Management II

Pharmacological treatment

If continuous treatment is required, an INCS is the first-choice treatment (except where contraindicated), especially in patients with asthma.² Intranasal corticosteroids:

are more effective than antihistamines in controlling symptoms of allergic rhinitis as well as non-allergic rhinitis.^{23
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are effective in managing ocular symptoms^{2,
23
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may contribute to asthma control in patients with asthma and allergic rhinitis.¹³

Intranasal preparations of mometasone, fluticasone, budesonide and triamcinolone do not have a clinically significant effect on the hypothalamic–pituitary–adrenal (HPA) axis or cause mucosal atrophy when taken continuously.^{2, 24
<Level II>}

Intranasal corticosteroids must be taken for up to 2 weeks before maximal efficacy is achieved.² They are most effective when taken continuously, but when used on an as-needed basis remain at least as effective as oral antihistamines.² Budesonide (Rhinocort), fluticasone propionate (Beconase Allergy), beclomethasone (Beconase Hayfever) and triamcinolone acetonide (Telnase) are available over the counter. Higher-dose budesonide (Rhinocort, Budamax) and mometasone furoate (Nasonex) are available on prescription.

If only intermittent therapy is required, options should be considered according to symptoms. As a general guide:

itching and sneezing respond well to oral H1-antihistamines²⁵
Second-generation, less sedating antihistamines should be used in preference to more sedating antihistamines, where possible. Before prescribing, check the individual agent for potential cardiac effects and interactions with other drugs, food supplements or complementary products.²
rhinorrhoea responds well to INCS or ipratropium bromide.^2,4
nasal congestion responds best to INCS ²
Oral antihistamines are ineffective for managing congestion.^2,26
In patients with asthma, leukotriene antagonists may also contribute to control of allergic rhinitis symptoms.²⁷

Emphasise correct inhalation technique

Explain to patients that correct use of an INCS inhaler is important for optimal effects, just as with asthma puffers. Demonstrate technique clearly. For best results, patients should:

Clear nose of mucus by blowing gently
Tilt head slightly forward
Introduce the nozzle into the nostril only; avoid pushing it right up into the nose.
Direct the nozzle laterally, never towards the middle of the nose, and avoid making contact with the septum.
Breathe in gently while actuating the inhaler according to manufacturer’s instructions, letting the mist fall onto the nasal mucosa rather than sniffing sharply. (The sensation of the spray reaching into the back of the nose indicates correct technique.)
Breathe out through the mouth.

Practice points

An INCS is the appropriate first-line option for most patients with persistent allergic rhinitis or moderate-to-severe intermittent allergic rhinitis, and should be initiated in those with mild intermittent allergic rhinitis who have experienced insufficient response to antihistamines.
Oral antihistamines can generally be added to INCS as needed, including pre-emptively when heightened allergic response is predicted.
Explain to patients that INCS are similar to asthma preventers: they must be taken regularly, pre-emptively and with correct inhalation technique. Explanation of the mechanisms of allergy can help reinforce adherence.
In patients with asthma already taking ICS, the INCS dose should be taken into account when determining the total daily corticosteroid dose.
Contraindications to INCS include severe nasal infections, especially candidiasis, haemorrhagic diatheses or a history of recurrent nasal bleeding

Pharmacy practice points

Emphasise that INCS should be used long-term where indicated.
Address unfounded concerns about taking topical corticosteroids. Reassure patients that INCS are well tolerated when prescribed by a doctor for correctly diagnosed allergic rhinitis, and that long-term studies of newer agents have not demonstrated unwanted systemic effects.
Whenever dispensing an inhaled medication for allergic rhinitis, show patients the inhalation device instructions and emphasise the importance of following them carefully.

Other agents and adjuncts

Intranasal antihistamines are as effective as oral antihistamines.² They have a rapid onset of action and might be considered as an alternative to oral antihistamines in a patient with mild allergic rhinitis, where quick relief of symptoms is required, as an add-on medication for patients experiencing insufficient relief with INCS alone, or in patients in whom INCS are contra-indicated or not tolerated.
Intranasal decongestants have a limited role in the management of allergic rhinitis because they should only be used for very short courses (up to 5 days’ maximum). Repeated or long-term use can cause rebound swelling of nasal mucosa necessitating dose escalation (rhinitis medicamentosa), with a risk of atrophic rhinitis. Intranasal decongestants might be considered in a patient with severe nasal congestion where rapid onset of action required until the full effect of INCS is achieved.
Oral decongestants should generally be avoided in the management of allergic rhinitis, since most patients will require long-term medication. These agents are indicated for short-term use only (e.g. acute infectious rhinitis), are contraindicated in patients with hypertension or coronary artery disease, and should be used with caution in people aged over 65 years, in patients with benign prostatic hyperplasia and those taking multiple medications.
Anticholinergic sprays (e.g. ipratropium bromide) are effective in managing persistent rhinorrhoea but not blockage or itch.⁴ They are mainly useful in the management of vasomotor rhinitis.
Ocular anti-allergy preparations (antihistamines, decongestants, mast-cell stabilising agents) may be considered if allergic conjunctivitis persists despite INCS. Check contraindications (e.g. glaucoma, pregnancy) for specific agents.
Oral corticosteroids should be avoided as a treatment for allergic rhinitis. In exceptional circumstances, their use might be considered in consultation with an allergy specialist.