Consultant. Vol. 50 No. 4

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Allergic Rhinitis: Update on Your Therapeutic Choices

By ROBERT S. VALET, MD and JOHN M. FAHRENHOLZ, MD
Vanderbilt University | March 31, 2010

Dr Valet is a research fellow at the Institute of Medicine and Public Health at Vanderbilt University School of Medicine in Nashville, Tenn. Dr Fahrenholz is assistant professor of medicine in the division of allergy, pulmonary, and critical care medicine at Vanderbilt University School of Medicine.

ALLERGEN AVOIDANCE

For persons with allergic rhinitis, a number of allergen avoidance recommendations are advocated in practice parameters⁷ and reviews.^37,38 For those with pollen allergy, these measures include wearing dust masks (although supporting data are limited,³⁹ and even high-efficiency respirators, such as N95 respirators, do not perform well if not fitted properly⁴⁰) and limiting time outdoors. For persons with mold allergy, avoidance measures include limiting soildisturbing activity or wearing masks while doing so, and for indoor mold, eliminating moisture sources, removing moisture-damaged materials, and cleaning nonporous surfaces with bleach.

To control dust mite antigen, reducing indoor humidity, using dust mite sheet covers, washing bedding in hot water, replacing carpeting with hard flooring, using acaricides, and using high-efficiency particulate air (HEPA) filters in vacuums and in heating/air conditioning units have all been advocated. However, the effectiveness of some of these measures is controversial.^41-43

Roach antigen control focuses on extermination and good sanitation to prevent reinfestation. Pet allergen is most effectively avoided by removing the pet, after which time it can take months for allergen to disappear from the home.^7,37,38

INDICATIONS FOR SPECIALTY REFERRAL

Consider referral to an allergist for patients whose rhinitis remains symptomatic or whose quality of life remains impaired despite treatment. Allergy skin testing may confirm suspected triggers or lead to the diagnosis of nonallergic rhinitis. Frequently, the combination of allergen avoidance and ongoing pharmacological therapy controls symptoms. For those patients with positive skin test results consistent with their symptoms (eg, peak symptoms in the fall in a patient with ragweed allergy) who remain uncontrolled with pharmacotherapy or who wish to limit the need for medication, consider allergen immunotherapy.

IMMUNOTHERAPY FOR ALLERGIC RHINITIS

Allergen immunotherapy involves exposing patients to initially escalating and then maintenance amounts of the allergens that cause the majority of their symptoms. Subcutaneous injection immunotherapy has been shown to be effective in numerous randomized, controlled trials in children and adults.^44-71 Allergen immunotherapy also appears to prevent sensitization to new allergens and may reduce the risk of asthma in patients with allergic rhinitis.^72-77 Further, allergen immunotherapy is the only treatment known to alter the natural history of allergic rhinitis, and the clinical benefits are usually sustained for years following a successful 3- to 5-year treatment period.

In the United States, immunotherapy is usually administered by subcutaneous injection, although sublingual immunotherapy may prove to be an effective alternative.⁷⁸ While substantial positive data about European sublingual extracts have accumulated over the past several years, data about sublingual extracts in the United States are limited and results have been mixed.^78,79 It is important to note that allergen extract potency is not uniformly standardized; different standardization methods are used in Europe. Thus, data from European sublingual immunotherapy trials (even with similar allergens) cannot be extrapolated directly for use with extracts manufactured in the United States. Currently, no form of sublingual immunotherapy is approved by the FDA.

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by ARLES RAY | July 08, 2010 6:14 PM EDT

You fail to mention the benefits of hypertonic saline irrigatrion and or spray. I personally have found that early and frequent use of this very inexpensive and safe non-prescription form of treatment to be as effective or more so than most of the previously mentioned therapies. I believe the medical literature bears this out.

Though there appears little evidence in the medical literature to the effect, I have also found that maximized doses of simple NSAIDs seem to have a considerable benefit for short term use. I wonder if you have run across any studies to this effect.

Thanks,

A. G. Ray, M.D.

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Therapeutic Agents in This Article
Azelastine (Astelin, Astepro)
Budesonide (Rhinocort Aqua)
Cetirizine (Zyrtec)
Chlorpheniramine (Chlor-Trimeton)
Ciclesonide (Omnaris)
Cromolyn (Nasalcrom)
Desloratadine (Clarinex)
Diphenhydramine (Benadryl)
Fexofenadine (Allegra)
Flunisolide (Nasarel)
Fluticasone furoate (Veramyst)
Fluticasone propionate (Flonase)
Hydroxyzine (Atarax)
Ipratropium (Atrovent)
Levocetirizine (Xyzal)
Loratadine (Claritin)
Mometasone (Nasonex)
Montelukast (Singulair)
Olopatadine (Patanase)
Oxymetazoline (Afrin, Dristan)
Phenylephrine (Neo-Synephrine)
Pseudoephedrine (Sudafed)
Triamcinolone (Nasacort AQ)

TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

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Allergic Rhinitis: Update on Your Therapeutic Choices

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