Allergic Rhinitis in Children: Practitioners Update and Consideration for Use of Intranasal Fluticasone Based Therapies

Allergic rhinitis (AR), an inflammatory disease caused by an IgE-mediated immune response to inhaled allergens, is a frequently occurring childhood disease and is dominantly noted among the age group of 8-11 years. (1) It is reported that AR affects boys more than girls during their growing years, often accompanied by nasal symptoms of congestion, rhinorrhea, sneezing, and ocular symptoms (redness, tearing, and itching). Making matters worse, studies highlight that comorbidities such as asthma, sinusitis, and otitis media might follow or aggravate if the former is left untreated. (1) With global studies revealing that the prevalence of AR in preschool age groups can range up to 42.7% (2), coupled with the lack of a global expert consensus on its management, it may be necessary for pediatric AR to be considered clinical entity on its own, and managed accordingly.

Allergic Rhinitis Hampers Learning Abilities and Academic Achievements- In children, symptoms of Allergic Rhinitis often interfere with sleep and lead to fatigue and loss of concentration, ultimately damaging academic abilities and quality of life. (1) Children with AR may experience social isolation, anxiety, and learning disabilities. (3) Accumulating evidence confirms that children's academic performance can be compromised by intellectual disability linked to AR. (4)

Need to treat allergic rhinitis early in children-It is documented that children with perennial allergic rhinitis (PAR) tend to live through maturity with the condition. In contrast, only up to 20% of children with seasonal allergic rhinitis (SAR) have their allergy symptoms resolved by early adulthood. (3) Complications like conjunctivitis, laryngitis, atopic dermatitis, recurrent upper respiratory tract infection (URTI), and obstructive sleep apnea (OSA) have been linked to AR. (5)

AR has also been linked to increased pediatric outpatients and hospital visits. By age of 20 years, more than 60% of children with AR exhibit comorbid ocular symptoms. Between one and two-thirds of them suffer severe chronic symptoms. (6) This may bring the need for optimizing management care among AR in children to avoid subsequent lifelong complications and substandard quality of life. (3)

Allergic Rhinitis in Children: Practice Pointers Recognizing that up to 40% of children suffer from AR at some point in their lives, the Indian Academy of Pediatrics (IAP) has recently issued recommendations on the pharmacological management of AR in children, as summarised below. (5)

• The choice of drugs may predominantly depend on the dominant symptoms of the child.
• Inhaled nasal steroids (INS) are the controller medications of choice.
• Choosing an INS with low systemic bioavailability like fluticasone furoate at a minimum dose required to achieve symptom control is advocated. The minimum recommended age is >2 years.
• The recommended dosage for fluticasone furoate for 2-11 years is 27.5 µg/nostril OD. For children aged >12 years, it is 55 µg/nostril OD. (7)
• Regular monitoring of the child is vital for the success of therapy. Maintaining a minimal or low dose of INS to keep the patient symptom free is advised.

Current Scenario in the Management of Pediatric Allergic Rhinitis (AR):

Despite using various pharmacologic drug classes to manage AR, intranasal Steroids (INSs) are the preferred treatment for seasonal allergic rhinitis. They are recommended by the American Academy of Allergy, Asthma and Immunology guidelines and the World Health Organization Allergic Rhinitis and Impact on Asthma guidelines (WHO ARIA), specifically for rhinitis with prominent nasal congestion, both in adults and children. (1,3)

These recommendations are rationalized by the fact that intranasal corticosteroids have been shown to have anti-inflammatory effects against the pathophysiologic components of both early and late-phase allergic responses, besides their beneficial impact on a variety of associated nasal and ocular symptoms. (1,4)

The role of Fluticasone-Fluticasone furoate nasal spray (FFNS) is presently licensed for use in more than 100 countries, including the US and Europe, as a therapy for AR. In the US and Europe, FFNS is allowed for treatment in patients with AR as young as two and six years old, respectively. (4)

Equipped with unique pharmacological characteristics, including very low systemic bioavailability (0.5%), 24-hour symptom relief with once-daily dosing, thorough coverage of both nasal and ocular symptoms, safety and tolerability with routine use, and availability in a novel, side-actuated delivery device that makes medication administration quick and reliable, Fluticasone furoate (FF), a relatively novel glucocorticoid, has been a game changer in the management of pediatric AR. The fact that FF, in recommended pediatric doses, does not affect the growth outcomes in children only adds to its clinical utility. (1)

Analyzing the clinical evidence with Fluticasone-

• A study designed to assess the efficacy and safety of fluticasone furoate (FF)in children aged 2-11 years and suffering from seasonal Allergic Rhinitis (SAR) concluded that the FF spray provides 24-hour relief of nasal symptoms in pediatric SAR. The team noted that relief was evident with once-daily FF 55 or 110mcg. (8)
• A study (3) undertaken to evaluate the safety and efficacy of once-daily fluticasone furoate (FF) nasal spray in children with perennial allergic rhinitis (PAR) concluded that considering the total nasal symptom score, FF 55 µg demonstrated significant improvement (p = 0.003) compared with placebo. The team also elaborated that FF, at both 55 g and 110 g doses, had minimal systemic effects that were considered clinically insignificant on hypothalamic–pituitary–adrenal (HPA axis) function in children aged 6 to 11 years. The team attributed poor aqueous solubility, limited mucosal contact time, and poor systemic absorption from the nasal administration site as the possible reasons for such clinical safety.
• Another study (4) aimed to assess the safety, efficacy, and systemic exposure of FF nasal spray in Japanese children aged 2 to <15 years with perennial allergic rhinitis (PAR). The team concluded that 12-week treatment with FFNS 55 µg, once daily, was well tolerated and effective with low systemic exposure in pediatric PAR. Resonating with the above findings, Japanese guidelines recommend INS as first-line therapy for treating AR symptoms.
• Yet another study (9) analyzed the efficacy and safety of fluticasone furoate nasal spray (FFNS) in the Asian pediatric population and noted favorable efficacy and safety profiles for FFNS 55 µg or 110 µg in the pediatric population (2–12 years); supporting its use in clinical treatment for AR children, including younger children aged 2–6 years.