Allergic Rhinitis

Mechanisms and Treatment

David I. Bernstein, MD*, Gene Schwartz, MD, Jonathan A. Bernstein, MD

KEYWORDS
 Mechanisms  Allergic rhinitis treatment  Leukotrienes  Intranasal corticosteroids
 Intranasal antihistamines  Subcutaneous immunotherapy  Treatment

KEY POINTS
 Allergic rhinitis is an immunoglobulin E (IgE) -mediated inflammatory disease.
 Allergic rhinitis has a significant impact on patient morbidity and is a major economic
burden to society.
 There are several effective treatment modalities available for allergic rhinitis that target re-
ceptors of bioactive mediators or inflammation.
 Subcutaneous allergen immunotherapy induces tolerance to aeroallergens and is highly
effective in mitigating symptoms and preventing progression of disease and comorbidities
such as asthma.
 Sublingual immunotherapy formulations offer an alternative approach to subcutaneous
immunotherapy, allowing for symptomatic relief to specific seasonal allergens also likely
through tolerogenic mechanisms.

INTRODUCTION

Atopic diseases, including allergic rhinitis (AR), are very prevalent, especially in devel-
oped countries. Prevalence estimates of chronic rhinitis around the world range be-
tween 10% and 40%.1–11 The impact of AR on quality of life is very significant.
Allergic rhinitis is a major contributor to the total cost of health-related absenteeism
(eg, missing work) and presenteeism (ie, showing up to work but having reduced pro-
ductivity). For example, costs of AR and allergic conjunctivitis in the United States
have been estimated at more than $6 billion per year.12–14 Lamb and colleagues15 esti-
mated the productivity loss from AR to be the highest of 15 chronic conditions among
employees in the United States.
There are multiple phenotypes and endotypes of rhinitis, but in recent years, rhinitis
control has been increasingly emphasized.16 AR has been traditionally categorized as

Division of Immunology and Allergy, Department of Internal Medicine, University of Cincinnati

College of Medicine, Cincinnati, OH, USA
* Corresponding author. 231 Albert Sabin Way, Cincinnati, OH 45267-0563.
E-mail address: [email protected]

Immunol Allergy Clin N Am 36 (2016) 261–278

http://dx.doi.org/10.1016/j.iac.2015.12.004 immunology.theclinics.com
0889-8561/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
262 Bernstein et al

seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), and mixed rhinitis (ie,
combined allergic and nonallergic phenotype). AR has recently been classified via
the ARIA (Allergic Rhinitis and its Impact on Asthma) guideline as mild versus moder-
ate to severe and intermittent versus persistent (Table 1).17,18 Regardless of the clas-
sification system, the main goal of treatment is to achieve control of nasal and ocular
symptoms of SAR and PAR.
The 3 key elements of AR management are reduction of exposure to the sensitizing
allergen, which includes a spectrum of environmental avoidance recommendations
specific to the inciting allergen, targeted pharmacotherapy, and either subcutaneous
or sublingual immunotherapy.19,20 Environmental control should focus on avoidance
of known allergens as well as nonspecific aggravating triggers, such as noxious odor-
ants and chemical irritants (eg, fragrances, cleaning agents, environmental tobacco
smoke) identified by medical history. Broad environmental control measures aimed
at reducing allergen exposure (eg, house dust mite) should not be instituted without
first confirming clinical relevance, which involves demonstrating sensitization by
skin prick testing or serum-specific IgE and correlation of symptoms with exposure
to the specific sensitizing allergen.17,19 Often patients may exhibit sensitization but
are not able to correlate their symptoms with exposure, and in these instances, nasal
provocation testing using standardized methodologies to the specific allergen may be
useful to confirm or exclude the clinical relevance of sensitization.21,22 Diagnosis of AR
is discussed more extensively elsewhere in this issue. (See Scadding GK, Scadding
GW: Diagnosing Allergic Rhinitis, in this issue.) The importance of environmental de-
terminants in causing AR and eliciting related symptoms with continuous or intermit-
tent exposures is discussed more extensively elsewhere in this issue. (See Dunlop J,
Matsui E, Sharma H: Allergic Rhinitis: Environmental Determinants, in this issue.) This
article focuses on providing a brief overview of the mechanisms related to AR and cur-
rent treatment options for this chronic and often debilitating condition.

Allergic Rhinitis Mechanisms

AR is caused by specific immunoglobulin E (IgE) -mediated reactions against inhaled
allergens driven by type 2 helper T (Th2) cells. AR results in mucosal inflammation with
tissue influx of eosinophils and basophils.23,24 IgE constitutes a very small fraction of
the total antibody amount in human serum, but its biological activity is enhanced by
specific cell surface receptors whose affinity can vary in strength.24 IgE is produced
as a result of complex interactions between B cells, T cells, mast cells, and basophils
and involves multiple cytokines, such as interleukin (IL) -4, IL-13, and IL-18.25 On
exposure of allergen into the upper respiratory tract, the allergen is taken up by
antigen-presenting cells (ie, dendritic cells, B cells) and processed to a small peptide

Table 1
Rhinitis severity grading based on joint task force rhinitis guidelines

Rhinitis Severity Medication Requirement Example

Step 1: Episodic —
Step 2: Mild 1 medication
Step 3: Mild to moderate 2 medications or change to another medication
Step 4: Moderate to severe 2–3 medications and/or change of 1 or more medications
Step 5: Severe Oral corticosteroid

Data from Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis:
an updated practice parameter. J Allergy Clin Immunol 2008;122(2 Suppl):S1–84.
 Allergic Rhinitis 263

that binds to specific major histocompatibility complex (MHC) class II molecules.25

The MHC class II-peptide complex is then expressed on the cell surface, where it is
recognized by Th0 receptor and other costimulatory molecules, resulting in differenti-
ation into Th2 CD41 lymphocytes that produce cytokines like IL-4, IL-5, and IL-13, all
important in driving different components of the IgE inflammatory immune response.25
The MHC class II-peptide complex activation of antigen-specific Th2 also can stimu-
late B-cell receptors, which in conjunction with B-cell costimulatory molecules cause
B-cell differentiation to antibody-producing plasma cells.25 Specific cytokines like IL-4
induce antibody class switching to IgE isotypes that specifically recognize the peptide
linked to the MHC class 2 molecule. The antigen-specific IgE binds to high-affinity IgE
receptors (FcER1 or CD23 1 molecules) on mast cells and basophils.25
On re-exposure to the antigen/allergen, the relevant peptide is recognized by the
FcER1 receptor, and after cross-linking these receptor molecules, a cascade of path-
ways is set in motion that lead to release of preformed bioactive mediators like hista-
mine and newly formed lipid mediators derived from membrane phospholipids, such
as leukotrienes, prostaglandins, and platelet-activating factor, that can cause smooth
muscle contraction, increased vascular permeability, and mucus secretion (Fig. 1).26
The release of these mediators leads to the early or immediate phase allergic
response. These lipid mediators also have chemoattractant properties important for
attracting inflammatory cells into the tissue, resulting in the late phase allergic
response that can manifest approximately 4 to 8 hours after the early or immediate
phase response.25 In addition, enzymes, such as mast-cell chymase, tryptase, and
serine esterases, are released that can activate matrix metalloproteinases that
down tissue matrix proteins leading to tissue damage.25 Tumor necrosis factor-a is
also released by activated mast cells that can activate endothelial cells, causing
increased expression of adhesion molecules that facilitates the influx of inflammatory
leukocytes (ie, eosinophils) and lymphocytes influx into tissues.25 The release of
epithelial cell cytokines, such as thymic stromal lymphopoietin, IL-25, and IL-33,
also bolsters the Th2 response further. Thus, the pharmacologic therapies to be dis-
cussed in later sections of this article target mediators, cytokines, or nonspecific
inflammation to attenuate or ablate allergic symptoms.25 Although these therapies
block receptors or reduce inflammation, allergen immunotherapy can modify Th2-
driven responses through different mechanisms, including through increased IgG4

Fig. 1. Mast cell activation by antigen cross-linking of specific IgE molecules on FcER126 (Fc
epsilon Receptor). TNF-a, tumor necrosis factor-a. (From Bernstein JA, Moellman J. Emerging
concepts in the diagnosis and treatment of patients with undifferentiated angioedema. Int J
Emerg Med 2012;5(1):39; with permission.)
264 Bernstein et al

blocking antibodies and increased production of T regulatory (CD41 Foxp31) cells

that produce immunomodulatory cytokines (IL-10 and transforming growth factor
[TGF] -b) and is the only potential curative treatment for AR.23,24

PHARMACOTHERAPY FOR ALLERGIC RHINITIS SUBTYPES

Seasonal Allergic Rhinitis
For the management of intermittent mild or intermittent SAR, an oral nonsedating
second-generation H1 receptor antihistamine (AH) is recommended over a first-
generation H1-antagonist, which is associated with more adverse effects, such as
sedation, excessive drying, and impaired motor coordination. For persistent moderate
or severe symptoms of seasonal rhinoconjunctivitis, daily use of an intranasal cortico-
steroid (INCS) or intranasal antihistamine (INAH) is the treatment of choice. Although
INCS have been consistently shown to reduce associated allergic conjunctival symp-
toms of SAR, a topical ocular H1 AH with mast cell stabilizing properties (eg, cromolyn,
pemirolast, nedocromil, olopatadine, azelastine) may be necessary to achieve better
control of ocular symptoms.27 Clinical studies have demonstrated little benefit of add-
ing oral AHs or a leukotriene-modifying agent like montelukast to INCSs for treating
moderate or severe SAR, although this approach may be beneficial in individual pa-
tients who are experiencing more nasal sneezing, itching, or conjunctival symptoms.28
If an INCS is the first treatment of choice for treatment of SAR or PAR and is not suf-
ficient for controlling symptoms, addition of an INAH would likely be the most appro-
priate next choice given the recent evidences reported in the literature regarding
combination therapy.16,20,29–31 A combination product of fluticasone proprionate
plus azelastine HCl has been demonstrated to have greater efficacy in reducing nasal
symptoms of SAR when compared with either drug alone.16,31,32
In patients with severe nasal and/or ocular symptoms of SAR or PAR refractory to
nasal corticosteroids and topical AHs, especially nasal congestion, a brief course of
oral corticosteroids should be considered to achieve symptomatic relief. Although still
commonly used by some practitioners, long-acting depot intramuscular corticosteroid
injections should not be used to treat SAR patients because of multiple systemic
adverse effects, such as adrenal insufficiency as well as localized tissue atrophy at
the site of the injection.33,34 In adults with allergic or mixed rhinitis, oral decongestants
such as pseudoephedrine may be added (if tolerated) in patients whose nasal symp-
toms (eg, nasal congestion, postnasal drainage) are not controlled with H1 blockers
and nasal corticosteroids.35 However, caution should be exercised in using these
agents in patients prone to hypertension, urinary retention, and cardiac arrhythmias.35
Daily use of montelukast, a LTD4 (leukotriene D) antagonist, may be considered in
selected patients with SAR but is considered less effective than nasal corticosteroids.
Despite good safety and tolerability in adults and children, montelukast, like oral AHs,
has limited efficacy for treatment of moderate or severe SAR comparable to oral
AHs.16,17,20,29,30,36

Perennial Allergic Rhinitis

As discussed in this issue, some environmental control measures for indoor aeroaller-
gens can be effective in reducing allergen exposure and symptoms but are often insuf-
ficient alone. (See Dunlop J, Matsui E, Sharma H: Allergic Rhinitis: Environmental
Determinants, in this issue.) Because rhinoconjunctival symptoms of PAR may not
always be as pronounced as those symptoms experienced by SAR patients, pharma-
cologic treatment may differ. Double-blind placebo-controlled studies have demon-
strated that second-generation oral AHs are more effective than placebo in patients
 Allergic Rhinitis 265

with PAR. Both cetirizine and levocetirizine have an indication for the treatment of AR
and are well tolerated.37 In a large controlled trial, montelukast was also found to be
more effective than placebo in treating adults with PAR.38 Thus, it may be reasonable
to initiate therapy of PAR with a second-generation oral AH for some patients with mild
persistent PAR followed by addition of an INCS or INAH if symptoms are not well
controlled. Ocular AHs and/or mast cell stabilizing agents should be initiated for
allergic conjunctivitis symptoms if necessary.27 Allergen immunotherapy is considered
an alternative for any patient requiring chronic controller medications or incompletely
responsive to medications and environmental control measures.16,17,20,30

Allergen Immunotherapy
Allergy immunotherapy (AIT) is the only potential curative therapy for SAR and/or
PAR.16,20,24,30,39 It has been reported that one-third of children and two-thirds of
adults with AR experience insufficient relief with pharmacotherapy alone.23,40,41
Allergen immunotherapy should be considered in patients uncontrolled by allergen
avoidance measures and daily use of medications. Patient preference, acceptance,
expected adherence, and costs are other important considerations in initiating either
subcutaneous (SCIT) or sublingual immunotherapy.16,30,42 Fig. 2 summarizes what is
known about the mechanistic responses to AIT.43 Initially, mast cell and basophil
desensitization is followed by an increase in T-regulatory cells driven by IL-10 and
TGF-b cytokines, resulting in tolerance.43 Blocking antibody and nasal mucosal tissue
expression of Th1 cytokines (eg, interferon-g), suggesting “Th1 shift,” is demonstrated
months after initiating SCIT.43 SCIT has been used worldwide for more than a century
and has been demonstrated to be effective in controlling symptoms of SAR and
PAR.44 Administration of high doses of allergens must be achieved to realize the full
efficacy of SCIT.45 A long-term placebo-controlled study conducted in patients with
grass pollen SAR demonstrated that 3 years of SCIT with a standardized grass pollen
allergen resulted in prolonged benefit for several years after discontinuation, suggest-
ing a disease-modifying effect.46 Although SCIT has been considered effective in the
treatment of PAR due to house dust mite, the published evidence supporting this indi-
cation is relatively weak.47 Benefits of SCIT must be weighed against the potential
risks of systemic reactions known to occur with approximately 0.1% of injections.48
Identifying and screening patients at high risk for fatal and near-fatal reactions, espe-
cially those with uncontrolled asthma, can significantly mitigate risk of severe systemic
allergic reactions.49,50 Allergen immunotherapy has many other benefits, including the
prevention or progression of allergic asthma and reduction of other comorbidities,
such as recurrent sinusitis.
Sublingual immunotherapy has been widely practiced in Europe for many years and
has only recently been approved for use in the United States for the treatment of
grass- and ragweed-induced SAR based on large placebo-controlled clinical tri-
als.51,52 Similar to SCIT, it too has a good safety profile. The most common side effect
associated with SLIT is local oral and pharyngeal itching and swelling reactions that
begin within days after initiation of therapy. In clinical trials, rare mild systemic reac-
tions were reported, but there were no cases of severe anaphylaxis related to treat-
ment. As with SCIT for grass pollen–induced SAR, a sustained therapeutic effect
was demonstrated for 2 years following discontinuation after 3 years of continuous
SLIT with grass tablets.53 One advantage of SLIT is that there is no required buildup
period and patients can self-administer the treatment at home after the first dose is
given under observation in the office. At least 12 weeks of preseasonal therapy fol-
lowed by coseasonal treatment with daily sublingual pollen tablets are required to
see optimal clinical benefit in reducing symptoms and rescue medication.54
266 Bernstein et al

Fig. 2. Immunologic changes during allergen immunotherapy showing time course of ef-
fects on effector cells (A) and changes in allergy specific IgE, IgG4 and skin test reactivity
(B). (From Burks AW, Calderon MA, Casale T, et al. Update on allergy immunotherapy: Amer-
ican Academy of Allergy, Asthma & Immunology/European Academy of Allergy and Clinical
Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2013;131(5):1290; with
permission.)

PHARMACOTHERAPY, MECHANISMS OF ACTION, AND DOSING

Allergen avoidance is a very important adjunctive therapy for AR but is often hard to
achieve. Nasal saline irrigation using a squeeze bottle or Neti Pot can be an important
component for removing excess secretions and crusting in the nasal passages while
also acting as a mild decongestant. If administered properly, it has minimal side ef-
fects. It is important to use boiled or distilled water to prepare the saline irrigation
 Allergic Rhinitis 267

solution.55 A recent meta-analysis of saline irrigation confirms it has a beneficial effect

in the management of AR.55
Pharmacotherapy with AHs was a milestone in pharmacology and immunology. The
Nobel Prize in Physiology and Medicine was awarded in 1957 to Daniel Bovet for the
discovery of AHs (anti-H1 receptor), and in 1988 to Sir James Black for the discovery
of anti-H2 receptor antagonists. Subsequently, additional H3 and H4 receptors were
identified, and although research investigating the pathobiology of these receptors is
ongoing, no specific receptor antagonists are currently available commercially in the
United States.56
The pharmacologic properties and dosing regimens for first and second generation
as well as INAH are summarized in Table 2.20 As discussed earlier, oral AHs are
considered first-line treatment recommendations for mild SAR and PAR.16,20,30
First-generation oral AHs should be used cautiously because of side effects such as
drowsiness but can be dosed relatively safely at bedtime and may be beneficial to
help some patients sleep and to dry up excessive postnasal drainage.16,20,56,57 INAHs
are also recommended for mild AR and can be used more effectively as needed
because of their relative quick onset of action (30 minutes). In general, oral AHs do
not induce tachyphylaxis or tolerance.16
INCS are key to the management of moderate to severe AR and have been shown to
be superior to either oral H1 AHs58 or leukotriene receptor antagonists.59,60 Character-
istics of INCS are summarized in Table 3. INCSs take at least 24 hours to demonstrate
a clinical effect and therefore are not as effective when used on an as-needed ba-
sis.20,61–63 Scheduled regular administration of INCS is therefore usually superior
and recommended.64,65
INAHs are often used to treat SAR and can be used as first-line treatment or in com-
bination with INCS for treatment of AR according to guidelines. A recent study found
that intranasal azelastine had comparable efficacy to intranasal fluticasone in the
treatment of moderate to severe SAR.32 The 2 available INAHs in the United States
are olopatadine and azelastine. Olopatidine is a selective H1 receptor antagonist,
whereas azelastine has multiple mechanisms of action, including H1 receptor antag-
onism, mast cells stabilization, and inhibition of leukotriene receptors.30,66,67 Intra-
nasal azelastine may also downregulate expression of adhesion molecules, regulate
chemotaxis, and enhance apoptosis of inflammatory cells.29,66–68
Intranasal cromolyn sodium is an over-the-counter topical mast cell stabilizing
agent that has been found to be effective in blocking release of allergic mediators
such as histamine from sensitized mast cells.69 Cromolyn sodium reduces both the
early- and the late-phase allergic response and has been approved for use in both
SAR and PAR.70 Cromolyn sodium nasal spray has minimal systemic absorption
and is very safe for chronic use without evidence of tachyphylaxis. The main disadvan-
tage of nasal cromolyn is its rather short duration of action, necessitating administra-
tion 4 to 6 times a day for ongoing treatment effect.16,71
Leukotrienes are newly formed mediators that have been found to be important me-
diators in allergic disease. Inhibition of leukotriene C4, D4, and E4 or 5-lipoxygenase
has been an important strategy for management of asthma and AR. However, the
leukotriene receptor antagonist montelukast is the only agent in this class approved
for the treatment of SAR and PAR. Studies have demonstrated similar efficacy of mon-
telukast to a second-generation oral AH, and there might be an additive effect in com-
bination with an AH.38,72–76 In patients with AR and asthma, montelukast could
potentially help treat both conditions if they are mild in severity because its effect
on asthma is relatively weak.76–79 Combination therapy with intranasal azelastine
and fluticasone (Dymista) has been shown to be more effective than either
 268
Bernstein et al
Table 2
First- and second-generation oral antihistamines and intranasal antihistamines properties, pharmacologic characteristics, and dosing

% Sedation/
Somnolence or
Skin Test Central Nervous
Trade Metabolites if Significant Suppression System
Name (T1/2 in Hours of Product or Tmax Hours Mean (Max) Impairment Age
Generic Drug Example Metabolite) (Metabolite) Days (Control) Dosage Forms Limit Adult Dose
Second generation
Acrivastined Semprex-D (1.4–3.1) 1.15 1.4 w3, T1/2 5 812 (6)PI 8 mg 12 y 8 mg qid
1.7 h
Azelastine Astelin Desmethylazelastine (22)PI 2.5 0.25a 2 11.5 (5.4)PI 137 mg/spray 5y 2 sp/nostril bid
hydrogen nasal
chloride
Cetirizined Zyrtec None (7–11) 1.0  0.5 3 14 (10)PI 5, 10 mg 5 mg/ 6 mo 5–10 mg qd
5 mL
Desloratadined Clarinex 3 Hydroxy desloratadine 3.17 (4.76) w7 (T1/2 5 2.1 (1.8)PI 5 mg 2.5 mg/5 mL 6 mo 5 mg qd
(7.8  4.2) 21–31 h)
Fexofenadined Allegra None (14.4–14.6) 2.6 2 1.3 (0.9)PI 30, 60, 180 mg 2y 180 mg qd or
30 mg/5 mL 60 mg bid
Levocetirizine Xyzal None (7  1.5) 0.9 1.25PI Unknown 6 (2)PI 5 mg 6y 5 mg qd
Loratadine d
Claritin Descarboethoxyloratadine 1.2  0.3 7 8 (6)PI 10 mg 5 mg/5 mL 2 y 10 mg qd
(7.8  4.2) (1.5  0.7)
Olopatadine Patanase No major metabolites 0.5–1.0PI Unknown 0.9 (03)PI 665 mg/spray 12 y 2 sp/nostril bid
hydrochloride nasal (8–12)PI
 First generation
Chlorpheniramined Chlor- Monodesmethyl and 2-6 2.8 3 (6) 45% 4, 8, 12 mg 2 mg/ 2 y 4 mg qid
Trimeton didesmethyl 5 mL
chlorpheniramine
(27.9  8.7)
Clemastined Tavist (21.3  11.6) 4.77  2.26 5 (10) 14 (1.5) 1.34, 2.68 mg 6y 1.34 mg bid to
.67 mg/5 mL tid
Cyproheptadine Periactin (16) 4 9 (11) 8-50 4 mg 2 mg/5 mL 2y 4 mg tid
Diphenhydramine Benadryl Nordiphenhydramine 2.6 1.7  1.0 2 (5) 50% 25, 50 2y 25–50 mg qid
(9.2  2.5) 12.5 mg/mL
Hydroxyzine Atarax (20  4.1) 2.1  0.4 5 (8) 80% 10, 25, 50, All ages 25 mg qid
100 mg 10 mg/
5 mL
Promethazine Phenergan Promethazine sulfoxide 4.4 3 (5) 60-73 12.5, 25, 50 mg 2y 25 mg qid
& N- 6.25 mg/5 mL
desmethylpromethazine
(9–16)PI
Triprolidine Actifed (3.2)PI 2.0 3 (7) 10% to 25% — — —

Abbreviations: bid, 2 times a day; d, available with decongestant; PI, package insert; qd, every day; qid, 4 times a day; T1/2, half-life; tid, 3 times a day.
a
Onset of action, not Tmax.
From Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol 2008;122:S20;
with permission.

Allergic Rhinitis
269
 270
Bernstein et al
Table 3
Intranasal corticosteroids: dosing and characteristics

Pregnancy/
Spray Trade Nursing Alcohol BKC
Name Generic Drug Type mg/Spray Adult Dose Usual Child Dose Age Limit (y) Risk Category Propylene Glycol
Beconase AQ Beclometasone, Pump 200 spray 42 1–2 spray nos bid 1–2 sp/nos bid 6 C Alcohol BKC
monohydrate
Flonase Fluticasone Pump 120 spray 50 2 spray nos qd 1–2 sp/nos qd 4 C Alcohol BKC
propionate
Nasarel Flunisolide Pump 200 spray 25 2 spray nos bid to 2 sp/nos bid 6 C BKC, propylene
tid glycol
Nasacort AQ Triamcinolone Pump 120 spray 55 1–2 spray nos qd 1–2 sp/nos qd 6 C No alcohol BKC
Nasonex Mometasone Pump 120 spray 50 2 spray nos qd 1 sp/nos qd 2 C No alcohol BKC
Rhinocort AQ Budesonide Pump 120 spray 32 1–4 spray/nos qd 1–2 sp/nos qd 6 C No alcohol, no
BKC
Veramyst Fluticasone Pump 120 spray 50 2 spray/nos qd 1 sp/nos qd 2 C No alcohol BKC
funoate
Omnaris Ciclesonide Pump 120 spray 50 2 spray/nos qd NA 12 C No alcohol, no
BKC

Abbreviations: bid, 2 times a day; BKC, benzalkonium chloride; NA, not applicable; nos, Nostril; qd, every day; tid, 3 times a day.
From Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol
2008;122:S21; with permission.
 Allergic Rhinitis 271

monotherapy alone.31 This treatment is approved for the management of SAR but is
also clinically effective for PAR.31 For many patients using Dymista, the ability to
use a single spray with the INCS and INAH without having to wait in between the 2
nasal sprays is of significant convenience and prevents potential loss of medication
if using the individual nose sprays separately.
Intranasal ipratropium bromide 0.03% is approved for treatment of rhinorrhea asso-
ciated with perennial or SAR or non-AR and the higher concentration 0.06% is
approved for rhinorrhea associated with the common cold. This medication is not
effective for treatment of nasal congestion or other AR symptoms, such as nasal itch-
ing, sneezing, or nasal obstruction.16,20,30,80,81 Intranasal ipratropium does not pro-
duce tolerance and therefore can be used on a daily basis.16,30
Although the chronic use of nasal decongestant spray is not currently recommen-
ded, recent studies indicate that they can be used in conjunction with INCS safely
for some adult and adolescent patients not sufficiently responding to INCS alone. Spe-
cifically, oxymetazoline nasal spray has recently been shown to be effective and safe
when used for an extended time period in conjunction with an INCS to treat recalci-
trant nasal congestion in SAR patients.82 Tachyphylaxis or rhinitis medicamentosa
associated with daily use of an intranasal decongestant can be prevented when
used with an INCS spray, which presumably prevents downregulation of the a-1 re-
ceptors.82–85 It has also been demonstrated that INCSs are effective for treating
rhinitis medicamentosa when intranasal decongestants are used inappropriately.84,85

MEDICATION ADMINISTRATION CAVEATS

It is essential to teach patients to administer nasal sprays away from the midline
septum in order to prevent septal bleeding and ulceration. Proper administration will
also help maximize the efficacy of nasal sprays by optimizing medication delivery
and is especially important for INCSs, which have a greater incidence of nasal septal
damage than INAH.86 Oxymetazoline nasal spray cannot be used more than 3 to
5 days without an INCS because of rhinitis medicamentosa risk.85 SCIT should not
be administered to a patient with uncontrolled asthma or during an acute upper res-
piratory infection.49,50,87 Management of local or systemic AIT reactions should
include dose or concentration reduction depending on the severity of the reaction.45

MEDICATION SAFETY AND SIDE EFFECTS

Oral AHs, especially first-generation oral AHs, can interact with other medications
and/or alcohol, causing sedation. In general, sedation is much less of a problem for
second- and third-generation AHs compared with first-generation AHs. Among the
second- or third-generation AHs, cetirizine is both more efficacious and also more
likely to cause sedation.88 All of the second- and third-generation H1 antagonists
are pregnancy category B except fofexofenadine. Over-the-counter cromolyn sodium
nasal spray is very safe and is pregnancy category B but requires administration every
4 to 6 hours because of its relatively short half-life and its decreased efficacy
compared with INCS and INAH, making it less practical for use in patients with mod-
erate to severe AR.16,71 INCS sprays are very safe to use long term but are all preg-
nancy category C except budesonide nasal spray. However, long-term clinical
experience indicates that INCSs are safe to use during pregnancy. INCS and to a
lesser extent INAH sprays can cause nasal dryness, epistaxis, and in some cases,
nasal septal ulceration and perforation. Debate is ongoing whether patients taking
INCSs long term are at risk for glaucoma; however, a recent study investigating the
effect of intranasal beclomethasone had no effect after 6 weeks of continuous
272 Bernstein et al

treatment on increasing intraocular pressure.89 Overall, INCS sprays have an excellent

safety track record in both adults and children at the recommended doses.58,60,90
Intranasal ipratropium may cause excessive nasal dryness but is otherwise very
safe and is pregnancy category B.16,20,80 The INAH sprays are generally very safe to
use but are designated as pregnancy category C. Intranasal azelastine in the original
phase 3 pivotal trials was associated with increased sedation, which has resulted in
this warning in the package insert. However, all subsequent azelastine studies have
not been associated with sedation compared with placebo.16,20,30,67,91
Recent meta-analyses found significant overuse of anticholinergic agents in cogni-
tively impaired individuals, preventing them from attending memory clinic.92,93 Many
of these medications were AHs.93 Therefore, special care should be taken when pre-
scribing sedating AHs to elderly patients, especially if they are at risk for being cogni-
tively impaired.94,95

FUTURE TREATMENT DIRECTIONS

Previously, H3 and H4 receptors have been well characterized, and work is ongoing to
develop an effective H3 antagonist.29,66 Recent studies seem to indicate that probiot-
ics may have a beneficial effect in the management of AR, but research is ongoing.96,97
Other therapeutic modalities currently under investigation for treatment of AR are
summarized in Fig. 3.43 Other therapeutic modalities include intralymphatic injection
of aqueous allergens, percutaneous administration of aqueous allergens using patch
application devices, intradermal injection of allergen-specific T-cell epitopes, and

Fig. 3. Novel therapies for AIT. TLR-9, toll-like receptor-9. (From Burks AW, Calderon MA,
Casale T, et al. Update on allergy immunotherapy: American Academy of Allergy, Asthma
& Immunology/European Academy of Allergy and Clinical Immunology/PRACTALL
Consensus Report. J Allergy Clin Immunol 2013;131(5):1297; with permission.)
 Allergic Rhinitis 273

development of tyrosine-absorbed polymerized allergens combined with lipid adju-

vants among others.43,97

SUMMARY

Treatment of AR involves a comprehensive approach, including environmental control

measures, pharmacotherapy, and if indicated, allergen immunotherapy. Treatment
regimens should be tailored to the severity and duration of the patient’s symptoms,
taking into account their tolerance of medications, costs, and personal preferences.
AR is very responsive to the spectrum of medications approved to treat this condition.
When patients are not responsive to treatment, it is important to confirm that they do
not have a component of non-AR, are not being adherent to medications, are not
chronically exposed to allergens at home or in the workplace, or have no subclinical
complications such as chronic sinusitis that is interfering with treatment responsive-
ness. Proper therapy can significantly improve patient quality of life and significantly
impact short- and long-term clinical outcomes.13,18

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