Pharmacological management of allergic rhinitis: MSAI issues consensus statement
Malaysia: The Malaysian Society of Allergy and Immunology has released a consensus statement on the pharmacological management of allergic rhinitis (AR). The guideline appears in the Journal of Asthma and Allergy.
The main aim of allergic rhinitis management is to achieve satisfactory symptom control to ensure good quality of life. Currently, most AR patients are treated with pharmacotherapy. Despite the availability of guideline recommendations, a knowledge gap on pharmacotherapy use still exists among physicians, particularly in the primary care setting. Further, it is general for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations.
Inadequate treatment can result in a significant reduction in quality of life affecting normal activities at home, school, and work. Considering these concerns, Baharudin Abdullah, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia, and colleagues developed a practical consensus statement to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.
The Role of Oral Antihistamines
Recommendation (Adults/Children)
Second-generation oral antihistamines play a key role in the treatment of AR due to their superiority over their predecessors. Yet, medical practitioners continue to use first-generation oral antihistamines, primarily due to their cheaper cost than second-generation antihistamines. Driving the shift from first-generation to second-generation oral antihistamines depends on the affordability of the latter and practitioners' greater awareness of the former's detrimental adverse effects.
The Role of Intranasal Corticosteroids with/without Intranasal Antihistamines
Recommendation (Adults/Children)
INCS are superior to oral antihistamines for the relief of nasal symptoms like obstruction, rhinorrhea, nasal itch, and postnasal drip. INCS also improves ocular symptoms and lower airway symptoms when there is concomitant allergic conjunctivitis and asthma. There is no added benefit of routinely combining INCS with an oral antihistamine or a leukotriene receptor antagonist (LTRA) in AR. Correct intranasal spray technique and adherence to prescribed dosage and dosing frequency are necessary to achieve the desired benefit from INCS or INCS-INA. Optimal effects of INCS are seen after 1–2 weeks of constant use. To sustain symptomatic control in persistent AR, maintenance therapy with INCS or INCS-INA over a period of months to years is necessary.
The Role of Systemic Corticosteroids
Recommendation
Systemic corticosteroids are not recommended in AR and are only considered a potential treatment option in exceptional cases.
The Role of Oral and Intranasal Decongestants
Recommendation (Adults/Children)
Oral decongestants are contraindicated in young children and pregnancy. A topical decongestant is an option in adults and older children.
The Role of Leukotriene Receptor Antagonists
Recommendation (Adults/Children)
Montelukast may be used in adults and children above 2 years. Recent evidence suggests that when used in combination with oral antihistamines, montelukast produces significant control of the overall symptoms of AR. Montelukast is useful in combination with antihistamines for the reduction of nasal symptoms.
The Role of Biologics
Recommendation (Adults/Children)
Omalizumab may be considered as an add-on therapy to immunotherapy for the prevention of immunotherapy-induced adverse effects. It is well tolerated in adults and children.
The Role of Immunotherapy
Recommendation (Adults/Children)
The administration of both SCIT and SLIT are efficacious and well tolerated in children and adults with AR.
The Role of Intranasal Sodium Cromoglycate
Recommendation (Adults/Children)
SC is recommended in children above 2 years of age and in pregnant women.
The Role of Intranasal Anticholinergics
Recommendation (Adults/Children)
IB can be prescribed in children above 12 years of age but is not recommended in pregnant women.
"Effective treatment of most allergic rhinitis can be done by pharmacological intervention at primary and secondary care settings. The effective control of symptoms ensures patient satisfaction and improves compliance and adherence to treatment which are key to obtaining superior outcomes and good quality of life," conclude the author.
"With a clear understanding of the benefit of each specific pharmacological agent, primary care practitioners can manage most AR patients circumventing the patients from having to consult specialists in secondary care. Patients with refractory or complicated AR require escalation to the secondary care level where appropriate specific pharmacological treatment can be initiated," they wrote.
Reference:
Abdullah B, Abdul Latiff AH, Manuel AM, Mohamed Jamli F, Dalip Singh HS, Ismail IH, Jahendran J, Saniasiaya J, Woo KCK, Khoo PC, Singh K, Mohammad N, Mohamad S, Husain S, Mösges R. Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology. J Asthma Allergy. 2022;15:983-1003 https://doi.org/10.2147/JAA.S374346
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