Allergic rhinitis, or hay fever, is a common condition affecting 10-25% of the global population. It is an inflammation of the nasal passages caused by an immune system response to allergens like pollen, dust mites, or pet dander. Symptoms include sneezing, nasal congestion, runny nose, and itchy eyes. Allergic rhinitis can impair quality of life and work or school performance. Intranasal corticosteroids are the most effective treatment for both intermittent and persistent allergic rhinitis. The ARIA guidelines recommend intranasal corticosteroids as first-line treatment alone or in combination with oral antihistamines depending on the severity

1. Treatment of Allergic Rhinitis :
“Another day, another spray”
Dr. (Mrs.) Kripa Jacob
Jr. Specialist - ENT
Shifa Al Jazeera Polyclinic
Al Khuwair

2. Allergic rhinitis-Definition
• Allergic rhinitis (AR) is defined clinically
by nasal hypersensitivity symptoms induced
by an immunologically mediated (most
often IgE-dependent) inflammation after the
exposure of the nasal mucous membranes to
an offending allergen. - Brozek J et al. Allergic Rhinitis and its
Impact on Asthma (ARIA) Guidelines – 2016 Revision

3. Allergic Rhinitis Represents a
Major Global Health Problem
•Prevalence
– 10% to 25% of the global population is affected
– Allergic rhinitis affects 40 million Americans annually
• 10% to 30% of adults
• Up to 40% of children
•Impact
– Impacts on quality of life, work/school performance and
productivity
•Economic burden
– Substantial costs of treatment
– Estimated cost of allergic rhinitis
• $6.3 billion (2000)

4. Impact of allergic rhinitis on
patients’ daily life
1. Scadding G et al. EAACI 2007, Abstract 1408. 2. Reilly MC et al. Clin Drug Invest 1996;11:278–88. 3. Tanner LA et al. Am J Manag Care 1999;5(Suppl
4):S235–S247. 4. Blanc PD et al. J Clin Epidemiol 2001;54:610–18. 5. Juniper EF et al. J Allergy Clin Immunol 1994;93:413–23. 6. Marshall PS, Colon EA.
SLEEP AND TIREDNESS
• 46% of patients feel tired1
• 77% of patients have trouble falling asleep1
Work and school productivity
• ≤90% effectiveness at work4
• ≤93% impaired classroom
performance3,5 Social/emotional
-Dysphoric mood changes
Impact of
allergic
rhinitis
Daily activities impaired Learning and cognitive
Functions disturbed6
AR- asthma relationship
-at least 60% asthmatics have AR
Increased Incidence of sleep
apnea
STUCK et al. J Allergy Clin Immunol, 2004.
Dental malocclusion
-high arched palate

7. Allergic Rhinitis: “another look at the
guidelines”

9. Symptoms of rhinitis
• Rhinorrhea, nasal obstruction or blockage,
nasal itching, sneezing, and postnasal drip
that are reversible spontaneously or with
treatment.
• Allergic rhino-conjunctivitis often
accompanies AR viz. itching and redness of
the eyes and tearing.
• Other symptoms include itching of the
palate, postnasal drip and cough. AR is also
frequently associated with asthma
AR. Brozek J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines
– 2016 Revision

10. In other words:
Eyes

11. Typical nasal exam findings
of allergic rhinitis with clear nasal
drainage and swollen inferior turbinate.
Pediatric patient with
allergic rhinitis
demonstrating “allergic
shiners” and mouth
breathing
The Allergic Salute
"Nasal crease" is a
horizontal crease across the
lower half of the bridge of
the nose that is caused by
repeated upward rubbing of
the tip of the nose by the
palm of the hand (i.e., the
"allergic salute").

13. Multi-sectoral care pathway for allergic
rhinitis (from Bousquet et al)

14. “MASK-rhinitis and asthma”
• “MASK-rhinitis and asthma” is a simple ICT tool
used to implement ICPs for AR and asthma by
means of a common language (for patients and
HCPs)and a CDSS (Clinical decision support
system)
• Disease control is assessed by VAS,
incorporated into apps for patients (ARIA Allergy
Diary) and HCPs (ARIA Allergy Diary
Companion), with the utility to assess patient
QoL and school/work productivity

15. Baseline questionnaire
Q1: I have rhinitis: yes/no
Q2: I have asthma: yes/no
Q3: My symptoms (tick)
Runny nose
Itchy nose
Sneezing
Congestion (blocked nose)
Red eyes
Itchy eyes
Watery eyes
Q4: How they affect me: my symptoms (tick)
Affect my sleep
Restrict my daily activities
Restrict my participation in school or work
Are troublesome
Q5: Medications
Q6: Are you currently receiving immunotherapy (a small
dose of the thing you are allergic to, usually taken as an
injection or placed under your tongue)? yes/no
If YES to Q6 (Q7 and Q8)
Q7: What allergy is this?
Grass pollen
Parietaria pollen
Birch pollen
Other pollen
Dust mite
Animal
Cypress tree pollen
Don’t know
Add allergy
Q8: How do you receive your treatment?
Injection
Tablet under the tongue
Drops under the tongue
Spray under the tongue
Other

16. Surgery
Nasal douching
Patient education
Bousquet J, et al for the Allergic
Rhinitis and its Impact on Asthma
(ARIA) Workshop Group. Allergic
rhinitis and its impact on asthma.
ARIA workshop report. J Allergy
Clin Immunol 2001
Nov;108(5):S147-S333

17. SELF-CARE
 It's not possible to completely avoid
allergens, but can reduce the signs and
symptoms by minimizing the exposure to
them.

18. To reduce exposure to pollen
or molds:
• Close doors and windows during pollen season
• Use air conditioning in the house and car
• Stay indoors on dry, windy days
• Use a dehumidifier to reduce indoor humidity
• Use a high-efficiency particulate air (HEPA) filter
in the bedroom
• Avoid mowing the lawn or raking leaves, which
stirs up pollen and molds

19. To reduce exposure to dust mites:
 Use allergy-proof covers on mattresses,
box springs and pillows
 Wash sheets and blankets in water heated
to at least 130 0 F
 Use a dehumidifier to reduce indoor
humidity
 Vacuum carpets weekly with a vacuum
cleaner equipped with a small-particle or
HEPA filter
 Consider removing carpeting, especially at
sleep places, if highly sensitive to dust mites

20. To reduce exposure to cockroaches:
 Block cracks and crevices where roaches
can enter
 Fix leaky faucets and pipes
 Wash dishes and empty garbage daily
 Sweep food crumbs from counters and
floors
 Store food, including pet food, in sealed
containers
 Consider professional pest extermination

21. To reduce exposure to pet dander:
 Remove pets from the house
 Bathe pets weekly
 Keep the pet out of the bedroom

22. Allergic Rhinitis:
Pharmacotherapy
• Drug therapy
– Antihistamines / Relievers: Nasal sprays
(Superior) / Oral
– Steroids / Preventers: Nasal (Superior) / Oral /
Drops
– Other preparations (Na Cromoglycate or
Chromone,
Ipratropium, Decongestants, LTRA or Montelukast)

25. ARIA guidelines for the treatment of
allergic rhinitis
• “Intranasal glucocorticosteroids are the
most effective agents available for the
treatment of allergic and non-allergic
rhinitis.”
• “If nasal congestion is present or symptoms
are frequent, an intranasal
glucocorticosteroid is the most appropriate
first-line treatment as it is more effective
than any other treatment.”
ARIA update, in collaboration with GA²LEN
Allergy 2007, Vol 62 Supplement s84, pp. 1–41

26. They work, but…
What about side effects, doc?
Won’t they damage the nose?
Won’t they stunt my
(or my child’s) growth?

27. Growth in children using nasal
CS
• Earlier concerns allayed
• 1 yr study using BDP 200ug bid (lg dose)
• Skoner et al, Pediatrics, 2000
• Mometasone 100ug od (1 spray od): 1 year
study in children: no difference in growth
• Schenkel et al, Pediatrics, 2000
• 1 year fluticasone study: again, no growth
difference
• Allen, et al, Allergy and Asthma Proc, Dec, 2002
• no adverse effects on growth or skeletal
formation have been reported for children
using intranasal budesonide for up to 2 years.
Moller C, et al. Clin Exp Allergy. 2003
• Long-term asthma studies (CAMP &
Pederson, 2000)

28. ARIA RECOMMENDATIONS
• Topical corticosteroids and oral
antihistamines (non-sedating) form the
mainstay of treatment
• The newer topical steroids e.g.
Mometasone furoate and Fluticasone
propionate were highest recommended
• Other drugs should only be considered
as second-line treatment
• Immunotherapy in selected patients can
be highly effective.

31. Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines
Management of Intermittent AR
Avoid Allergens
Mild Intermittent AR Moderate-Severe Intermittent AR
Nasal H1 blocker / Spray
Oral H1 blocker
Decongestants
LTRA
Nasal H1 blocker / Spray
Oral H1 blocker
Decongestants/LTRA/Chromone
FLUTICASONE - 2
sprays/nostril OD
LTRA= Leukotriene Receptor Antagonists

32. Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines
Management of Persistent AR
Avoid Allergens
Nasal H1 blocker
Oral H1 blocker / LTRA
Decongestants / Chromone
Intranasal CS / MOMETASONE/
/FLUTICASONE
Review patients after 2-4 weeks
Step up if no improvement Continue: 1 month if improvement

33. Treatment of Allergic Rhinitis
Class I
Mild /
intermittent
Class II
Moderate-severe /
intermittent
Mild / persistent
Class
III
Moderate /
persistent
Class IV
Moderate – severe
/ persistent
Surgery
Immunotherapy
Oral steroids
LTRAs
Intranasal corticosteroids
Oral H1 antihistamines
Allergen / irritant avoidance
Small et al. J Otolaryngol. 2007

35. • The 2016 Allergic Rhinitis and its Impact
on Asthma (ARIA) guidelines provide a
targeted update and new recommendations
about the pharmacological treatment of
allergic rhinitis (AR)

36. Update and new recommendations
• For patients with seasonal AR, either a combination of an intranasal
corticosteroid with an oral H1- antihistamine or an intranasal corticosteroid alone
is recommended.
• In patients with perennial allergic rhinitis, an intranasal corticosteroid alone
rather than a combination of an intranasal corticosteroid with an oral H1-
antihistamine is recommended.
• In patients with seasonal AR or perennial AR, either a combination of an
intranasal corticosteroid with an intranasal H1-antihistamine or an intranasal
corticosteroid alone is recommended.
• In patients with seasonal AR, a combination of an intranasal corticosteroid with
an intranasal H1-antihistamine rather than an intranasal H1-antihistamine alone
is recommended.
• In seasonal AR, a leukotriene receptor antagonist or an oral H1-antihistamine is
recommended; however, in perennial AR, an oral H1-antihistaimine is preferred
over leukotriene receptor antagonist.
• In both seasonal AR and perennial AR, intranasal corticosteroid is
recommended over intranasal H1-antihistamine.
• In both seasonal AR and perennial AR, either intranasal or oral H1-antihistamine
is recommended.

37. Drug options for Allergic Rhinitis
Drug type Itch /
sneezing
Discharge Blockage Impaired
smell
Nasal
preparations
Antihistamines +++ ++ + _
AZELASTINE
Anticholinergics _ +++ _ _ Ipratropium
Decongestants _ + +++ _ Xylometazoline
Oxymetazoline
Mast Cell
Stabilizers
+ + + _ Sodium
cromoglycate
Topical
Corticosteroids +++ +++ ++ +
Fluticasone
Mometasone
2 sprays/nostril
OD

38. l Involves repeated administration of an allergen
extract to induce a state of immunological
tolerance
l More effective in limited spectrum of allergies in
particular seasonal pollen allergy
l Severe symptoms failing to respond to usual Px
l Subcutaneous injection/sublingual route
l Studies indicate that 3 years therapy necessary

39. l 4 years and older treated as for adults
l Children (>4) with AR and Asthma treated with
combination of newer generation topical and
inhaled corticosteroids with low risk of
complications
l Diagnosis in smaller children is difficult as can
have up to 6 to 8 colds per year
l Small children – oral antihistamines, saline
sprays and corticosteroids if symptoms severe
l < 2 years fortunately rare

42. l FDA considers no drugs are considered completely
safe
l FDA RISK Categories for drugs in pregnancy (based
on good studies in pregnant women)
A – safe to baby in 1st trimester
B – safe in pregnant animals, no human studies
C – drugs show foetal problems in animal studies
but benefits may outweigh the potential risks
D – clear risk to foetus but there may be
instances
X – should not be used in pregnancy

43. l Nasal Saline
l Nasal corticosteroids – all Category C except
Budesonide which was recently reassigned B –
nasal steroid of choice
l Antihistamines – usually not very effective but
older antihistamine chlorpheniramine,
loratadineand cetrizine are B
l Oral steroids C
l Decongestants - C

47. THANK YOU FOR YOUR
ATTENTION !