Rhinitis - Allergic Management

Evaluation

The assessment of the patient’s condition will be based on the patient’s symptomatology, the patient’s exposure to allergens, and the visual analog scales (VAS).

Assess the pattern of symptoms based on severity and frequency or duration:

• Mild intermittent allergic rhinitis
• Moderate-severe intermittent allergic rhinitis
• Mild persistent allergic rhinitis
• Moderate-severe persistent allergic rhinitis 

*Please refer to Classification for further information.

Visual Analog Scales (VAS)

The visual analog scale is a psychometric response scale for the subjective characteristics or attitudes of disease-related symptom severity in each patient that is used to classify symptom severity and disease control. The control of allergic rhinitis is graded as follows:

• ≥5: Uncontrolled (VAS score of 5 suggests moderate-severe allergic rhinitis)
• ≥2 to <5: Partially controlled
• <2: Well-controlled

Evaluation of Disease Control 

The factors that are considered when evaluating a patient’s response to treatment include symptom scores, measures of nasal obstruction (eg peak nasal inspiratory flow, acoustic rhinometry, rhinomanometry), Allergic Rhinitis and its Impact on Asthma (ARIA) severity classification, Quality of Life (QOL) result, itemized scoring, symptom-medication scoring, and VAS. 

A low VAS score with the establishment of treatment (<5) shows an amount of improvement, as indicated in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) as well as in terms of work efficiency, and treatment is usually maintained or continued. A VAS score of <2 means well-controlled allergic rhinitis and treatment is usually stepped down. A high VAS score (≥5) shows no effect in symptom relief and treatment is usually stepped up. 

MACVIA-ARIA Sentinel NetworK for Allergic Rhinitis (MASK-Rhinitis)

MASK-Rhinitis is a clinical approach used to diagnose and classify patients based on the disease severity, as well as a tool to evaluate symptom control after initiation of treatment strategies by using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on ARIA guidelines. 

Electronic monitoring of allergic diseases includes a cell phone-based VAS assessment (uses MASK aerobiology which is a simple IOS/Android app), Control of Allergic Rhinitis and Asthma Test (CARAT), an e-Allergy screening, and the RhinAsthma Patient Perspective (RAPP) tool for smartphones. 

Principles of Therapy

Treatment is based on the duration and severity of symptoms. A stepwise approach to treatment is recommended for adolescents and adults. Step down therapy as the patient’s symptoms improve and step up when the symptoms worsen. 

Similar therapeutic principles are applied in children; however, care should be taken to avoid the adverse effects of certain classes of drugs in the pediatric population. Drugs used for rhinitis are usually administered either orally or intranasally. 

Combination or step-up therapy is recommended for patients with disease progression after monotherapy or those with severe allergic rhinitis. Recommendations depend on the pattern of exposure to allergens.

For patients with moderate to severe seasonal allergic rhinitis, the following principles are applied:

• Combination therapy of an intranasal corticosteroid with an oral antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Combination therapy of an intranasal corticosteroid with an intranasal antihistamine is preferred over monotherapy with an intranasal antihistamine
• Leukotriene receptor antagonist or an oral antihistamine: No specific preference
• Intranasal antihistamine or an oral antihistamine: No specific preference 

For patients with moderate to severe perennial allergic rhinitis, the following are recommended: 

• Monotherapy with intranasal corticosteroid is preferred rather than the combination of an intranasal corticosteroid with an oral antihistamine
• For combination therapy of an intranasal corticosteroid with an intranasal antihistamine or monotherapy with an intranasal corticosteroid: No specific preference
• Intranasal antihistamine or an oral antihistamine: No specific preference 

A combination of intranasal antihistamine and intranasal steroid should be considered if antihistamine monotherapy, intranasal steroid monotherapy, or oral antihistamine and intranasal corticosteroid combination remains ineffective. For patients with persistent rhinorrhea on intranasal corticosteroid therapy, the addition of intranasal Ipratropium may be considered. 

Immunotherapy  

Repeated administration of specific allergens to patients with IgE-mediated conditions to provide protection against allergic symptoms associated with exposure to these allergens; most effective if secondary to pollen, dust mites, and animal dander and less effective if due to mold.  

Specific immunotherapy is effective when optimally administered. It is the only treatment that may cause long-term remission of rhinitis (3-5 years). The initial dose should be performed in a medical facility by trained personnel. Its recommended course is usually 4-5 years.  

Immunotherapy may be given to children and adults who have evidence of specific IgE antibody to allergen and any of the following:

• Patient’s preference
• Adherence to therapy
• Required medications
• Adverse effects to medications
• Poor response to avoidance measures
• Prevention of asthma in allergic rhinitis patients
• Clinically diagnosed with both allergic rhinitis and asthma

Pharmacological therapy

Anticholinergics

Example drug: Ipratropium bromide

Anticholinergics work by blocking the muscarinic receptors of the seromucinous glands. They effectively control watery rhinorrhea but do not affect sneezing or nasal congestion, which precludes their use as a first-line medication. They may be used together with intranasal corticosteroids or antihistamines in patients in whom rhinorrhea is the predominant symptom, or in whom rhinorrhea does not respond well to the other medications. 

Antihistamines

H₁-receptor antagonists reduce nasal itching, sneezing, and rhinorrhea, but are less effective for nasal obstruction. They are considered as first-line treatment for mild-moderate intermittent and mild persistent rhinitis. They are added to intranasal corticosteroids for moderate-severe persistent rhinitis with eye symptoms uncontrolled by intranasal corticosteroid monotherapy. 

Nasal Antihistamines 

Example drugs: Azelastine, Levocabastine, Olopatadine

Nasal antihistamines have a rapid onset of action (<15-30 minutes). They are recommended in patients with seasonal, perennial, or episodic allergic rhinitis. They are also recommended as a first-line option for patients with intermittent allergic rhinitis. They are the preferred treatment for allergic rhinitis when compared to intranasal cromones. They are associated with a significant effect on nasal congestion. 

They are considered effective at the site of administration and may be used for mild, organ-limited disease or as an “as required” medication used together with a continuous one. They are as effective as oral antihistamines but they require twice-daily dosing. 

Oral Antihistamines 

Oral antihistamines have the advantage of relieving other allergic symptoms of other sites (eg conjunctivitis) along with nasal symptoms. They may be used to prevent symptoms associated with occasional allergy exposure. They are preferred over leukotriene receptor antagonists (LTRA) in patients with moderate-severe perennial allergic rhinitis. 

Second-generation antihistamines are preferred over intranasal antihistamines. The use of first-generation antihistamines should be limited as they may reduce academic ability in school children and may produce performance impairment in adults while driving. They have an onset of action that occurs within 1 hour. 

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Subcutaneous Immunotherapy (SCIT)   

The indications of SCIT include inadequate control with medications, patient refusal to receive pharmacotherapy or to undergo treatment on a long-term basis, and intolerable or unacceptable adverse effects from medications.   

SCIT should be considered in patients with seasonal allergic rhinitis due to pollens and perennial allergic rhinitis triggered by house dust mites. The efficacy of SCIT for allergic rhinitis is comparable to that of nasal glucocorticoids. However, it is limited by frequent injections on a regular basis and the small risk of an anaphylactic reaction.   

Sublingual Immunotherapy (SLIT)  

SLIT should be considered in patients with allergic rhinitis triggered by house dust mites and grass or ragweed pollen, regardless of whether the patient has asthma. It is considered a more viable treatment compared to SCIT as self-administration is encouraged with this form. Its use should be limited to those who can tolerate systemic reactions and its treatment. It has been associated with mild oral and gastrointestinal (GI) symptoms; however, it has less risk for anaphylaxis compared to SCIT.  

Alternative Therapies  

A variety of herbal preparations and honey have been suggested for allergic rhinitis but there is lack of sufficient evidence to support this recommendation. St. John’s wort may decrease the effectiveness of antihistamines, while Echinacea purpurea may cause anaphylaxis in atopic patients.

Nonpharmacological

Allergen Avoidance 

The first step to symptom control is the identification and avoidance of the trigger allergens. Identifying the specific causal allergens by skin testing or laboratory testing may encourage patients to comply with allergen avoidance instructions. The effectiveness of avoidance will be measured by relieving the patient’s symptoms and decreasing the need for medications. 

Elimination of the allergen results in diminished severity of the disease and decreased requirement for medications. In most cases, it is not possible to completely avoid allergens, but these measures should be considered where appropriate. 

House Dust Mites 

House dust mites are the major allergen found in houses. Advise patients to wash sheets and blankets in hot water (60°C) and to vacuum-clean beds weekly. It is advised to use anti-mite covers on mattresses, beds, and pillows, and clean furniture in the bedroom with damp rags. For indoors, the use of an exhaust circulation-type cleaner is recommended.

Pollen 

Advise patients to avoid going outdoors on days when pollen counts are high. Advise patients to wear a mask and use glasses during heavy pollen dispersal period, avoid wearing woolen coats, and avoid activities which can increase exposure to allergens (eg mowing grass). Inform the patient to shake the dust off (eg suit and hair) before entering the house, shower after outdoor activities where pollen exposure is high, keep doors and windows closed at home and when inside cars, and use air conditioning. 

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Surgery

Inferior Turbinate Reduction

Inferior turbinate reduction may be offered to patients with nasal airway obstruction and hypertrophic inferior turbinates who are unresponsive to pharmacological therapy. It should be reserved for patients with persistent allergic rhinitis.