Download allergic rhinitis

FEBRUARY 2012
A
ALLERGIC RHINITIS
llergic rhinitis or ‘hayfever’ is one of the most common
chronic respiratory conditions in Australia. Predominant
symptoms are rhinorrhoea (‘runny nose’), nasal
obstruction, nasal itching and sneezing. It can cause significant
irritation and interference in daily activities, considerably
reducing quality of life.
Intermittent allergic rhinitis is defined as symptoms that are
present for less than 4 days per week, or less than 4 weeks at a
time.
Persistent allergic rhinitis is defined by symptoms that are
present for more than 4 days per week, and for more than 4
weeks at a time.
Other conditions that commonly occur with allergic rhinitis
include asthma, chronic sinusitis, otitis media (middle ear The severity of allergic rhinitis is classified as either mild
infection) and decreased quality of sleep.
or moderate/severe. With mild allergic rhinitis, there is no
impairment of sleep, daily activities, leisure or sport; and the
symptoms are not considered troublesome by the patient. With
Prevalence
Allergic rhinitis affects around 15% of the Australian moderate/severe allergic rhinitis, these impairments are present
population or around 3 million people. It is reported slightly and considered troublesome.
more commonly by females than males. The condition is
most commonly reported by those aged 25-44 years, and less Management
common by young people less than 14 years of age and people Although there is no cure for allergic rhinitis, effective treatment
older than 75 years, but the incidence is still around 10% in the is available.
older age group.
Optimal symptom control can be achieved through allergen
In a recent Australian Institute of Health and Welfare (AIHW) avoidance, pharmacotherapy, non-medicated treatments and
report the ACT and Western Australia had the highest rates of immunotherapy.
allergic rhinitis in Australia, with Queensland and New South
Wales the lowest.
Drug Treatment
First line therapy for the management of allergic rhinitis is
Causes
intranasal corticosteroids and oral antihistamines.
Genetic and environmental factors contribute to the onset and
development of allergic rhinitis.
For persistent allergic rhinitis and for moderate/severe
intermittent allergic rhinitis, guidelines recommend use of
Common triggers of allergic rhinitis include dust mites, animal intranasal corticosteroids as the first-line therapy. If patients
fur, pollens, fungal spores, air pollutants and occupational are not adequately controlled by intranasal corticosteroids, the
sources. Evidence of the effectiveness of allergen avoidance additional use of oral antihistamines is recommended.
measures, particularly house dust mite, is limited.
For mild intermittent allergic rhinitis, the use of antihistamines
is recommended as first-line therapy. For those whose symptoms
Signs and Symptoms
The symptoms of allergic rhinitis are caused by an allergic not adequately controlled by antihistamines, the additional use
reaction in the inner linings of the nose resulting in inflammation. of intranasal corticosteroids is recommended.
Common signs and symptoms include:
■■
itch
■■
mucus discharge
■■
sneezing
■■
post-nasal drip
■■
cough
■■
facial fullness and pain
■■
obstruction
■■
snoring
■■
sleep interference
Classification
Allergic rhinitis can be classified into two categories:
■■
Intermittent
■■
Persistent
© Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2012
Intranasal corticosteroids
Examples of intranasal corticosteroids include:
■■
Beclomethasone (Beconase 12 hour)
■■
Triamcinolone (Telnase)
■■
Fluticasone (Avamys, Flixonase)
■■
Budesonide (Rhinocort Hayfever, Rhinocort, Budamax)
■■
Mometasone (Nasonex)
Benefit appears after 3 to 8 hours but maximum effect may
require up to 2 weeks. Intranasal corticosteroids should be used
regularly, but still have benefit if used on intermittent basis, for
example in pollen season.
Intranasal corticosteroids have been shown to improve quality
Allergic Rhinitis, continued
of life and reduce sleep problems associated with nasal
congestion. They are more effective than oral or intranasal
antihistamines or topical sodium cromoglycate.
Intranasal corticosteroids have good long-term safety data, but
the lowest dose that will control symptoms should be used.
The total steroid dose should be considered if used with
intercurrent asthma. Systemic side effects typical of steroids
such as osteoporosis, diabetes and hypertension have not been
reported.
Antihistamines
Oral and topical antihistamines are effective in allergic
rhinoconjunctivitis and histamine related symptoms such as
itching, rhinorrhoea and sneezing. They are less effective for
nasal blockage.
Oral antihistamines that are less sedating are preferred:
■■
Cetirizine (Zyrtec)
■■
Desloratadine (Claramax, Aerius)
■■
Fexofenadine (Telfast, Fexotabs, Xergic)
■■
Levocetirizine (Xyzal)
■■
Loratadine (Claratyne, Allereze)
There may be a marked variation in response to different
antihistamines, but there is no evidence that any one agent
is superior. If unresponsive it is worth trying a different
antihistamine.
Older antihistamines (e.g. Polaramine, Phenergan, Vallergan)
should be avoided in older people as they cause sedation,
somnolence, fatigue and impaired psychomotor performance,
as well as anticholinergic effects (dry mouth, constipation,
blurred vision, urinary retention).
Nasal antihistamines including azelastine (Azep) and
levocabastine (Livostin) are as effective as oral antihistamines,
but not as effective as intranasal corticosteroids.
Other nasal sprays
Cromoglycate nasal spray (Rynacrom) is an effective mast
cell stabiliser. It may cause irritation of nasal mucosa and
infrequently nosebleeds.
Ipratropium (Atrovent Nasal, Atrovent Nasal Forte) is an
anticholinergic nasal spray which dries nasal secretions and
may reduce rhinorrhoea, but has no effect on nasal blockage or
on other symptoms of allergic rhinitis.
Nasal decongestants
Nasal decongestants such as oxymetazoline (Drixine),
tramazoline (Spray-Tish) or xylometazoline (Otrivin) may be
used in cases of severe nasal blockage, but only for up to 5
days, as rebound congestion may occur.
Eye drops
Anti-allergy eye drops are effective additional therapy when
ocular symptoms persist despite treatment with intranasal
steroids or oral antihistamines. Antihistamine-mast cell
stabilisers such as ketotifen (Zaditen) and olopatadine (Patanol)
are effective for rhinoconjunctivitis and require twice daily
instillation. Other antihistamine eye drops such as azelastine
© Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2012
(Eyezep) and levocabastine (Livostin) often need to be used 3
or 4 times daily.
Leukotriene antagonists
Leukotriene receptor antagonists (montelukast, zafirlukast) are
oral preparations used also for asthma and allergic rhinitis, but
are less effective than intranasal corticosteroids.
Immunotherapy
Immunotherapy should be considered for patients with
moderate or severe persistent allergic rhinitis that is not
responsive to usual treatments. Oral (sublingual) and injectable
(subcutaneous) forms of immunotherapy are available.
Adherence
A common reason for treatment failure is non-adherence due
to local side effects such as dryness, irritation and epistaxis.
Nasal saline spray can be used before intranasal steroids to
clear mucus, improving contact with the steroid and potentially
reducing the dose required to be effective.
Administration
Correct administration technique is vital to gain the most
benefit from intranasal sprays. First the bottle should be shaken
gently. The resident should tilt the head forward slightly and
close one nostril with a finger. Use the right hand for the left
nostril and put the nozzle just inside the nose and aim to the
side away from the central ridge of the nose. Breathe in gently.
Switch nasal inhaler to other hand and repeat for the other side.
Breathe out through the mouth. Finish by wiping the nozzle
and replacing the cap.
Summary
Allergic rhinitis or hayfever is a chronic condition experienced
by about 1 in 10 older people. It is the most common chronic
respiratory condition in Australia. Allergic rhinitis may
significantly affect quality of life, worsen asthma control and
cause sleep and cognitive disturbances. The goal of allergic
rhinitis management is to achieve optimal symptom control.
References
Australian Institute of Health and Welfare 2011. Allergic rhinitis (‘hay
fever’) in Australia. Cat. no. ACM 23. Canberra: AIHW.
ARIA in the pharmacy: management of allergic rhinitis symptoms in the
pharmacy. Allergy 2004:59:373–387.