Available at: www. Asthma and other atopic diseases in Australian children. Med J Aust ; Fineman SM. The burden of allergic rhinitis: beyond dollars and cents. Ann Allergy Asthma Immunol ; Australian Institute of Health and Welfare.
Allergic Rhinitis Treatments Chart
Health expenditure Australia — Health and Welfare Expenditure Series no. Canberra: AIHW; AIHW Catalogue no. HWE Rhinitis as an independent risk factor for adult-onset asthma. J Allergy Clin Immunol ; Long-term risk factors for developing asthma and allergic rhinitis: a year follow-up study of college students. Allergy Proc ; Epidemiologic evidence for asthma and rhinitis comorbidity. The effect of treatment of allergic rhinitis on asthma morbidity, including emergency department visits.
Curr Opin Allergy Clin Immunol ; 3: Relationships between atopy and bacterial infections. Curr Allergy Asthma Rep ; 3: Naclerio R. Clinical manifestations of the release of histamine and other inflammatory mediators. Allergy Clin Immunol ; Puy R. Diagnosing and treating allergic rhinitis. Med Today ; 4: Sheikh A, Hurwitz B. House dust mite avoidance measures for perennial allergic rhinitis: a systematic review of efficacy.
Br J Gen Pract ; House dust mite control measures in the management of asthma: meta-analysis. BMJ ; Clinical evaluation of the effect of anti-allergic mattress covers in patients with moderate to severe asthma and house dust mite allergy: a randomised double blind placebo controlled study. Thorax ; Consensus statement on the treatment of allergic rhinitis. Allergy ; Dykewicz MS, Fineman S. Yanez A, Rodrigo GJ. Stempel DA, Thomas M. Treatment of allergic rhinitis: an evidence-based evaluation of nasal corticosteroids versus nonsedating antihistamines.
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Australian Asthma Handbook
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Adelaide: Australian Medicines Handbook Ltd, Comparison of a nasal glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in the treatment of seasonal allergic rhinitis. Implementation of guidelines for seasonal allergic rhinitis: a randomized controlled trial. Galant SP, Wilkinson R. Clinical prescribing of allergic rhinitis medications in the preschool and young school-age child: what are the options?
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Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics ; e Safety of nasal budesonide in the long-term treatment of children with perennial rhinitis. Clin Exp Allergy ; Fluticasone propionate aqueous nasal spray: a well-tolerated and effective treatment for children with perennial rhinitis.
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Do you have any competing interests to declare? Evidence suggests that intranasal beclomethasone and triamcinolone, but not other intranasal corticosteroids, may slow growth in children compared to placebo. However, long-term studies examining the impact of usual doses of intranasal beclomethasone on growth are lacking [ 26 , 27 , 28 , 29 ].
It is important to note that most patients with allergic rhinitis presenting to their primary-care physician have moderate-to-severe symptoms and will require an intranasal corticosteroid. Bousquet et al. This combination spray has been shown to be more effective than the individual components with a safety profile similar to intranasal corticosteroids [ 31 , 32 , 33 , 34 ].
The LTRAs montelukast and zafirlukast are also effective in the treatment of allergic rhinitis; however, they do not appear to be as effective as intranasal corticosteroids [ 35 , 36 , 37 ].
Australian Asthma Handbook
Although one short-term study found the combination of LTRAs and antihistamines to be as effective as intranasal corticosteroids [ 38 ], longer-term studies have found intranasal corticosteroids to be more effective than the combination for reducing nighttime and nasal symptoms [ 20 , 39 ]. It is important to note that in Canada, montelukast is the only LTRA indicated for the treatment of allergic rhinitis in adults. Allergen immunotherapy is an effective treatment for allergic rhinitis, particularly for patients with intermittent seasonal allergic rhinitis caused by pollens, including tree, grass and ragweed pollens [ 40 , 41 , 42 , 43 ].
It has also been shown to be effective for the treatment of allergic rhinitis caused by house dust mites, Alternaria, cockroach, and cat and dog dander although it should be noted that therapeutic doses of dog allergen are difficult to attain with the allergen extracts available in Canada. Allergen immunotherapy should be reserved for patients in whom optimal avoidance measures and pharmacotherapy are insufficient to control symptoms or are not well tolerated. Since this form of therapy carries the risk of anaphylactic reactions, it should only be prescribed by physicians who are adequately trained in the treatment of allergy and who are equipped to manage possible life-threatening anaphylaxis [ 1 ].
Immunotherapy may also reduce the risk for the future development of asthma in children with allergic rhinitis [ 41 ]. After this period, many patients experience a prolonged, protective effect and, therefore, consideration can be given to stopping therapy. Pre-seasonal preparations that are administered on an annual basis are also available [ 1 , 14 ]. Sublingual immunotherapy is a way of desensitizing patients and involves placing a tablet of allergen extract under the tongue until it is dissolved.
It is currently available for the treatment of grass and ragweed allergy, as well as house dust mite-induced allergic rhinitis with or without conjunctivitis. The sublingual route of immunotherapy offers multiple potential benefits over the subcutaneous route including the comfort of avoiding injections, the convenience of home administration, and a favourable safety profile.
Like subcutaneous immunotherapy, sublingual immunotherapy is indicated for those with allergic rhinitis who have not responded to or tolerated conventional pharmacotherapy, or who are adverse to the use of these conventional treatments. The most common side effects of sublingual immunotherapy are local reactions such as oral pruritus, throat irritation, and ear pruritus [ 42 ]. There is a very small risk of more severe systemic allergic reactions with this type of immunotherapy and, therefore, some allergists may offer the patient an epinephrine auto-injector in case a reaction occurs at home.
The risk of systemic allergic reactions is much lower with sublingual immunotherapy compared to traditional injections [ 42 ]. Similar to subcutaneous immunotherapy, sublingual immunotherapy is contraindicated in patients with severe, unstable or uncontrolled asthma. It should ideally be avoided in patients on beta-blocker therapy as well as in those with active oral inflammation or sores [ 46 , 47 , 48 , 49 , 50 ].
Sublingual immunotherapy should only be administered using the Health Canada approved products discussed above. A simplified, stepwise algorithm for the treatment of allergic rhinitis is provided in Fig. Note that mild, intermittent allergic rhinitis can generally be managed effectively with avoidance measures and oral antihistamines. However, as mentioned earlier, most patients presenting with allergic rhinitis have moderate-to-severe symptoms and, therefore, will require a trial of intranasal corticosteroids.
Oral and intranasal decongestants e. However, the side-effect profile associated with oral decongestants i. Furthermore, these agents are contraindicated in patients with uncontrolled hypertension and severe coronary artery disease.
Oral corticosteroids have also been shown to be effective in patients with severe allergic rhinitis that is refractory to treatment with oral antihistamines and intranasal corticosteroids [ 1 , 4 ]. Although not as effective as intranasal corticosteroids, intranasal sodium cromoglycate Cromolyn has been shown to reduce sneezing, rhinorrhea and nasal itching and is, therefore, a reasonable therapeutic option for some patients. The anti-IgE antibody, omalizumab, has also been shown to be effective in seasonal allergic rhinitis and asthma [ 1 ], however, it is not currently approved for the treatment of allergic rhinitis.
Surgical therapy may be helpful for select patients with rhinitis, polyposis, or chronic sinus disease that is refractory to medical treatment. Most surgical interventions can be performed under local anesthesia in an office or outpatient setting [ 1 ].
It is important to note that allergic rhinitis may worsen during pregnancy and, as a result, may necessitate pharmacologic treatment. The benefit-to-risk ratio of pharmacological agents for allergic rhinitis needs to be considered before recommending any medical therapy to pregnant women.