News in the Treatment of Allergic Rhinitis

Introduction

Allergic rhinitis manifests as watery nasal secretions, nasal itching, sneezing, and nasal obstruction. It is often accompanied by ocular symptoms, i.e., allergic conjunctivitis. The aim of the treatment is not only to improve the quality of life but also to prevent complications such as sinusitis or otitis media. Allergic rhinitis is also a risk factor for the development of asthma bronchiale, which is diagnosed in 15–38% of patients with AR. At the same time, more than 85% of asthmatics suffer from it.

Assessing Symptom Intensity

According to recent recommendations, the treatment of allergic rhinitis should be based on assessing the severity of symptoms on a visual analog scale, where 0 = no symptoms and 10 = very severe symptoms. First-line medications are second-generation oral H₁-antihistamines, nasal corticosteroids (CS), or a combination of nasal CS and H₁-antihistamines. For patients with persistent AR and VAS > 5, the first choice is nasal CS or their combination with nasal H₁-antihistamines.

In cases of intermittent AR, if exposure to the causative allergen does not persist, treatment can be de-escalated or interrupted. In cases of persistent AR and ongoing exposure, treatment can be continued or escalated. Efficacy assessment according to VAS should be done by the third day. With VAS > 5, therapy can be escalated to nasal CS or their combination with nasal H₁-antihistamines. By the seventh day, the efficacy should be reassessed.

The recommendations are based, among other things, on these study results:

• The efficacy of oral H₁-antihistamines is lower than that of nasal CS, but a significant portion of patients prefers oral medication.
• The efficacy of nasal H₁-antihistamines is lower than that of nasal CS.
• The onset of action of nasal H₁-antihistamines is within minutes, while for nasal CS, it takes hours to days.
• The combination of nasal CS with oral H₁-antihistamines does not have a synergistic effect.
• The combination of nasal CS and H₁-antihistamines is more effective in patients with moderate to severe AR than CS in monotherapy.
• The onset of action of nasal CS combined with nasal H₁-antihistamines is within minutes.
• Leukotriene antagonists are less effective than nasal CS.

Currently Used Drug Groups

Second-generation oral H₁-antihistamines do not have the sedative effect of first-generation representatives. Their low toxicity is also an advantage. They reduce watery nasal secretions, nasal itching, and sneezing. Specific representatives of this group include desloratadine, loratadine, levocetirizine, cetirizine, fexofenadine, bilastine, and rupatadine. Locally applied antihistamines (in the form of nasal sprays and eye drops) without systemic effects include azelastine, levocabastine, olopatadine, and emedastine.

Nasal CS have anti-inflammatory effects with minimal side effects. They reduce mucosal edema (i.e., nasal obstruction) and watery nasal secretions. They include beclomethasone, budesonide, fluticasone propionate, fluticasone furoate, and mometasone furoate.

A fixed combination of nasal CS with anti-inflammatory effects and H₁-antihistamines with a fast onset of action is represented by fluticasone propionate + azelastine hydrochloride. This combination is suitable for treating intermittent and persistent AR as a first-line modality or as part of treatment escalation.

A newly available fixed combination is mometasone furoate + olopatadine hydrochloride. Efficacy and safety in adults and adolescents over 12 years have been validated in several randomized double-blind controlled clinical studies on intermittent and persistent allergic rhinitis compared with placebo and the individual components of the medication in monotherapy. With intranasal application, this fixed combination reduces nasal discharge, itching, and sneezing and eliminates ocular symptoms, with good treatment safety and tolerability. Onset of action can be expected within 15 minutes.

Source: Lipiec A., Jurkiewicz D. A new therapeutic option in the management of allergic rhinitis. Otolaryngol Pol 2021 Nov 2; 75 (5): 1–5, doi: 10.5604/3001.0015.4556.