Allergy: Management

Diagnosing allergic rhinitis

The American Academy of Allergy, Asthma & Immunology (AAAAI) issued practice parameters for treating rhinitis in 2008. These guidelines suggest that pharmacotherapy treatment should be individualised, and depends on a variety of factors, including:²

The type of rhinitis—seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), or non-allergic rhinitis (NAR)
Symptoms, their duration, and their severity
Physical exam findings
Comorbidities
Age
Patient preferences

Tailoring allergy treatment³

Nasal congestion is the primary complaint:

Treatment should include:

Intranasal corticosteroids (INCS), e.g. Budesonide, fluticasone furoate, fluticasone propionate, or triamcinolone acetonide
Decongestants, e.g. Pseudoephedrine, oxymetazoline, or phenylephrine
Xylometazoline

Mild symptoms, e.g. intermittent/episodic sneezing, nasal itching, and rhinorrhea:

Treatment should include:

Oral antihistamines, e.g. Cetirizine, loratadine, fexofenadine, diphenhydramine, levocetirizine

Moderate/severe symptoms:

Treatment should include:

INCS
Combination therapy

INCS are considered the most effective treatment for moderate, intermittent, and all stages of persistent rhinitis, and for all nasal symptoms, ocular symptoms, and sinusitis.⁴

The role of INCS in the treatment of AR

INCS are recognised as the most effective class for controlling symptoms of long-term anti-inflammatory treatment for AR, as they:^2,4

Relieve nasal symptoms
Are active in both early and late phases of the allergic cascade
High concentrations at receptor sites are achieved with a single dose

According to the 2008 Rhinitis Updated Practice Parameter from the AAAAI, INCS are the most effective first-line medication class for controlling symptoms of AR.²

In the treatment of SAR, INCS have been shown to be more effective than the combined use of an antihistamine and a leukotriene (LT) antagonist.²

INCS may provide significant symptom relief for patients with SAR, whether they’re used on a regular basis or on an as-needed basis.²

Management of AR in young children

AR in young children (<2 years of age)

AR in young children (<2 years of age)

AR is not common in children under two years of age. Other disorders should be considered initially, such as adenoidal hypertrophy or chronic rhinosinusitis before diagnosing AR.⁵

Treatment options include the following:

Cromolyn sodium nasal spray:

Due to its safe profile, some parents and clinicians prefer cromolyn sodium. However, it is less effective than INCS.⁶

Second-generation antihistamines:

Cetirizine, loratadine, and fexofenadine are available in liquid formulations and are approved for children ≥6 months of age.^7,8

Intranasal corticosteroid spray:

INCS are very effective for relieving nasal symptoms. However, it should be used for limited period (less than two weeks) due to the age-limited dose approval and the concern for potential systemic side effects (eg, adrenal suppression) in children at the higher dose.^9,10

Advice on how to avoid allergies

In addition to oral antihistamines and intranasal corticosteroids, first‐line treatment for allergies also involves the avoidance of triggers that may cause an allergic reaction.¹¹

Avoidance strategies include:¹¹

The use of allergen‐impermeable covers for bedding
Keeping relative humidity in the home below 50% to inhibit mite growth
Reducing pollen exposure by keeping windows closed, using air conditioning, and limiting the amount of time spent outside during peak pollen season
Avoiding exposure to, or ownership of, pets