Allergic Rhinitis

Author: Quoc A Nguyen, MD, Associate Clinical Professor, Director, Sinus and Allergy
Center, Department of Otolaryngology-Head & Neck Surgery, University of California, Irvine
Medical Center
Contributor Information and Disclosures

Updated: Jun 1, 2009

• Print This

• Email This
• Overview
• Differential Diagnoses & Workup
• Treatment & Medication
• Follow-up
• Multimedia

• References
• Keywords
• Further Reading

Information from Industry

Four experts review metastatic GIST case
Connect with the GIST Exchange to view a new program on diagnosising and
treating metastatic progressive gastrointestinal stromal tumors (GIST) in a 55-year-
old male.
Review case study

Introduction
Background

Allergic rhinitis is a common health problem for which many patients do not seek appropriate
medical care. Although not a life-threatening condition in most cases, it has a substantial impact
on public health and the economy.

According to findings in a recent study, the total estimated cost of allergic rhinitis in 1994 was
between 1.2 and 1.5 billion dollars.1 The illness resulted in more than 6 million missed work
days, 2 million missed school days, and 28 million reduced-activity days. These figures are
certainly higher today because of the higher cost of new medications and the increasing
prevalence of the condition.
Boggy inferior turbinate in an allergic patient.

[ CLOSE WINDOW ]
Boggy inferior turbinate in an allergic patient.

Pathophysiology

Because the nose is the most common port of entry for allergens, in patients with allergies, signs
and symptoms of allergic rhinitis, not surprisingly, are the most common complaints.

Four types of hypersensitivity responses exist, as initially classified by Gell and Coombs and
later modified by Shearer and Huston. Individuals with allergic rhinitis are thought to have type I
reactions.

After initial exposure to an antigen, antigen-processing cells (macrophages) present the

processed peptides to T helper cells. Upon subsequent exposure to the same antigen, these cells
are stimulated to differentiate into either more T helper cells or B cells. The B cells may further
differentiate into plasma cells and produce immunoglobulin E (IgE) specific to that antigen.
Allergen-specific IgE molecules then bind to the surface of mast cells, sensitizing them.

Further exposures result in the bridging of 2 adjacent IgE molecules, leading to the release of
preformed mediators from mast cell granules. These mediators (ie, histamine, leukotrienes,
kinins) cause early-phase symptoms such as sneezing, rhinorrhea, and congestion. Late-phase
reactions begin 2-4 hours later and are caused by newly arrived inflammatory cells. Mediators
released by these cells prolong the earlier reactions and lead to chronic inflammation.

Frequency

United States

Approximately 39 million Americans are reported to have allergic rhinitis. From various studies,
17-25% of the population in the United States are estimated to have the condition.

Mortality/Morbidity

• Allergic rhinitis is frequently associated with otitis media, rhinosinusitis, and

asthma, either as a precipitating and/or aggravating factor or a symptomatic
comorbid condition.
• Allergic rhinitis can significantly decrease the quality of life and impair social
and work functions, either directly or indirectly, because of the adverse
effects of medications taken to relieve the symptoms.

Sex

Males and females tend to be affected by allergic rhinitis in fairly equal proportions.
Age

• Allergic rhinitis appears mainly to affect individuals younger than 45 years.

• The condition may begin to appear in patients as young as 2 years and
usually reaches a peak in those aged 21-30 years.
• It then tends to remain stable or slowly decrease until patients are aged 60
years, when again the prevalence may increase slightly.

Clinical
History

• Allergy history
o For the clinician who treats patients with allergic rhinitis, nothing is
more crucial than the allergy history. It is important not only in
identifying an allergy but also in guiding the treatment plan.
o Although history taking begins at the initial encounter, it should not be
completed at a single sitting, and it should be continued during
subsequent visits, as needed.
o Details about the presenting symptoms (eg, onset, fluctuation,
severity) should be obtained. In addition, the interviewer should note
any recent changes in the patient's life (eg, at home, in the workplace,
in leisure activities, in diet).
• Family history
o Children of individuals with allergies have been shown to have a higher
incidence of allergies than that of other children.
o If both parents have allergies, their child has a 50% chance of having
the same problem.
• Past medical history
o In children, a history of recurrent otitis media, upper respiratory tract
infection, asthma, chronic rashes, and formula intolerance are
suggestive of allergies.
o Other pertinent medical problems (eg, asthma, aspirin
hypersensitivity) and the use of medications (eg, beta-blockers,
tranquilizers) that could interfere with the treatment for allergies
should be evaluated.
o Inquire about the results of previous allergy tests and treatment.

Physical

Patients with allergies frequently have a characteristic physical appearance.

• Face
o Patients with allergic rhinitis frequently grimace and twitch their face,
in general, and nose, in particular, because of itchy mucus
membranes.
o Chronic mouth breathing secondary to nasal congestion can result in
the typical adenoid facies.
 • Eyes
o Patients may have injected conjunctiva; increased lacrimation; and
long, silky eyelashes.
o Dennie-Morgan lines (creases in the lower eyelid skin) and allergic
shiners (dark discoloration below the lower eyelids) caused by venous
stasis may be present.
• Ears
o Ears are frequently unremarkable.
o Eczematoid otitis externa and middle ear effusion may be present.
• Nose
o A transverse nasal crease may be present because of the patient's
repeated lifting of the nasal tip to relieve itching and open the nasal
airway.
o The turbinates are frequently hypertrophic and covered with a boggy
pale or bluish mucosa.
o Nasal secretions can range from clear and profuse to stringy and
mucoid.
o The presence of polyps does not necessarily indicate that the affected
individual has allergic rhinitis.
• Mouth
o A high arched palate, narrow premaxilla, and receding chin may be
present secondary to long-term mouth breathing.
o The posterior oropharynx may be granular because of irritation from
persistent postnasal discharge.

Causes

For practical purposes, allergens can be divided into seasonal and perennial groups.

• Seasonal allergens are primarily pollens. In general, trees bloom in the

spring; grasses, in the summer; and weeds, in the fall. Information about
regional allergens can be obtained from manufacturers of allergy-treatment
supplies, local botanic gardens, universities, and newspapers.
• Perennial allergens of importance are molds, house dust, and animal
danders. Although these allergens are present throughout the year, they tend
to be more problematic during the winter, when people spend most of their
time indoors.
o Molds can be either indoor or outdoor allergens. Perennial symptoms
that worsen in cool, humid weather suggest mold sensitivity. The major
manufacturers of allergy-treatment supplies have lists of predominant
molds in each region. Significant reservoirs of molds include indoor
plants, refrigerator drip pans, areas under sinks, and compost piles.
o House dust is a mixture of approximately 28 allergenic components.
The actual major allergen appears to be a collection of degrading
lysine residues.
 For practical reasons, the component of house dust that most
closely resembles the overall extract consists of dust mites
(although they are much less immunologically potent than the
overall extract).
  The 2 major dust mites in the United States are
Dermatophagoides pteronyssinus and Dermatophagoides farina.
These mites thrive in warm (65-80°F), humid (>70% relative
humidity) environments. They are abundant in mattresses,
pillows, upholstered furniture, and carpets.
 Another significant ingredient of house dust is decomposing
cockroach body parts, which can be a problem even in buildings
that appear to be free of the live insect.
o A person does not need to own a pet to be exposed to dander, such as
cat dander, which can cling to clothing and be brought into classrooms
and homes. Dog dander, however, tends to be primarily a problem for
its owner. The dander of other pets such as rabbits and hamsters is
also highly allergenic.

Differential Diagnoses
Allergic Fungal Sinusitis

Workup
Laboratory Studies

• The diagnosis of allergic rhinitis is based on the history, and tests are used
only to confirm atopy.
• Nasal cytologic studies may be needed.
o Nasal secretions are stained with hematoxylin and eosin.
o In general, the presence of eosinophils and goblet cells is suggestive of
allergy, whereas the presence of neutrophils and bacteria is
characteristic of infection.
• An elevated eosinophil count can occur in patients with asthma, nonallergic
rhinitis with eosinophilia syndrome (NARES), and parasitic infection.
Therefore, this finding is not specific to allergic rhinitis.
• Skin tests may be performed.
o Skin testing is generally considered to be the standard of allergy
workup. The classic wheal-and-flare responses result from the
interaction between the antigen and sensitized mast cells in the skin.
o In general, the acute phase starts within 2-4 minutes and reaches a
maximum in 10-20 minutes. It may be followed by a late phase 4-6
hours later. A number of factors affect the responses; these include the
following:
 Volume and potency of the antigen
 Reactivity of the skin
 Age and race of the patient
 Area of body tested
 Distance between the injections and time of day of testing
 Medications (eg, antihistamines and tricyclic antidepressants)
o Because of these variables, positive and negative controls must be
used to ensure the validity of the results.
 o In addition, patients receiving beta-blocker therapy are at risk for
severe reactions, and the drugs should be switched to another class of
medication before testing is initiated.
o Currently, 3 types of skin tests are in use.
 Prick testing is rapid and safe, and scores are graded from 0-4
according to both wheal and flare responses. However, low-
grade sensitivities can be missed. Therefore, the test is often
used as a screening tool, which is followed by intradermal
testing if necessary.
 Single-dilution intradermal testing involves injecting 0.01-0.05
mL of antigen into the epidermis. The resulting wheal and flare
are measured after 10-20 minutes and graded as in prick
testing. This test can be used to detect most low-degree atopies
if a 1:500 concentration is used. However, as with prick testing,
it does not permit accurate quantitation of the sensitivity to the
antigen involved.
 Progressive-dilution intradermal testing (skin endpoint titration)
involves a series of 5-fold dilutions, starting with a concentration
that is sufficiently dilute to be nonreactive. Progressively
stronger concentrations are injected until a wheal forms. The
endpoint is confirmed when the wheal with the next stronger
dilution is 2 mm larger than the previous wheal. This endpoint
indicates the relative sensitivity of the patient to the allergen
and designates the starting point for immunotherapy. This
method allows both qualitative and quantitative assessment of
sensitivity to the antigen in question.
• The IgE count may be determined.
o In contrast to total IgE, which has a poor clinical correlation, antigen-
specific IgE antibodies are important in the diagnosis of inhalant
allergy.
o Compared with skin testing, in vitro testing is more specific, and it is
not affected by skin reactivity or medications. It also has no risk of
systemic reaction and is better tolerated, because it is less traumatic.
However, in vitro testing is less sensitive than skin testing, especially
in regard to molds. Also, the results are not available immediately and
must be verified with skin testing before immunotherapy can be
started.
o The original method for obtaining an IgE count, the radioallergosorbent
test (RAST), has evolved from a radioimmunoassay to a test that
involves enzymatic or fluorometric processes (eg, enzyme-linked
immunosorbent assay [ELISA]).
 Fadal and Nalebuff have modified the test to increase its
sensitivity and to improve the correlation of its findings to those
obtained with the skin endpoint titration method.
 Scores do not necessarily correlate with the severity of the
clinical symptoms. Although they can be used to establish the
starting dose for immunotherapy, a vial test still is required
before immunotherapy can be initiated.
Imaging Studies

• No radiologic studies are necessary in the evaluation of patients with

allergies because the diagnosis is made on the basis of the history and
confirmed with relevant physical findings and test results.
• Imaging findings, if available for other reasons, are usually nonspecific and
may be the same as those in other types of rhinosinusitis (eg, mucosal
thickening, turbinate hypertrophy).

Other Tests

• Many other alternative tests for allergies are available, but they have not
been fully validated yet.
• These include the following:
o Basophilic histamine-release test
o Cytotoxic test
o Leukocyte antibody test for related antigens

Treatment
Medical Care

The 3 basic approaches for the treatment of allergies are (1) avoidance, (2) pharmacotherapy, and
(3) immunotherapy. Treatment should start with avoidance of allergens and environmental
controls. In almost all cases, however, some pharmacotherapy is needed because the patient is
either unwilling or unable to avoid allergens and to control the occasional exacerbations of
symptoms. For patients with a severe allergy that is not responsive to environmental controls and
pharmacotherapy or for those who do not wish to use medication for a lifetime, immunotherapy
may be offered.

• Avoidance of allergens and environmental controls

o Patients who have seasonal allergies should avoid outdoor activities
when allergens are in the air. The patient's house and workplace
should be kept as clean as possible.
o House dust mites thrive in warm, humid conditions, and the antigen is
found in their feces. Control measures include removing reservoirs (eg,
stuffed animals, carpets, heavy drapes), covering bedding with dust-
mite–proof covers, and washing potential reservoirs in hot water.
Frequent vacuuming with a high-efficiency particulate-arresting (HEPA)
vacuum and use of acaricides (eg, benzyl benzoate) and products that
denature dust mite antigen (eg, tannic acid) are encouraged. In
addition, lowering the relative humidity to less than 50% and lowering
the temperature to less than 70°F are helpful in controlling the dust
mite population.
o If removing pets is not feasible, they should be kept at least out of the
bedroom. Also, frequent vacuuming with an HEPA vacuum and washing
the animals are helpful in decreasing the allergen load.
 oMolds are present throughout the year in damp areas, both indoors
and outdoors. Attention should be paid to reservoirs such as
refrigerator drip pans, areas around air conditioner condensers and
under sinks, indoor plants, and decaying vegetation in the yard. The
use of a dehumidifier and an HEPA air-filtration system is also
encouraged.
• Immunotherapy
o Immunotherapy is indicated for patients whose symptoms are not well
controlled with avoidance measures and pharmacotherapy. It is also
appropriate for those with symptoms lasting more than 1 season and
documented allergen-specific IgE antibodies.
o Immunotherapy should be considered only in individuals who can
comply with weekly injections for approximately 3 years.
o Immunotherapy should be avoided in those receiving beta-blockers
and those who have poorly controlled asthma, autoimmune disorders,
or immunodeficiency disorders.
o During pregnancy, injections should not be initiated, and doses should
not be increased.
o Although the exact mechanisms of immunotherapy are not known,
they are associated with decreased allergen-specific IgE levels and
increased allergen-specific immunoglobulin G (IgG) levels. These IgG
molecules are thought to be blocking antibodies that are important in
impeding the allergic reaction.
o Immunotherapy involves regular injections (every 5-7 d) of increasing
amounts of each reacting allergen until the symptoms are relieved or
the maximum tolerated dose is reached, at which time a maintenance
dose is given every 2-4 weeks. This dose is maintained until symptoms
are controlled for 2-3 seasons and then tapered.
o Although systemic reactions are rare when immunotherapy is properly
administered, only qualified personnel should give injections, and
resuscitative equipment should be available.

Surgical Care

Although allergic rhinitis is a medical condition, adjunctive surgery may be offered to alleviate
obstructive symptoms in appropriate individuals. Examples are nasal polypectomy in the patients
who have severe polyposis and various inferior turbinate reduction maneuvers in patients who
have nasal obstruction caused by turbinate hypertrophy that persists despite maximal medical
therapy.2

Consultations

A pulmonologist may be consulted.

Diet

Food allergies can cause nasal symptoms similar to those caused by inhalant allergies. Therefore,
a workup for possible food allergies should be considered if the patient has a history of food
reactions, if findings of the inhalant allergy evaluation are negative, and if appropriate treatments
fail to yield improvement.

Activity

• In general, patients with allergies should avoid working and playing in areas
that are known to exacerbate symptoms.
• Outdoor activities should be restricted when the inciting allergens are in
season.
• Individuals who are sensitive to pollen should stay indoors in the morning,
and patients who are allergic to molds should remain indoors in the early
evening, because the allergens are more prevalent in the air at these times.

Medication
At one time or another, most patients with allergies require pharmacologic intervention.

Many classes of medications are available; the use of each must be tailored to the individual
patient's symptoms.

Antihistamines

These medications are H1 receptor antagonists and relieve sneezing, itching, and rhinorrhea.

Chlorpheniramine (Chlor-Trimeton, Aller-Chlor, Chlo-Amine)

A representative first-generation antihistamine; competes with histamine for H1 receptor sites on

effector cells in blood vessels and in the respiratory tract.

Adult

4 mg PO q6h

Pediatric

<6 years: Not established

6-12 years: 4 mg PO q12h
>12 years: Administer as in adults

CNS toxicity increases with coadministration of other CNS depressants, tricyclic antidepressants,
MAOIs, and phenothiazines

Documented hypersensitivity; asthma attacks; narrow-angle glaucoma; symptomatic prostate

hypertrophy; bladder neck obstruction; stenotic peptic ulcer
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

May cause significant confusion; not for use in premature or full-term neonates

Loratadine (Claritin)

Selectively inhibits peripheral histamine H1 receptors.

Adult

10 mg PO qd

Pediatric

<6 years: Not established

>6 years: Administer as in adults

Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels

Documented hypersensitivity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Initiate therapy with lower doses in liver impairment

Fexofenadine (Allegra)

A representative third-generation antihistamine; competes with histamine for H1 receptors in the

GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions; does not cause
sedation.
Adult

60 mg PO q12h or 180 mg PO qd

Pediatric

<6 years: not established

6-12 years: 30 mg PO q12h
>12 years: Administer as in adults

Toxicity increases with coadministration of erythromycin and ketoconazole

Documented hypersensitivity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

No data about use while breastfeeding

Azelastine (Astelin)

Topical antihistamine nasal spray; competes with histamine for H1 receptor sites in the blood
vessels, GI tract, and respiratory tract.

Adult

2 sprays in each nostril q12h

Pediatric

<5 years: Not established

5-11 years: 1 spray in each nostril q12h
>12 years: Administer as in adults

Increases CNS toxicity of depressants

Documented hypersensitivity
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Adverse effects include local irritation and unpleasant taste; caution in hepatic or renal
dysfunction; doses >10 mg/d may cause drowsiness

Desloratadine (Clarinex)

Long-acting tricyclic histamine antagonist selective for H1 receptor. Relieves nasal congestion
and systemic effects of seasonal allergy. Is a major metabolite of loratadine, which, after
ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine.

Adult

5 mg PO qd

Pediatric

<12 years: Not established

>12 years: Administer as in adults

Limited data exist; erythromycin and ketoconazole increase desloratadine and 3-

hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse
effects, including QTc, was observed

Documented hypersensitivity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Decrease dose in hepatic impairment; rarely causes pharyngitis or dry mouth

Olopatadine (Patanol)
Topical antihistamine ophthalmic solution.

Adult

1-2 gtt OU bid

Pediatric

<3 years: Not established

3-12 years: 1 gtt OU bid
>12 years: Administer as in adults

None reported

Documented hypersensitivity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Do not use with contact lenses; not for injection; caution in hepatic or renal dysfunction, doses
>10 mg/d may cause drowsiness

Mometasone (Nasonex)

Nasal spray; demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic

activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial
cells and modulate pretranscriptional mechanisms.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

2 sprays (50 mcg/spray)each nostril qd

Pediatric

<2 years: Not established

2-11 years: 1 spray (50 mcg/spray) each nostril qd
>12 years: Administer as in adults

None reported

Documented hypersensitivity, nasal septal perforation, nasal surgery, nasal trauma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Use with caution inpatients with active or quiescent tuberculosis of the respiratory tract;untreated
fungal, bacterial, systemic viral infections; or ocular herpes

Ciclesonide (Omnaris)

Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically
hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following
intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg,
mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines,
eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50
mcg.

Adult

2 sprays (50 mcg/spray) in each nostril qd (ie, 200 mcg/d)

Pediatric

<12 years: Not established

>12 years: Administer as in adults

Data limited; oral ketoconazole increases desciclesonide AUC by approximately 3.5-fold at

steady state

Documented hypersensitivity
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Caution when replacing systemic corticosteroids because of risk of adrenal insufficiency; may
decrease growth velocity in pediatric patients; caution with active or quiescent tuberculosis
infection or with untreated fungal, viral, or bacterial infections; rare instances of wheezing, nasal
septum perforation, cataracts, glaucoma, and increased intraocular pressure reported

Prednisone (Deltasone, Orasone, Sterapred)

Immunosuppressant for treatment of allergic reactions; may decrease inflammation by reversing

increased capillary permeability and suppressing PMN activity; dosage and tapering schedule
vary.

Adult

40-60 mg PO qd; taper over 7-10 d

Pediatric

Not established

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause
digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase
metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia
with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction;

connective tissue infections; fungal or tubercular skin infections; GI disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema,

osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis,
myasthenia gravis, growth suppression; infections may occur with glucocorticoid use; adverse
effects include adrenal suppression, hyperglycemia, hypokalemia, edema, tachycardia,
hypertension, GI irritation, anxiety, insomnia, osteoporosis, cataracts

Triamcinolone (Kenalog-40)

Injectable corticosteroid used to treat inflammatory dermatosis responsive to steroids; decreases

inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary
permeability.

Adult

0.5 cc into each inferior turbinate q6-8wk

Pediatric

Not established

Coadministration with barbiturates, phenytoin, and rifampin decreases effects

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy,

peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth
suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis

Beclomethasone (Beconase AQ, Vancenase AQ)

Topical nasal steroid spray that inhibits bronchoconstriction mechanisms and produces direct
smooth muscle relaxation; may decrease number and activity of inflammatory cells, decreasing
airway hyper-responsiveness.

• Dosing
• Interactions
• Contraindications
• Precautions
Adult

2 sprays in each nostril bid

Pediatric

<6 years: Not established

6-12 years: 1 spray in each nostril bid
>12 years: Administer as in adults

• Dosing
• Interactions
• Contraindications
• Precautions

Coadministration with ketoconazole may increase plasma levels (does not appear to be clinically
significant)

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; bronchospasm; status asthmaticus; other types of acute episodes of

asthma

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Weight gain, increased bruising, cushingoid features, acneiform lesions, mental disturbances,
and cataracts may occur (taper medication slowly if these occur)

Fluticasone propionate (Flonase)

Topical nasal steroid spray. Has an extremely potent vasoconstrictive and anti-inflammatory
activity. Has weak HPA axis inhibitory potency when applied topically.
 • Dosing
• Interactions
• Contraindications
• Precautions

Adult

2 sprays in each nostril qd

Pediatric

<4 years: Not established

4-12 years: 1 spray in each nostril qd
>12 years: Administer as in adults

• Dosing
• Interactions
• Contraindications
• Precautions

None reported

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; viral, fungal, and bacterial skin infections

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Prolonged use, application over large surface areas, application of potent steroids, and occlusive
dressings may increase systemic absorption of corticosteroids and cause Cushing syndrome,
reversible HPA-axis suppression, hyperglycemia, and glycosuria
Mast cell stabilizer

Mast cell stabilizers inhibit mast cell degranulation and influence granulocyte chemotaxis. They
are most effective when used prophylactically, and they have an excellent safety profile.

Cromolyn (Nasalcrom)

Inhibits degranulation of sensitized mast cells after exposure to specific antigens; available over
the counter; may require several days to work.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1 spray in each nostril tid/qid

Pediatric

<6 years: Not established

>6 years: Administer as in adults

• Dosing
• Interactions
• Contraindications
• Precautions

None reported

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use in severe renal or hepatic impairment; symptoms may reoccur when withdrawing
drug

Anticholinergic

These drugs relieve rhinorrhea but have no effect on other symptoms of allergy.

Ipratropium (Atrovent)

Chemically related to atropine; has antisecretory properties; when applied locally, inhibits
secretions from serous and seromucous glands lining the nasal mucosa; available in 0.03% and
0.06% strengths; also effective in relieving rhinorrhea from other causes (eg, cold air, gustation).

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

2 sprays in each nostril bid/qid

Pediatric

<6 years: Not established

6-12 years: 1-2 sprays each nostril bid
>12 years: Administer as in adults

• Dosing
• Interactions
• Contraindications
• Precautions

Drugs with anticholinergic properties, such as dronabinol, may increase toxicity; albuterol may
increase effects

• Dosing
• Interactions
• Contraindications
 • Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not indicated for acute episodes of bronchospasm; caution in narrow-angle glaucoma, prostatic
hypertrophy, bladder neck obstruction

Decongestants

Decongestants are available in oral and topical preparations. These drugs act on alpha-adrenergic
receptors in the nasal mucosa, causing vasoconstriction that concomitantly reduces turbinate
edema and rhinorrhea.

Oxymetazoline (Afrin)

A representative topical decongestant applied directly to mucous membranes, where it stimulates

alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic
changes in BP, vascular redistribution, and cardiac stimulation.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

2-3 sprays in each nostril q12h

Pediatric

<6 years: Not established

6-12 years: 1-2 sprays in each nostril q12h
>12 years: Administer as in adults
 • Dosing
• Interactions
• Contraindications
• Precautions

Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa

may increase vasopressor response; concurrent use of MAOIs and ephedrine may cause
hypertensive crisis; pressor sensitivity to mixed-acting agents (eg, ephedrine) may be increased;
guanethidine potentiates epinephrine effects and inhibits ephedrine effects; phenothiazines may
reverse action; TCAs potentiate vasopressor response and may cause dysrhythmias

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; MAOI therapy

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions

Prolonged use can lead to rebound rhinitis; caution in hyperthyroidism, coronary artery and
ischemic heart disease, diabetes mellitus, increased intraocular pressure, prostatic hypertrophy;
because of increased vasoconstriction, patients with hypertension may have change in BP; do not
use topical decongestants for longer than 3-5 d

Pseudoephedrine (Sudafed)

A representative oral decongestant; stimulates vasoconstriction by directly activating alpha-

adrenergic receptors in the respiratory mucosa; also induces bronchial relaxation and increases
the heart rate and contractility by stimulating beta-adrenergic receptors.

• Dosing
• Interactions
• Contraindications
• Precautions
Adult

30 mg PO q4-6h

Pediatric

<2 years: Not established

2-6 years: 15 mg PO q6h
>6 years: Administer as in adults

Follow-up
Further Outpatient Care

Monitor doses and adverse effects of medication.

Inpatient & Outpatient Medications

Regimen depends on the patient's symptoms and other coexisting medical problems.

Transfer

• Candidates for immunotherapy may be transferred to an allergist for care,

and therapy is administered at the discretion of the treating physician.
• The clinician should be familiar with immunotherapy and its risks. He or she
should be able to deal with any allergic emergency.

Deterrence/Prevention

See Avoidance of allergens and environmental controls for methods of deterrence and
prevention.

Complications

• Bacterial rhinosinusitis
• Exacerbation of asthma

Prognosis

Most patients with allergic rhinitis can expect an improved quality of life with appropriate
environmental control measures; pharmacotherapy; and, when necessary, immunotherapy.
Patient Education

• The clinic should have literature about allergies, and the office staff should
continually educate patients and reinforce their understanding of avoidance
and environmental control techniques.
• Patients undergoing immunotherapy should be instructed to report any
reactions from the previous injection and any changes in their health status
during each visit (eg, change in medication, new onset of upper respiratory
tract infection, worsening of asthma).

Miscellaneous
Medicolegal Pitfalls

• Only qualified personnel should administer immunotherapy.

• A protocol to treat anaphylaxis must be in place, and drills must be
conducted at regular intervals.
• Patients must stay in the office for 15-20 minutes after each injection. They
should report any reaction or change in their medical status before the next
injection is administered, because doses may need to be adjusted.
• Multimedia
Media file 1: Boggy inferior turbinate in an allergic patient.

(Enlarge Image)