Allergic Rhinitis: Latest Practice Insights and Treatment Approach

Rhinitis is generally defined as inflammation of the nasal mucosa. Allergic rhinitis (AR) is a disease that affects 400 million people worldwide. AR is often associated with co-morbid diseases such as asthma, leading to reduced quality of life and significant health economic impact. (1)

Indian Burden of AR: AR imposes a significant burden, accounting for approximately 55% of all allergies. The reported incidence of AR in India ranges between 20% and 30%. (2) As per the Global Asthma Network Survey in India, the prevalence of AR in 6-7-year-olds (children) is 7.7%, while in 13-14-year-olds (adolescents), it is 23.5%. Among adolescent school children in India, reportedly 25% experience AR, and 8.5% suffer allergic rhinoconjunctivitis. (3)

Pathophysiology of AR: Practical Overview: AR involves infiltrating inflammatory cells, including mast cells, T cells, B cells, macrophages, and eosinophils, into the nasal lining in response to allergen exposure. Activating T helper 2 (Th2) cells leads to the production of IgE by plasma cells, triggering the release of histamine, leukotrienes, and other mediators that cause symptoms such as itching, rhinorrhea, and nasal congestion. A late-phase inflammatory response further maintains symptoms by releasing additional mediators and cytokines. (2) Seasonal change and air pollution often trigger this pathway. (4)

Risk Factors for AR: The prevalence of AR has indicated an upward trend over the years, attributed to various factors. Global urbanization has led to increased levels of pollutants, including traffic-related pollutants and particulate matter. Urban areas have been reported to have a higher incidence of AR than rural areas. Climate changes have also contributed to a prolonged pollen season, resulting in more frequent seasonal allergies. Smoking and tobacco consumption have been associated with an increased risk of AR. (1)

Diagnosis of AR: Patient Assessment, Physical Examination & Allergy Testing

During patient history-taking, individuals with AR commonly report several hallmark symptoms. These include nasal congestion, nasal itching, rhinorrhea (runny nose), and sneezing. Allergic conjunctivitis, which refers to inflammation of the membrane covering the white part of the eye, is often associated with AR. Typical symptoms of allergic conjunctivitis include redness, excessive tearing, and itching of the eyes. (2)

The physical examination of individuals with suspected AR involves assessing various areas. Signs such as persistent mouth breathing, nose rubbing, nasal crease, frequent sniffling or throat clearing, and allergic shiners (dark circles under the eyes) may indicate AR. Nasal examination reveals swollen nasal mucosa and pale secretions. Nasal examination reveals swollen nasal mucosa and pale secretions. The internal endoscopic examination helps identify structural abnormalities like septal deviation, nasal ulcerations, and nasal polyps. Ears are evaluated for Eustachian tube dysfunction and fluid behind the eardrum. Sinus examination includes palpation for tenderness and sensitivity testing of the maxillary teeth. The posterior oropharynx is examined for signs of postnasal drip, while the chest and skin are checked for concurrent asthma or dermatitis. Skin prick testing is the primary method used to identify specific allergic triggers. Allergen-specific IgE tests can be performed, measuring specific IgE levels against allergens (2)

Avoid Exposure to Allergens: The initial approach to treating AR is to avoid exposure to relevant allergens and irritants. This includes minimizing contact with common triggers such as house dust mites, moulds, pets, and pollens. Additionally, it is important to advise patients to avoid tobacco smoke, as it can exacerbate symptoms of AR. (2)

Pharmacological Therapy: The first-line pharmacological treatment for AR consists of second-generation oral antihistamines, such as fexofenadine, cetirizine, desloratadine, and loratadine. These medications have effectively reduced sneezing, itching, and rhinorrhea symptoms. Second-generation oral antihistamines are widely used to relieve and improve the overall quality of life among individuals with AR. They have a better safety and tolerance profile for long-term use with a lower risk of sedation or impaired cognitive function. (2)

Other common pharmacological agents, such as intranasal corticosteroids(INS), and Leukotriene Receptor Antagonists (LTRA), such as montelukast and zafirlukast, are used to treat AR. (2)

Fexofenadine, a second-generation antihistamine, is an active metabolite of terfenadine. It is approved by the US FDA (United States Food and Drug Administration) for treating seasonal AR in children (6 months and older) and adults. The mechanism of action involves selective antagonism of H1 receptors on various cell surfaces in different organ systems. Additionally, fexofenadine can inhibit the release of inflammatory mediators from mast cells, basophils, and other inflammatory cells. After oral administration, fexofenadine is rapidly absorbed, reaching peak plasma concentrations within one hour. It has a plasma protein binding capacity of up to 70%. (6) The leukotriene receptor antagonist Montelukast binds to the cysteinyl leukotriene receptor for leukotrienes D4 and E4 with a high affinity. Following oral treatment, montelukast is immediately absorbed. Montelukast is the most widely used anti-leukotriene and the only one authorized for use in pediatric patients (7)

• Allergic Rhinitis(AR) is a common allergic condition that impacts the quality of life of an individual. In India, AR affects approximately 20-30% of the population.
• The management of AR is allergen avoidance, antihistamines and immunotherapy, nasal steroids, leukotriene receptor antagonists, and their combination with antihistamine agents.
• A combination of fexofenadine and montelukast could boost the therapeutic efficacy of AR treatment.
• Clinical studies have demonstrated the efficacy of fexofenadine plus montelukast in relieving symptoms of AR.

1. Nur Husna, S. M., Tan, H.-T. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic rhinitis: A clinical and pathophysiological overview. Frontiers in Medicine, 9, 874114.

2. Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology, 14(Suppl 2), 51.

3. Barne, M., Singh, S., Mangal, D. K., Singh, M., Awasthi, S., Mahesh, P. A., Kabra, S. K., Mohammed, S., Sukumaran, T. U., Ghoshal, A. G., Sinha, S., Kochar, S. K., Singh, N., Singh, U., Patel, K. K., Sharma, A. K., Girase, B., Madas, S., Chauhan, A., … Salvi, S. (2022). Global Asthma Network Phase I, India: Results for allergic rhinitis and eczema in 127,309 children and adults. The Journal of Allergy and Clinical Immunology. Global, 1(2), 51–60.

4. Naclerio R, Ansotegui IJ, Bousquet J, Canonica GW, D'Amato G, Rosario N, Pawankar R, Peden D, Bergmann KC, Bielory L, Caraballo L, Cecchi L, Cepeda SAM, Chong Neto HJ, Galán C, Gonzalez Diaz SN, Idriss S, Popov T, Ramon GD, Ridolo E, Rottem M, Songnuan W, Rouadi P. International expert consensus on the management of allergic rhinitis (AR) aggravated by air pollutants: Impact of air pollution on patients with AR: Current knowledge and future strategies. World Allergy Organ J. 2020 Apr 3;13(3):100106. doi: 10.1016/j.waojou.2020.100106.

5. Walekar, A., Chodankar, D., Naqvi, M., & Trivedi, C. (n.d.). Assessment of bioequivalence of fexofenadine and montelukast fixed-dose combination tablet versus separate formulations of the individual components at the same dose levels. Ijpsonline.com. Retrieved July 15, 2023, from https://www.ijpsonline.com/articles/bioequivalence-of-fexofenadine-and-montelukast-fixed-dose-combination-tablet-with-individual-components-singledose-rando.pdf

6. Craun, K. L., & Schury, M. P. (2022). Fexofenadine. StatPearls Publishing.

7. Baççıoğlu, A. (2013). Role of leukotriene antagonists and antihistamines in the treatment of allergic rhinitis and asthma comorbidity. Journal of Medical Updates, 3(1), 34–39.

8. Mahatme, M. S., Dakhale, G. N., Tadke, K., Hiware, S. K., Dudhgaonkar, S. D., & Wankhede, S. (2016). Comparison of efficacy, safety, and cost-effectiveness of montelukast-levocetirizine and montelukast-fexofenadine in patients of allergic rhinitis: A randomized, double-blind clinical trial. Indian Journal of Pharmacology, 48(6), 649–653.

9. Naik, M., Nayak, A., Khandeparkar, P., & Mukaddam, Q. (2013). Efficacy and safety of montelukast plus fexofenadine fixed-dose combination in allergic rhinitis : Results of a post-marketing study in India.

10. Abha Kumari, Sandeep Kumar. A Study of Levocetirizine and Monteleukast versus Fexofenidine and Monteleukast in School Going Children with Allergic Rhinitis. Int J Med Res Prof. 2018 Jan; 4(1):268-71. DOI:10.21276/ijmrp.2018.4.1.054