Guidelines Updated for Diagnosis and Treatment of Rhinitis

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

August 18, 2008 —The Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology have issued updated guidelines for the diagnosis, management, and treatment of rhinitis. The updated recommendations are published in the August issue of the Journal of Allergy and Clinical Immunology.

"Rhinitis is characterized by 1 or more of the following symptoms: nasal congestion, rhinorrhea (anterior and posterior), sneezing, and itching," write Dana V. Wallace, MD, from Nova Southeastern University in Davie, Florida, and colleagues from the Joint Task Force on Practice Parameters. "Rhinitis is usually associated with inflammation, but some forms of rhinitis such as vasomotor rhinitis or atrophic rhinitis are not predominantly inflammatory. Rhinitis frequently is accompanied by symptoms involving the eyes, ears, and throat."

Key updates included in these guidelines are as follows:

• Pharmacologic products that have become available since publication of the previous 1998 guidelines on diagnosis and management of rhinitis are reviewed.
• On the basis of more recent evidence, positioning of agents used in management, such as leukotriene receptor antagonists (LTRA), is better defined.
• The term episodic is introduced referring to rhinitis brought about by sporadic exposures to inhalant aeroallergens, and implications for treatment of episodic rhinitis are discussed.
• Certain agents, namely intranasal corticosteroids (INS), are recommended for use on an as-needed basis.
• The importance of recognizing comorbidities of allergic rhinitis (AR) is emphasized. These include asthma, sinusitis, and obstructive sleep apnea. Also highlighted is the importance of conducting appropriate studies, such as pulmonary function testing and sleep apnea studies.
• Evidence regarding use of combination therapy is reviewed, particularly the use of LTRA with antihistamines.
• The updated guidelines highlight the need to consider the benefits vs recently raised safety concerns regarding oral decongestants before using them in children younger than 6 years of age.
• It is now recommended that second-generation antihistamines be considered as safe agents for use during pregnancy.
• INS may be used for symptoms of allergic conjunctivitis associated with rhinitis.
• Use of a Rhinitis Action Plan should be considered.
• Recently available and emerging diagnostic and surgical procedures, including acoustic rhinometry and radiofrequency volumetric tissue reduction, are reviewed.

The main pharmacotherapeutic options for AR are as follows:

• When used continuously, oral antihistamines, or oral H1-receptor antagonists, are most effective for seasonal AR and perennial AR, but their relatively rapid onset of action also makes them appropriate for as-needed use in episodic AR.
• Oral antihistamines are less effective for nasal congestion vs other nasal symptoms, and other options are generally preferred for more severe AR. For AR, oral antihistamines are less effective for AR vs INS, but they are similarly effective to INS for associated ocular symptoms.
• Oral antihistamines are typically ineffective for non-AR, resulting in other choices being better for mixed rhinitis.
• Second-generation oral antihistamines are usually preferred over first-generation antihistamines to minimize sedation, performance impairment, and anticholinergic effects. At recommended doses, the second-generation oral antihistamines fexofenadine, loratadine, and desloratadine do not cause sedation.
• Oral corticosteroids may be appropriate for very severe nasal symptoms when given as a short course (5 - 7 days) and are preferred to single or repeated administration of intramuscular corticosteroids, which should be discouraged.
• Oral decongestants include pseudoephedrine, which reduces nasal congestion, although adverse effects include insomnia, irritability, palpitations, and hypertension.
• Of the LTRA, montelukast is approved for seasonal AR and perennial AR, and adverse effects are minimal. However, with loratadine as the usual comparator, LTRA have not been shown to have significantly different efficacy from oral antihistamines. Because LTRA are approved for both rhinitis and asthma, they may be considered in patients who have both conditions.
• Intranasal antihistamines are effective for both seasonal AR and perennial AR. Their clinically significant, rapid onset of action also makes them suitable for as-needed use in episodic AR. Although their efficacy for AR is as good as or better than oral second-generation antihistamines, with a clinically significant effect on nasal congestion, they are not as effective as INS for nasal symptoms. Because they are also approved for vasomotor rhinitis, they are a suitable option for patients with mixed rhinitis. The adverse effects of intranasal azelastine are a bitter taste and somnolence.
• Intranasal anticholinergic (ipratropium) has a rapid onset of action and is therefore appropriate for episodic rhinitis. Although it reduces rhinorrhea, it is ineffective for other symptoms of seasonal AR and perennial AR. There may be dryness of nasal membranes, but adverse effects are otherwise minimal.
• INS are the most effective monotherapy for seasonal AR and perennial AR because of their efficacy for all symptoms of seasonal AR and perennial AR, including nasal congestion. As-needed use of INS may be effective for seasonal AR and may also be considered in patients with episodic AR. The typical onset of action is within 12 hours, which is less rapid than with oral or intranasal antihistamines, but symptom relief may begin within 3 to 4 hours in some patients.
• For seasonal AR and perennial AR, INS are more effective than combination therapy with oral antihistamine and LTRA. For associated ocular symptoms of AR, efficacy of INS is similar to that of oral antihistamines. INS are also a suitable option for mixed rhinitis, because agents in this class are also effective for some non-AR. INS do not have significant systemic adverse effects in adults, and when used at recommended doses, they have not been shown to cause growth suppression in children with perennial AR. Local adverse effects are minimal, but nasal irritation and bleeding occur, and nasal septal perforation has rarely been reported.
• Intranasal cromolyn may be useful for maintenance treatment of AR. The onset of action is within 4 to 7 days, but the full benefit may not be evident for weeks. Administration just before allergen exposure for episodic rhinitis protects against the allergic response for 4 to 8 hours. Intranasal cromolyn is not as effective as INS, and data are insufficient to compare INS with LTRA and antihistamines.

"Initial treatment of nonsevere rhinitis may include single-agent or combination pharmacologic therapy and avoidance measures," the guidelines authors conclude. "Oral antihistamines are generally effective in reducing rhinorrhea, sneezing, and itching associated with allergic rhinitis but have little objective effect on nasal congestion."

J Allergy Clin Immunol. 2008;122:S1-S84.