Treatment of Allergic Rhinitis

The principle of treatment is to avoid allergen exposure as much as possible, use antihistamines and glucocorticoids rationally, and specific immunotherapy can be used in patients who can afford it. In addition, monoclonal antibodies against IgE also have good effects on severe allergic rhinitis but are expensive. Aggressive and effective treatment of allergic rhinitis can prevent and reduce asthma attacks. Although allergic rhinitis can’t be completely cured yet, standardized comprehensive treatment can achieve optimal symptom control and significantly improve a patient's quality of life.

How to treat allergic rhinitis in the acute stage?

When severe nasal congestion affects breathing, or induces bronchial asthma, or severe allergies such as anaphylactic shock occur, you should seek immediate medical attention to receive emergency treatment.

What are the general treatments for allergic rhinitis?

Avoid contact with allergens: Try to avoid contact with known allergens. Hay fever patients should go out less during the pollen season, and can also use some allergen control tools (such as special masks, glasses, nasal filters, pollen blocker cream, nasal cellulose powder, etc.) to reduce nasal inhalation or conjunctivitis contact with allergenic pollen, so as to reduce nose and eye symptoms; those who are allergic to fungi and dust mites should ventilate frequently and keep the room clean and dry; those who are allergic to animal dander, feathers, excrement, etc. should avoid contact with animals as much as possible.

What medications are available for allergic rhinitis?

Due to large individual differences, there is no absolute best, fastest, or most effective medication. Except for commonly used OTC medications, the most appropriate medication should be fully combined with individual situations under the guidance of a doctor. Because medication is easy to take and has clear effects, medication is the first choice for treating this disease.

Antihistamines

H1 antihistamines are the drugs of choice for the treatment of mild intermittent rhinitis and persistent rhinitis. It is effective in treating symptoms of nasal itching, sneezing, and increased nasal secretions, but has no significant effect on symptoms of nasal congestion. The first-generation antihistamines (such as chlorpheniramine, brompheniramine, cyproheptadine, etc.) are rarely used because of their obvious drowsiness effects. Second-generation antihistamines are long-acting, safe, and non-drowsy, and are now commonly used.

Oral Antihistamines

It usually takes effect half an hour after taking the medicine. Commonly used ones include cetirizine, loratadine, etc.

Nasal Spray Antihistamines

It takes effect quickly, usually 10 to 15 minutes after administration. Levocarbastine nasal spray is sprayed 2 times (80ug) into each nostril, 2 times a day, and for severe patients, it can be increased to 3 to 4 times: Amidlastine nasal spray is sprayed 2 times into each nostril, 2 times a day, with a total daily dose of 0.56 mg.

Glucocorticoids

Intranasal glucocorticoid preparations are often used, which are characterized by strong local effects on the nasal mucosa and the ability to minimize systemic adverse reactions. Commonly used drugs include nasal sprays such as budesonide, mometasone furoate, propionic acid, or fluticasone furoate, which are usually sprayed twice into each nostril, 1 to 2 times a day.

For moderate-severe intermittent or persistent rhinitis, intranasal corticosteroids should be the first choice, and second-generation H1 antihistamines can also be added as appropriate, usually for 4 to 12 weeks.

Pollen allergy patients have a clear onset time, so intranasal corticosteroids should be started two weeks before the onset of the disease every year, and antihistamines should be used during the onset of the disease, which can generally significantly reduce the patient's symptoms.

A small number of severe patients with seasonal exacerbation, those with poor efficacy of topical medication, those with severe symptoms such as nasal congestion and runny nose, and those with lower respiratory tract symptoms require systemic glucocorticoids. The course of treatment generally does not exceed two weeks, and contraindications to medication should be noted. Generally, oral prednisone acetate is used, 30 mg per day, or methylprednisone 16 to 24 mg per day. After 7 days of continuous administration, it is reduced by 5 mg per day, and finally it is changed to intranasal topical application.

Decongestant

Local application in the nose is often used to treat nasal congestion. The blood vessels that cause swelling of the nasal mucosa include adrenergic receptors a-1 and a-2. The former is more sensitive to catecholamines and is commonly treated with 1% ephedrine (0.5% for children); the latter is more sensitive to isopyrazole derivatives and is commonly treated with oxymetazoline. Oral decongestants such as phenylpropanolamine (PPA) are more effective for longer but should be used with caution in patients with high blood pressure and cardiovascular disease. It is generally used for 7 to 10 days. Long-term use may cause drug-induced rhinitis and make nasal congestion more serious.

Anticholinergics

For the treatment of patients with severe rhinorrhea, 0.03% ipratropium bromide nasal spray can significantly reduce nasal mucosal secretion.

Mast Cell Stabilizer

Sodium cromoglycate can stabilize the mast cell membrane and prevent its degranulation and release of mediators. Generally, a 4% solution is used for intranasal dripping or spraying; Nidocorol can also be taken orally and is significantly more effective than sodium cromoglycate.

Anti-IgE Antibody

Omalizumab is a human recombinant anti-lqE monoclonal antibody. Its main indication is patients with severe allergic rhinitis or asthma that can’t be controlled after other drug treatments. However, its treatment cycle is long and its economic cost is high, so it has not been widely used.

LTRA

Leukotrienes are one of the main mediators involved in the pathogenesis of allergic rhinitis, acting by attracting eosinophils, increasing capillary leakage and increasing mucus gland secretion. Leukotriene receptor antagonists can improve nighttime symptoms and relieve sleep disorders.

The most commonly used one is montelukast, which can improve nasal and eye symptoms caused by allergens. Application of montelukast before the pollen season can significantly improve symptoms. You can choose liquid or orally disintegrating tablets. Montelukast is a category B drug during pregnancy and can also be taken by pregnant women. The step-by-step treatment plan for allergic rhinitis recommended by IARIA (2008)

Type

mild intermittent rhinitis
Moderate-severe intermittent rhinitis
Mild persistent rhinitis
Moderate-severe persistent rhinitis
Persistent rhinitis and/or with asthma

Treatment

H1 antihistamines and/or decongestants, oral or intranasal Use intranasal glucocorticoids twice a day. Review after 1 week of treatment. If necessary, add H1 antihistamines and/or short-term oral glucocorticoids (prednisone). H1 antihistamine (oral or intranasal) or intranasal low-dose corticosteroid once daily Intranasal glucocorticoids twice daily; or oral H1 antihistamines; or oral glucocorticoids for a short period at the beginning of treatment

Specific Immunotherapy

What are the surgical treatments for allergic rhinitis?

For patients with hyperplasia and hypertrophy of the inferior turbinate, partial mucosal resection of the inferior turbinate can improve ventilation.
There is no gold standard for surgical treatment, but the following principles should be followed:

Strictly follow the indications and contraindications for surgery;
Appropriate surgical procedures and techniques should be selected based on the patient's anatomy, severity of disease, and comorbidities.

How to treat allergic rhinitis with traditional Chinese medicine?

The traditional Chinese medicine method of treating allergic rhinitis is to tonify the kidneys, nourish the lungs, and strengthen the spleen. Both traditional Chinese medicine and acupuncture have certain curative effects.

What other treatments are available for allergic rhinitis?

Specific immunotherapy

By repeatedly exposing patients to allergen extracts and gradually increasing the dosage, the therapy improves the patient's tolerance to allergens and thereby alleviates allergic symptoms. It is currently the only method that can change the natural course of allergic rhinitis. The problems with immunotherapy are its long cycle (usually 2.5 to 3 years) and safety. Currently, the commonly used methods in clinical practice include subcutaneous injection and sublingual administration.

Subcutaneous Injection

The selected standardized allergen vaccine used for subcutaneous injection is prepared from the allergen extract with positive skin test. It is injected starting from a very low concentration, once a week, and gradually increasing its dose and concentration over several weeks or months to achieve optimal maintenance dose. The main risk is the possibility of inducing systemic hypersensitivity reactions or even anaphylactic shock.

Sublingual Administration

It is a therapy that gradually increases the dose through the oral mucosa to enable patients to achieve immune tolerance. The incidence of systemic reactions is very low, and there are no life-threatening systemic reactions; there may be local adverse reactions such as itching and swelling of the lips and under the tongue. The frequency of these reactions increases with the dose, but they are all mild and under tolerance, which does not require treatment or dose adjustment and generally resolves spontaneously with continued treatment.

Nasal Saline Irrigation (NSI)

This is a simple and inexpensive treatment that can achieve following goals:
It has a direct cleaning effect. When the saline passes through the nasal cavity, it can moisten the nasal cavity and remove blocked mucus and scabs, which may immediately improve breathing;

It can remove or reduce inflammatory mediators and proteins, such as histamine, prostaglandins, leukotrienes, major basic proteins released by eosinophils, and pollen:
It can restore the damaged ciliary function of nasal mucosa and increase the frequency of ciliary beating;

It may increase the effectiveness of topical medications by clearing excess nasal secretions and reducing edema.

Therefore, NSI has been suggested as a good adjunctive treatment option to improve the effectiveness of other treatments.