherapy. (87) Immunotherapy works by gradually increasing doses of allergen administered subcutaneously by an allergy specialist to induce tolerance to the allergen. Immunotherapy has been shown to be effective and has a high safety profile, although treatment is typically required over a number of years (88) and anaphylaxis anaphylaxis (ăn'əfəlăk`sĭs), hypersensitive state that may develop after introduction of a foreign protein or other antigen into the body tissues. following injection can be fatal. (89)
Although not yet a United States Food and Drug Administration-approved treatment for PAR, omalizumab has been shown to be an effective treatment for patients with PAR and seasonal AR. (90) Omalizumab is an antibody that binds IgE, preventing IgE from binding to basophils, thereby attenuating mediator release and reducing allergic symptoms. (91) Omalizumab has been shown to be well tolerated. (91)
Perennial AR has a significant negative impact on patient quality of life and may further exacerbate a number of common comorbidities. Allergen avoidance can improve symptoms; however, the allergens most frequently associated with PAR are ubiquitous and complete avoidance is difficult. Many patients affected by PAR require medication to control symptoms.
A number of options exist for the treatment of PAR, including INS, antihistamines, decongestants and chromones. While INS and antihistamines are first-line therapies for mild symptoms, ARIA guidelines have recommended INS therapy as the gold-standard treatment for moderate-to-severe PAR symptoms. The safety profiles of INS agents are associated with few systemic adverse events, with the newer INS agents being associated with little or no HPA-axis suppression and no significant long-term growth reduction in children. The efficacies of the currently available aqueous agents are broadly equivalent. To maximize symptom relief and improve patient quality of life, it is important that patients adhere to an INS treatment regimen. Recent studies have suggested that tailoring treatment to patient preference improves treatment adherence, hence improving long-term clinical outcome.
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Stephen A. Brunton, MD, and Leonard M. Fromer, MD
From the Cabarrus Family Medicine Residency Program, Charlotte, NC, and the Department of Family Medicine, UCLA UCLA University of California at Los Angeles
UCLA University Center for Learning Assistance (Illinois State University)
UCLA University of Carrollton, TX and Lower Addison, TX School of Medicine, CA.
Reprint requests to Dr. Stephen Brunton, Cabarrus Family Medicine Residency Program, 7011 Summerhill Ridge Drive, Charlotte, North Carolina “Charlotte” redirects here. For other uses, see Charlotte (disambiguation).
Charlotte is the largest city in the state of North Carolina and the 20th largest city in the United States. 28226. Email: OzDoc@aol.com
Stephen A. Brunton, MD, is a consultant to Sanofi-Aventis, Schering Plough and GlaxoSmithKline; Leonard M. Fromer, MD, has been a participant in CME CME
See: Chicago Mercantile Exchange
See Chicago Mercantile Exchange (CME). events and advisory boards funded by unrestricted educational grants from Sanofi-Aventis.
Accepted January 4, 2007.
RELATED ARTICLE: Key Points
* Several classes of pharmacologic agents are available for the treatment of perennial allergic rhinitis (PAR), including intranasal corticosteroids (INS), [H.sub.1]- antihistamines, local chromones and decongestants.
* Intranasal corticosteroids are the first-line option in moderate-to-severe PAR and can also be used in mild PAR, due to their proven efficacy.
* Second-generation oral antihistamines are effective at controlling mild-to-moderate PAR, have a fast onset of action and good safety profiles.
* Oral decongestants, usually in combination with oral antihistamines, are recommended for mild nasal congestion and as add-on therapy to INS for moderate-to-severe nasal congestion. Intranasal decongestants can also be used in severe cases of blockage.
* Local chromones are available as intranasal formulations for reducing the nasal symptoms of PAR, particularly in children.
* Successful treatment of PAR requires long-term treatment and patient adherence. Therefore, patient quality of life and patient preference for an agent should be considered when choosing a therapeutic option.
Table. ARIA classification of allergic rhinitis Intermittent Symptoms are present: * Less than 4 days a week * OR, for less than 4 weeks Persistent Symptoms are present: * More than 4 days a week * AND, for more than 4 weeks Mild None of the following are present: * Sleep disturbance * Impairment of daily activities, leisure and/or sport * Impairment of school or work * Troublesome symptoms Moderate-severe One or more of the following are present: * Sleep disturbance * Impairment of daily activities, leisure and/or sport * Impairment of school or work * Troublesome symptoms Reprinted with permission from Bousquet J, et al. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108(Suppl 5):S147- S334.