Allergic Rhinitis-Approach to Holistic Management

Epidemiology- Indian Statistics- As per the Global Asthma Network (GAN) survey, the prevalence of AR in India among 6-7-year-olds and 13-14-year-olds was 7.7% and 23.5%, respectively. Nearly a quarter of the adolescent school children in India suffer from AR, and 8.5% have allergic rhinoconjunctivitis. (2)

The burden of AR is enormous, constituting about 55% of all allergies. The reported prevalence of AR in India also ranges between 20%-30%. (3)

Risk factors of AR- The GAN survey revealed that the coexisting atopic condition, parental history of atopy, and some environmental factors were significant risk factors among children and adolescents. AR or eczema in either parent strongly predicted the same atopic condition among their adolescent offspring. Among adults, coexisting atopic condition was the strongest predictor of either AR or eczema. (2)

Clinical Signs and Diagnosis: AR is a clinical diagnosis rooted firmly in history and objective examination findings. The presence of symptoms (rhinorrhea, nasal congestion, sneezing paroxysms, nasal pruritus, cough, postnasal drip, etc.) and other atopic conditions (atopic dermatitis, food allergy, asthma) support the diagnosis. A thorough history should focus on symptom frequency and duration, specific symptoms and intensity, with previous therapies and their efficacy. Reassessment of alternative diagnoses is important when treatments are ineffective. (1)

Physical examination of the patient with AR should include an assessment of the eyes, ears, nose, and throat. Pale, boggy, edematous nasal mucosa are common in AR, with a 67% sensitivity and 37% specificity. Nasal polyps carry a 95% specificity and 12% sensitivity. (1)

Clinical examination with anterior rhinoscopy helps identify the presence of nasal polyps, mucosal swelling, abnormal secretions and other structural abnormalities. Sinuses examination helps diagnose sinuses' palpation for signs of tenderness and maxillary tooth sensitivity. Posterior oropharynx aids in diagnosing postnasal drip, lymphoid hyperplasia and tonsillar hypertrophy. (4)

Management of AR:

Prevention Modalities: The best method to control AR is prevention by avoiding allergens. If practical, the patient and provider should develop avoidance strategies to minimise or eliminate exposure to causative agents.

The Indian guidelines on AR (2021) laid down some recommendation for the prevention of AR, which includes breastfeeding infants for 6 months irrespective of the family history, no avoidance diet in pregnant and breastfeeding women, total avoidance of smoking in children and pregnant women and reduction of early life exposure to house dust mites. The guideline also recommended avoidance of exposure to indoor moulds (if allergic), animal dander (if allergic), and immediate and total cessation of exposure to occupational allergens in patients with occupational asthma. (4)

Pharmacological Modalities: Patients can often only minimally change or control their environment, eventually leading to pharmacological therapy to control symptoms. (1)

When mild AR, properly performed nasal saline rinses provide significant symptom relief. Treating with intranasal glucocorticoid sprays can improve symptoms in both mild and moderate-severe AR. ARIA (Allergic Rhinitis and its Impact on Asthma) 2020 practice update recommends starting therapy for intermittent AR with either an oral antihistamine or intranasal corticosteroid. Leukotriene receptor antagonists can reduce the inflammatory response in the nasal and respiratory mucosa. These continue to be adjunctive therapy options in patients with associated asthma. (1)

Agent selection: Consideration of Various Modalities

Antihistamines have long been the mainstay in the therapy for AR. First-generation antihistamines are not first-line options because of the potential side effects of sedation and urinary retention. (1) Second-generation histamine H1 receptor antagonists and newer antihistamines have been developed to reduce or eliminate the sedation and anticholinergic adverse effects that occur with earlier-generation H1 receptor antagonists in the treatment of intermittent AR. The selection of optimal second-generation antihistamines depends on many factors, particularly drug safety and efficacy, impact on psychomotor abilities, and sedation. (3) Fexofenadine, a well-known member of the second generation of antihistamines, is known for its least sedating properties, with fewer adverse effects and an increased H1 -receptor specificity compared with first-generation antihistamines. (5)

Present-Day Evidence on Second-Generation Antihistamine: Fexofenadine:

A single-centre, sequential, parallel-group, double-blind, randomised study evaluated the efficacy and safety of fexofenadine HCl 180 mg versus placebo. The study was conducted in an environmental exposure unit (EEU) during sequential exposures: Period 1 (ragweed pollen alone), Period 2 (ragweed pollen+ diesel exhaust particle), and Period 3 (ragweed pollen+ diesel exhaust particle +single-dose fexofenadine HCl 180 mg or placebo). Efficacy and safety were evaluated in Period 3. 251 subjects were included in the modified intent-to-treat population. Total nasal symptom scores (TNSS) were calculated as the sum of rhinorrhoea, sneezing and nasal itching scores. The least squares mean difference (95% CI) for TNSS in Period 2 versus Period 1 was 0.13 (0.081–0.182; p<0.0001). The least squares mean difference in hours 2-12 for fexofenadine HCl versus placebo during Period 3 was −0.24 (−0.425–−0.047; p=0.0148). The study concluded that Fexofenadine HCl 180 mg effectively relieved pollen-induced, air pollution-aggravated AR symptoms. (6)

Fexofenadine Stands Out Over Bilastine: Indian Evidence (3)

A Prospective comparative study was conducted on patients aged 20 years and above, attending the outpatient department of ENT, and diagnosed with Intermittent AR. Participants were divided into two groups; one was given Fexofenadine (120mg), and the other, Bilastine (20mg), orally, once a day at night for a month. Follow-up was done on Day-10 and Day-30, which included a comparison of symptom scores, measurement of sedation, and ECG changes. Total nasal symptom scores (TNSS) were calculated as the sum of each symptom, including sneezing, nasal congestion, nasal itching, and rhinorrhea.

Better scores of improvement in rhinorrhea were observed in patients treated with Fexofenadine over 30 days (mean value 0.97) over those treated with Bilastine (mean value 1.50). Similarly, there was more improvement perceived in the TNSS in patients treated with Fexofenadine over 30 days (mean value 3.47) over those treated with Bilastine (mean value 4.37), concluding that Fexofenadine had more effective symptom control as compared to Bilastine.

Fexofenadine Safety Profile in Pediatric Population:

A multicenter, double-blind, randomised, placebo-controlled, parallel-group study compared the safety and tolerability of twice-daily fexofenadine hydrochloride, 30 mg, and placebo in preschool children aged 2 to 5 years with AR. In this study, Fexofenadine hydrochloride, 30 mg twice daily, was well tolerated, with a good safety profile, in children aged 2 to 5 years with AR. The finding suggests that fexofenadine hydrochloride, 30 mg, is an appropriate dose for children aged 2 to 5 years and validates the 30-mg twice daily dose of fexofenadine hydrochloride is safe. (7)

Clinical Care Pointers:

• AR is a common condition that can impact the quality of life.
• Diagnosis of AR is based mainly on history, physical examination and clinical examination.
• Physical examination of the patient with AR should include an assessment of the eyes, ears, nose, and throat. Clinical examination includes examination of anterior rhinoscopy, sinuses, and posterior oropharynx.
• Avoidance of allergens during early life, breastfeeding infants for 6 months, and no avoidance diet in pregnant and breastfeeding women are some of the prevention steps of AR.
• Antihistamines have long been a mainstay in the therapy for AR. Second-generation antihistamines are preferred to first-generation due to their less sedation and anticholinergic adverse effects properties.
• Fexofenadine, a well-known member of the second generation of antihistamines, is safe and effective in managing AR.

References:

1. Czech, Eric & Overholser, Andrew & Schultz, Paul. Allergic Rhinitis. Primary Care: Clinics in Office Practice. 2023.

2. Barne, Monica & Singh, Sheetu & Mangal, et.al. Global Asthma Network Phase-I, India: Results for allergic rhinitis and eczema in 127,309 children and adults. 2022. Journal of Allergy and Clinical Immunology: Global.

3. Bhavya Jolly et al: Comparative Study of Bilastine and Fexofenadine in Control of Intermittent Allergic Rhinitis. 2022. Medica Innovatica

4. The Association of Otolaryngologists of India. Indian Guidelines on Diagnosis and Management of Allergic Rhinitis. 2021. Retrieved on 20^th March 23 from http://www.aoiho.org/pdf/AOI%20AR%20Guidelines.pdf

5. Scadding GK, Kariyawasam HH, Scadding G, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017;47(7):856-889.

6. Ellis AK, Murrieta-Aguttes M, Furey S, Picard P, Carlsten C. Effect of fexofenadine hydrochloride on allergic rhinitis aggravated by air pollutants. ERJ Open Res. 2021;7(2):00806-2020. Published 2021 Apr 6.

7. Milgrom, Henry et al. “Safety and tolerability of fexofenadine for the treatment of allergic rhinitis in children 2 to 5 years old.” Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology vol. 99,4 (2007): 358-63.