Allergic Rhinitis

Allergic rhinitis, a systemic anti-inflammatory disease affecting the upper respiratory

system with prominent nasal symptoms in response to second exposure to allergens, it
is a worldwide problem that affects adults and children.

Allergic rhinitis is triggered by indoor and outdoor environmental allergens.

Common outdoor aeroallergens (airborne environmental allergens) include
pollen and mold spores, pollutants (e.g., ozone and diesel exhaust particles) are
considered environmental triggers and are becoming more of a concern in highly
populated areas.
Common indoor aeroallergens include house dust mites, cockroaches, mold
spores, cigarette smoke, and pet dander.
Occupational aeroallergens include the following: wool ,dust, latex, resins, organic dusts
(e.g., flour)

Symptoms of allergic rhinitis generally begin after the second year of life, and the
disease is prevalent in children and adults ages 18-64 years. After age 65 years, the
number of cases decreases.

The pathogenesis of allergic rhinitis is complex, involving numerous cells and

inflammatory mediators, and consists of four phases:
First is the sensitization phase, which occurs on initial allergen exposure. The allergen
stimulates IgE production.
Second is the early phase, occurring within minutes of subsequent allergen exposure.
The early phase consists of rapid release of preformed mast cell mediators (e.g.,
histamine and proteases), as well as the production of additional mediators (e.g.,
prostaglandins,, leukotrienes, and neuropeptides).
The third phase is cellular recruitment where the circulating leukocytes,
especially eosinophils, are attracted to the nasal mucosa and release more
inflammatory mediators.
Fourth is the late phase, which begins 24 hours after allergen exposure series of
allergic symptoms`are then presented including sneezing ,nasal congestion
,rhinorrhea ,itching ,red and watery eyes.

Risk factors for developing allergic rhinitis include family history of atopy (allergic
disorders) in one or both parents; filaggrin (skin barrier protein) gene mutation; elevated
serum IgE greater than 100 IU/mL

Allergic rhinitis has been classified as seasonal allergic rhinitis (“hay fever”) usually in
late summer or spring
, perennial allergic rhinitis occurs through out the year .
 New classifications , intermittent allergic rhinitis (IAR) occurs less than 4 days or less
than 4 weeks per year and persistent allergic rhinitis (PER)more than 4 days or more
than 4 weeks per year.

Classification of Allergic Rhinitis to sever, moderate and mild is according to duration of

symptoms, impairment of sleep; impairment of daily activities.

There is another type of rhinitis is called non allergic rhinitis.

Causes of non allergic rhinitis

Hormonal Pregnancy, puberty, thyroid disorders

Infectious rhinitis a)acute sinusitis viral infection last up to

10 days
b)chronic sinusitis it is bacterial infection
lasts up to12 weeks

Environmental or occupational rhinitis strong odours or cold air

Drug Induced Cocaine, betablockers, ACEIs,
chlorpromazine, clonidine, reserpine,
hydralazine, oral contraceptives, aspirin or
other NSAIDs, overuse of topical
decongestants

Structural Septal deviation, adenoid hypertrophy

Traumatic Recent facial or head trauma

Gustatory rhinitis hot or spicy foods

Acute complications of allergic rhinitis include sinusitis and otitis media with
effusion.
Chronic complications include nasal polyps, sleep apnea, sinusitis, and
hyposmia(diminished sense of smell).

Treatment of Allergic Rhinitis

Allergic rhinitis cannot be cured. The goals of therapy are to reduce symptoms and
improve the patient’s functional status and sense of well being.

General Treatment Approach

Allergic rhinitis is treated in three steps: allergen avoidance, pharmacotherapy, and

immunotherapy.
Health care providers should maximize each step before going on to
the next intervention. Patient education is an important part of all three steps

Non pharmacologic Therapy

Allergen avoidance is the primary non pharmacologic measure for allergic rhinitis
House dust mites ‫( عته الغبار‬Dermatophagoides spp.), found in warm, humid
environments.

Avoidance strategies, targeted at 1)reducing the mite population in mattress,pillows

2) lowering the household humidity to less than 40%, 3)applying acaricides, and
4)reducing mite harboring dust by removing carpets, upholstered furniture, stuffed
animals, and bookshelves from the patient’s bedroom.

Mold is challenging to eliminate due to ability to grow in wall cracks ,carpet fibers and
difficult to reach areas where spores are the reproductive unit of and other fungi.

We are surrounded by mold spores indoors and outdoors .

Indoor mold exposure is minimized by lowering household humidity, removing
houseplants, venting food preparation areas and bathrooms, repairing damp
basements, and frequently applying fungicide to obviously moldy areas.

Cat derived allergens are small and light, and they stay airborne for several hours. Cat
allergens can be found in the house months after the cat is removed.
Ventilation systems with high efficiency particulate air (HEPA) filters remove pollen,
mold spores, and cat allergens from household air.
Filters need to be changed regularly to maintain effectiveness.
HEPA filters are also found in some vacuum cleaners. Weekly vacuuming of carpets,
drapes, and upholstery with a HEPA filter equipped vacuum cleaner may help
reduce household allergens.

Pharmacological Therapy plan

1)Intranasal corticosteroids
2)Oral antihistamincs
3)Oral leukotrien receptor antagonist
4)Intranasal antihistaminics
5)Decongestants
6)Intranasal mast cell stabilizers
7)Intranasal anticholinergics
8)combination therapy

Intranasal corticosteroids (INCS) also known as glucocorticoids have been shown to

be the most effective treatment for most symptoms of allergic rhinitis such as itching,
rhinitis, sneezing, and congestion as they inhibit multiple cell types and mediators,
including histamine, and so effectively stop the “allergic cascade.
First generation INSCS
Beclomethasine(Beclo) ,triamcinolone acetonide (Nasacort),budesonide (rhinocort
aqua) and flusenolide(Nastarel) are more bioavailable and more systemic side effects
Second generation INCS
fluticasone propionate (Flonase) and fluticasone furoate(Avamys)
,momentasone(nasonex) are less bioavailable and limited systemic side effects .

FDA in 2012 has approved beclomethasone(Qnasal) dry nasal aerosol to be the first
non aquous nasal formulation available.
Complete symptom control may not be seen for up to 1 week. Patients should be
instructed to shake the bottle well before each use and discard the
product after a total of 60 or 120 doses, depending on which size was purchased, even
if the bottle does not feel completely empty.

Oral Antihistamines

Antihistamines are indicated for relief of symptoms of allergic rhinitis (e.g., itching,
sneezing, and rhinorrhea) and other types of immediate hypersensitivity reactions
They are classified as sedating (first generation, nonselective i.e. brompheniramine ,
chlorpheniramine , promethazine)
or non sedating (second generation, peripherally selective i.e.acrivastine,ebastine,
loratadine,cetrizine),(third generation i.e. levocetrizine ,desloratidine,fexofenadine)

Sedating antihistamines expose patients to risks of anticholinergic effects i.e. dryness of

the eyes and mucous membranes (mouth, nose, vagina); blurred vision; urinary
retention; constipation; and reflex tachycardia in addition to sedation and impaired
performance (e.g., impaired driving performance, poor work performance)
and so should be used with caution.

Antihistamines compete with histamine at central and peripheral histamine (H1)receptor

sites, preventing the histamine receptor interaction and subsequent mediator release.
In addition, second generation antihistamines inhibit the release of mast cell mediators
and may decrease cellular recruitment.
Onset of action:15 to 30 minutes . It approved by FDA as safe for children above 2
years.

Loratadine is the nonprescription antihistaminic of choice, followed by fexofenadine and

Cetirizine]

Oral leukotriene receptor antagonist

Montelukast is the only approved oral leukotriene receptor antagonist for use in
seasonal and perennial allergic rhinitis.
It is particulary useful for patients with coexisting asthma because it reduces
bronchospasm and attenuates inflammatory response.

Intranasal antihistamines

i.e. Azelastine
They ara targeted delivery drugs increasing dosage to nasal tissues

They are not recommended as first line therapy due to high cost ,less effective and
more adverse effects than INCS

Decongestants

Congestion is a common allergic rhinitis symptom controllable with systemic

decongestants or short term(≤5 days) topical nasal decongestants.
i.e. pseudoephedrine ,oxymetazoline and phenylepherine.
Topical decongestants develop rebound congestion if used more 5 days so patient
counseling should be verified.

Intranasal mast cell stabilizers

Cromolyn sodium is thought to work by blocking the influx of calcium into mast
cells thereby preventing mediator release
It is useful for patients with specific known allergy and are planning to be in contact with
that allergen so it is given 30 minutes before allergen exposure.

Intra nasal anticholinergics

Ipratropium(atrovent)
It has antisecretory properties inhibiting secretions from nasal lining mucosa so used in
relieving rhinorrhia and congestion symptoms

Nasal wetting agents nasal irrigation with warm saline (isotonic or hypertonic) may
relieve nasal mucosal irritation and dryness.That process also aids in the removal of
dried or thick mucus from the nose.
It is only for the symptoms not treating therapy.

Immunotherapy
Subcutaneous immunotherapy SCIT, commonly called allergy shots is a unique way of treating
allergies and asthma.
Medications treat the symptoms of allergies while immunotherapy changes the way a person’s
immune system is reacting to the environment.

First allergen skin testing identifies a person’s allergic triggers. A personalized vaccine is then
formulated using all natural protein extracts. This extract is then administered subcutaneously
with small doses by developing immunity or tolerance to the allergen.

Allergy shot treatment involves two phases. The first phase involves
frequent injections of increasing amounts of allergen extract. This
is followed by a maintenance phase, during which the injections are
given about once a month.

Another form of allergy immunotherapy was recently approved in the

United States called sublingual immunotherapy (SLIT) allergy
tablets.
FDA approved four allergy tablets products. Two are directed at
different kinds of grass pollen, one is for dust mites and one is for
short ragweed.

Anti-immunoglobulin E antibody

Omalizumab (Xolair) anti-immunoglobulin E antibody approved for asthma and had

shown effectiveness in reducing nasal symptoms and improving quality of life.
It only limitation yet is its high cost.

References
2015 American academy of otolaryngology-head and neck surgery foundation(AAO-
HNSF) guidelines for allergic rhinitis.

Handbook of non prescription drugs

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