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Rhinitis guidelines revised for first time in 10 years.

New guidelines for the diagnosis and treatment of rhinitis emphasize the value of newer medications and treatment combinations, especially in identifying drugs that are effective in symptom-provoking environments.

The guidelines, last issued in 1998, depart from some international guidelines by discussing options for patients who don't tolerate certain medications or prefer certain routes of administration.

"There are now more data on the positioning of oral anti-leukotriene agents as well as the intranasal antihistamines," said Dr. Mark S. Dykewicz, chair of the task force that prepared the guidelines for the American Academy of Asthma, Allergy, and Immunology; the American College of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology.

Dr. Dykewicz said in an interview that the guidelines introduce the concept of episodic allergic rhinitis, defined as "allergic nasal symptoms elicited by sporadic exposures to inhalant aeroallergens that are not usually encountered in the patient's indoor or outdoor environment."

"If you're anticipating that a patient is going to be going into an allergen-laden environment," it's worthwhile to consider "which medicine would be more appropriate for the patient to use on an as-needed basis, because some of them are going to take an hour or so to kick in and some, like the nasal steroids, are not going to help," said Dr. Dykewicz, chief of the division of allergy and immunology at Saint Louis University.

"For instance, oral antihistamines, because of the time required for absorption, are not good options necessarily if you're going to be taking the medication just prior to exposure," he said.

The guidelines also contain "greater coverage of [treatment options for] concomitant eye symptoms" with allergic rhinitis, he said. Meta-analyses show that oral antihistamines are not more effective than intranasal corticosteroids for eye symptoms.

The task force recommended that clinicians consider evaluating patients for obstructive sleep apnea syndrome, in addition to other comorbidities of rhinitis, including asthma and sinusitis.

The task force found that combinations of some medications, such as the addition of an oral antihistamine to an oral leukotriene receptor antagonist, may provide greater benefit for treating allergic rhinitis than monotherapy alone, but they are not as effective as monotherapy with an intranasal steroid.

Intranasal antihistamines can be just as effective as oral second-generation antihistamines for seasonal allergic rhinitis, but they generally are less effective than intranasal corticosteroids for seasonal and perennial allergic rhinitis. The combination of intranasal antihistamines and intranasal corticosteroids may be especially beneficial, according to the guidelines, published as a supplement to the Journal of Allergy and Clinical Immunology (2008;122:S1-84).

First- and second-generation oral antihistamines have not been adequately compared for allergic rhinitis, but the task force generally preferred second-generation oral antihistamines because they are associated with fewer adverse effects, such as sedation, performance impairment, and anticholinergic effects.

Oral decongestants are effective for nasal congestion in patients with allergic or nonallergic rhinitis but can be associated with side effects in patients taking stimulants or with conditions such as high blood pressure, cerebrovascular or cardiovascular disease, hyperthyroidism, closed-angle glaucoma, and bladder neck obstruction.

Treatment combinations for allergic rhinitis that add oral antihistamines to intranasal corticosteroids or intranasal antihistamines do not seem to provide any additive benefit, the guidelines state. But concomitant use of an intranasal corticosteroid and an intranasal anticholinergic agent such as ipratropium bromide can be more effective for rhinorrhea than either drug alone.

The task force also advised that second-generation antihistamines can be regarded as safe for use during pregnancy, similar to first-generation antihistamines, which are given a category B pregnancy risk status. Sodium cromolyn and montelukast (Singulair) also have a category B rating for safety. Most intranasal steroids have been given a category C rather than B rating, but the guidelines consider it reasonable to continue the drugs at the lowest effective dose if they have adequately controlled the patient's symptoms before pregnancy.

Dr. Dykewicz and many other members of the task force reported having consulting arrangements, receiving research support, and being on the speakers bureaus for many pharmaceutical companies that manufacture medications for rhinitis.


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Author:Evans, Jeff
Publication:Internal Medicine News
Geographic Code:1USA
Date:Sep 1, 2008
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