- An inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens.
- Mediated by immunoglobulin E (IgE). Exposure to allergens results in the release of histamine and other inflammatory agents from mast cells.
- Rhinitis is found in up to 40 % of population. Lifetime prevalence of allergic rhinitis in adult population is 20 to 30 %. Some studies suggest the incidence is increasing.
- Often associated with asthma and atopic dermatitis.
- Initial presentation of AR or exacerbation of pre-existing AR symptoms occurs commonly in pregnancy.
- Children of school age and adolescents most commonly affected by intermittent (seasonal) AR.
- Adults more likely to have persistent (perennial) AR.
- Common allergens: Seasonal - pollens, molds; Perennial: house dust mite, pets.
- Can significantly impair quality of life. Symptoms can interfere with work and school performance, cause absenteeism and even traffic accidents.
- Classification based on the following:
- Impairment of daily activities, sport, leisure
- Impairment of work and school
- Troublesome symptoms
- Frequency/Duration of symptoms
- Severity / Effect
- Early phase:
- Rhinorrhea - discharge usually clear and watery
- Itchiness - eyes and throat
- Minor congestion
- Late phase:
- Major congestion
- Early phase symptoms
AR is diagnosed based on the presence of typical symptoms (listed above). Rule out the following conditions that may present with similar signs/symptoms:
- Rapid onset (within hours)
- Anaphylaxis - symptoms associated with difficulty breathing, difficulty swallowing, swelling of face, mouth or throat.
- Ensure patient receives medical attention immediately.
Infective rhinitis: colds, influenza, sinusitis
- Rapid onset, short duration
- Sudden onset, duration 1 week or less, associated with upper respiratory tract infection symptoms such as fever, purulent nasal discharge, swollen glands which are not typical of AR. Other distinguishing features of AR are itchiness (throat, eyes) and persistent symptoms.
- Recommend appropriate nonpharmacological, and/or over-the-counter treatment.
Irritant (non-allergic, vasomotor) rhinitis:
- Symptoms follow a known physical or chemical irritant - change in temperature, humidity; exercise; exposure to chemicals, odours. Patient history is important in differentiating irritant and allergic rhinitis because symptoms are similar.
- Identify irritant and avoid when possible.
- AR symptoms following start of treatment with drugs such as angiotensin-converting enzyme inhibitors, methyldopa, alpha-blockers, beta-blockers, chlorpromazine, nonsteroidal anti-inflammatory drugs (including ASA).
- Rebound symptoms after discontinuing use of nasal decongestants (for longer than 3 - 5 days).
- Can medication be changed /discontinued?
- AR symptoms coinciding with pregnancy, starting oral contraceptives or thyroid dysfunction (hypo- or hyper-).
Structural or mechanical factors:
- Deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy.
- Foreign bodies and nasal tumours (rare) suggested by unilateral symptoms (only one nostril involved).
- Primary defects in mucus (e.g. cystic fibrosis), primary ciliary dyskinesia (Kartagener's syndrome), and granulomatous disease (e.g. Wegener's granulomatosis, sarcoidosis).
Patients with typical symptoms of AR often do not require further investigation, however an assessment by a proper health care practitioner should be recommended in the following situations:
- Children with moderate to severe symptoms – immunotherapy may alter progression of allergies, and may prevent subsequent asthma.
- Persistent moderate to severe symptoms.
- Patient is interested in allergy testing and/or immunotherapy.
- Pregnancy (since the symptoms could be due to hormonal rhinitis, rather than allergic rhinitis)
- Co-morbidities - asthma, recurrent or chronic sinusitis, otitis media.
- Shortness of breath, wheezing (uncontrolled asthma).
- Symptoms primarily unilateral nasal symptoms (polyps, foreign body, structural problem, etc.).
- Suspected adverse effect of a prescription medication.
- Pain in eyes (infection, iritis, etc.).
- Persistent headache, facial pain (sinusitis, etc.).
- Patient education regarding allergen and irritant avoidance:
- Central air conditioning
- Removing dusty furniture
- Hypo-allergenic mattress cover
- Saline rinses
- Small benefit in AR
- Adherence difficult
- Nasal gels
- Small benefit in AR
- Reduces irritation
Over-The-Counter Drug Options
- First line therapy for mild, intermittent AR.
- Effective in reducing symptoms of itching, sneezing, and rhinorrhea.
- First generation and older second generation antihistamines have little effect on nasal congestion. Fexofenadine and desloratadine have some decongestant activity.
- May also reduce symptoms of allergic conjunctivitis associated with AR.
- Little or no benefit in other forms of rhinitis (e.g., vasomotor, infectious).
- Effective on an as needed basis, but work best to control AR symptoms when taken regularly.
- When exposure to an allergen is anticipated, antihistamines can be administered as prophylaxis 2 - 5 hours prior to exposure.
- Oral and nasal decongestants are effective in reducing AR-induced nasal congestion.
- Can be used in combination with antihistamine and intranasal corticosteroids.
- Long-term use may be required in AR so intranasal decongestants are generally not recommended. If used, limit duration to 3 - 7 days to prevent rebound congestion.
- Avoid use in children under 6.
- Sodium cromoglycate - less effective than nasal corticosteroids; 4 - 7 days to onset of activity; full benefit several weeks.
- Triamcinolone acetate (Nasacort®) is available. Two sprays in each nostril once daily for adults; 4-11 years old use 1 spray in each nostril once daily.
- Fluticasone Proprionate 50mcg / dose is now available is an OTC preparation. Two sprays, each nostril, once daily. Can use one spray in each nostril once daily once symptoms controlled.
Prescription Drug Options
Intranasal corticosteroids (INCS) (Table 1)
- Note: Fluticasone is now available OTC, and is not eligible for billing the assessment fee.
- Drugs of choice for moderate to severe intermittent symptoms or mild persistent rhinitis.[Grade A recommendation (consistent high-quality evidence)].
- Control the four major symptoms of AR - sneezing, itching, rhinorrhea and nasal blockage - may also improve ocular symptoms.
- Superior to oral and intranasal antihistamines, antileukotrienes and cromolyn in relieving AR symptoms.
- A combination of antihistamine and INCS is needed in 50 % of patients to adequately control symptoms.
- Available prescription products: beclomethasone, budesonide, ciclesonide, fluticasone furoate, fluticasone propionate, mometasone. (See Table 1 below).
- No evidence that any one agent is more effective than the other.
- Considerations in choice of product:
- aqueous solution provides better intranasal deposition than dry powder
- patient preference for scented (formulations containing phenylethyl alcohol) versus non-scented products
- newer products (ciclesonide, mometasone) have a smaller spray volume
- convenience of once daily dosing versus multiple daily doses
- pediatric dosing limits vary, see table 1
- An unobstructed airway is necessary for optimal effect. Use of a intranasal decongestant spray prior to the intranasal corticosteroid for first 2 – 3 days of therapy may be recommended to improve deposition of the corticosteroid.
- Prescribe maximum dose to start, then taper dose at intervals of one week to the lowest effect dose. Some patients can be adequately controlled with one dose every other day or as needed dosing.
- Can be dosed as-needed in seasonal AR but regular use is likely to provide better symptom relief.
- Well tolerated: some nasal irritation or nose bleeds possible if spraying on septum. Minor headache in some.
- For adults, once daily dosing in the evening is suggested since inflammation is usually more severe at night.
- Pregnancy: Refer pregnant patients to their primary care provider. Note that INCS are not effective for hormonal rhinitis in pregnancy (nasal congestion without any signs of upper respiratory infection or known allergic cause). If the patient has previously diagnosed allergic rhinitis, treatment with antihistamines and/or intranasal corticosteroids is considered safe.
- Lactation: Use of nasal corticosteroids while breastfeeding is considered acceptable.
- Children: Mometasone or fluticasone recommended because systemic absorption is minimal and there is no evidence of growth suppression with long-term use. Once daily dosing in the morning is preferred as this appears to reduce risk of growth suppression.
Other prescription drug options for AR (primary care provider prescription required)
- Intranasal ipratropium - decreases rhinorrhea but little effect on congestion - may be useful for vasomotor rhinitis
- Leukotriene receptor antagonists - montelukast has modest effect, approved for AR when other agents are ineffective or not tolerated
- Intranasal and ocular antihistamines
- Short course of prednisone for severe symptoms
TABLE 1: Intranasal Corticosteroids
2 sprays in each nostril BID Max: 12 sprays/day
> 6 yrs: 2 sprays in each nostril
Max: 8 sprays/day
Susp: 2 sprays in each nostril daily or 1 spray in each nostril BID
Pwdr: 2 applications in each nostril AM or 1 application in each nostril BID
Max: 400 ug/day
> 6 yrs: As per adults
2 sprays in each nostril daily Max: 200 ug/day
> 12 yrs: As per adults
2 sprays in each nostril daily Max 400 ug/day
> 12 yrs: As per adults
4 - 11 yrs: 1-2 sprays in each nostril daily. Max 200 ug/day
2 sprays each nostril daily Max: 110 ug/day
> 12 yrs: As per adults
2 – 11 yrs: a spray in each nostril daily. Max: 110 ug/day
2 sprays in each nostril daily Max: 800 ug/day
> 12 yrs: As per adults
3 – 11 yrs: 1 spray in each
Max 100 ug/day
Formulation contains phenylethyl alcohol which has a floral scent; ** Available with or without phenylethyl alcohol
* Now available as an OTC product. Private insurance may not cover, and you cannot bill the assessment fee if choosing fluticasone.
Provide verbal and printed instructions on use of INCS:
- Use of saline spray to clean nose prior to corticosteroid if the nose is crusted or contains mucus.
- Spray should be directed away from the nasal septum.
- Small sniff after spray to pull it into the higher parts of the nose. Avoid a strong sniff as this will draw medication down into the throat.
- Holding the other nostril closed with a finger may improve ability to draw the spray into the upper nose.
- Spit out medicine that drains into the throat.
Assess benefit after 1 - 2 weeks
- Symptomatic relief within 1 - 2 days; may take up to 2 weeks for maximum benefit. (For INCS)
- If not effective, assess compliance and administration technique.
- If being used appropriately but not effective, refer to appropriate healthcare practitioner for further evaluation of condition.
- If partially effective, consider adding antihistamine; reassess in 1 -2 weeks.
- If symptoms are controlled, consider tapering to maintenance dose. If the patient requires year-round therapy, refer to their primary care provider.
Assess for adverse effects
- Drowsiness (if using an antihistamine): Instruct patient to take at bedtime, or switch to less sedating agent, or switch to an INCS.
- Frequent nose bleeds: ensure patient is directing spray away from septum.
- Persistent nasal irritation: Switch to a different INCS, or add a moisturizing nasal gel or spray.
- Change in vision - refer to appropriate healthcare practitioner (glaucoma, cataracts).
50ug/dose AQUEOUS NASAL SPRAY
64ug/dose NASAL SPRAY
100ug/dose NASAL SPRAY
100ug/dose POWDER FOR INHALATION
50ug/dose METERED DOSE NASAL SPRAY
27.5ug/dose NASAL SPRAY
Mometasone Furoate Monohydrate
|50ug/dose AQUEOUS NASAL SPRAY|
*Not a listed benefit of the Saskatchewan Drug Plan
- pseudoDIN: 00951090
- May bill 4 claims per 365 days per patient
- May bill 4 claims per 365 days per patient
- May prescribe sufficient quantity for patient's allergy season (but only one assessment fee applicable).
- Ensure patient is having adequate response before giving refills
- If the patient requires year-round therapy, must refer to their primary care provider
- Only products with an official indication from Health Canada for allergic rhinitis and/or recommended by reputable and reliable guidelines are considered for these guidelines. Only the active ingredients in the "products" section are approved for pharmacist prescribing
- Fluticasone propionate has been removed from the list, since it is now available OTC. If you choose this product for a patient, you cannot bill an assessment fee
- Fluticasone furoate is not a listed benefit of the Saskatchewan Drug Plan
- Keith P. Allergic Rhinitis. In RxTx - CTC online. Available at www.e-therapeutics.ca (by subscription).
- Kendrick J. Allergic Rhinitis. In RxTx - CTMA. Available at www.e-therapeutics.ca (by subscription).
- Sheikh J. Allergic Rhinitis. In Emedicine. Available at http://emedicine.medscape.com/article/134825-overview (free access).
- C-Health. Allergic Rhinitis Fact Sheet. Available at www.chealth.canoe.com (free access).
- Intranasal corticosteroids chart. RxFiles Charts. Available at www.rxfiles.ca .
- Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1-43. Available at http://www.ncbi.nlm.nih.gov/pubmed/25644617.
- The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clinic Immunol 2008;122:S1-84 (American guidelines). Available at www.aaaai.org (free access).
- deShazo R, Kemp S. Pharmacotherapy of allergic rhinitis. In UpToDate online. Available at www.uptodate.com (by subscription).
- Allergic rhinitis. In Dynamed online. Available at www.dynamed.com (by subscription).
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Reviewed by Dr. L. Sandomirsky, Family Physician and Dr. J. Taylor, Professor, College of Pharmacy and Nutrition,
Funded by the Saskatchewan College of Pharmacy Professionals
Posted May 2010, Updated May 2017