Allergic rhinitis involves inflammation of the nasal mucosa triggered by an IgE-mediated immune response to airborne allergens. It is characterized by symptoms like sneezing, rhinorrhea, and nasal congestion. Treatment involves allergen avoidance, pharmacotherapy with antihistamines, decongestants, intranasal corticosteroids, and immunotherapy to induce tolerance to allergens long-term.

1. Allergic Rhinitis
Prepared By
Dr/Nada Elnaidany
PhD/Clinical Pharmacy
3/3/2020 1Dr/Nada Elnaidany

2. Allergic rhinitis
• involves inflammation of nasal mucous
membranes in sensitized individuals when
inhaled allergenic particles contact mucous
membranes and elicit a response mediated by
immunoglobulin E (IgE).
• There are two types:
– Seasonal
– persistent (formerly called “perennial”) allergic
rhinitis
3/3/2020 2Dr/Nada Elnaidany

3. PATHOPHYSIOLOGY
• Allergens enter the nose and processed by
lymphocytes, produce antigen-specific IgE, sensitizing
genetically predisposed hosts to those agents.
• On nasal reexposure, IgE bound to mast cells interacts
with airborne allergens, triggering release of
inflammatory mediators.
• An immediate reaction occurs within seconds to
minutes, resulting in rapid release of preformed and
newly generated mediators from the arachidonic acid
cascade.
3/3/2020 3Dr/Nada Elnaidany

4. PATHOPHYSIOLOGY
• Mediators of immediate hypersensitivity include histamine,
leukotrienes, prostaglandin, tryptase, and kinins.
• These mediators cause vasodilation, increased vascular
permeability, and production of nasal secretions. Histamine
produces rhinorrhea, itching, sneezing, and nasal obstruction.
• A late-phase reaction may occur 4 to 8 hours after initial allergen
exposure due to cytokine release from mast cells and thymus-
derived helper lymphocytes.
• This inflammatory response causes persistent chronic symptoms,
including nasal congestion
3/3/2020 4Dr/Nada Elnaidany

5. CLINICAL PRESENTATION
• Seasonal (hay fever) allergic rhinitis
– specific allergens (pollen from trees, grasses, and weeds)
present at predictable times of the year (spring and/or
fall) and typically causes more acute symptoms.
• Persistent allergic rhinitis
– occurs year-round in response to nonseasonal allergens
(eg, dust mites, animal dander, and molds) and usually
causes more subtle, chronic symptoms.
• Many patients have a combination of both types,
with symptoms year-round and seasonal
exacerbations
3/3/2020 5Dr/Nada Elnaidany

6. Symptoms
• clear rhinorrhea, sneezing, nasal congestion,
postnasal drip, allergic conjunctivitis, and pruritic eyes,
ears, or nose.
• In children, physical examination may reveal dark circles
under the eyes (allergic shiners), a transverse nasal crease
caused by repeated rubbing of the nose, adenoidal
breathing, edematous nasal turbinates coated with clear
secretions, tearing, and periorbital swelling.
• Patients may complain of loss of smell or taste, with
sinusitis or polyps the underlying cause in many cases.
3/3/2020 6Dr/Nada Elnaidany

7. Symptoms
• Postnasal drip with cough or hoarseness can be
bothersome
• Untreated rhinitis symptoms may lead to insomnia,
malaise, fatigue, and poor work performance.
• Allergic rhinitis is associated with asthma; 10% to 40%
of allergic rhinitis patients have asthma.
• Complications include recurrent and chronic sinusitis
and epistaxis
3/3/2020 7Dr/Nada Elnaidany

8. DIAGNOSIS
• Medical history:-
– symptoms, environmental factors and exposures,
– results of previous therapy, use of medications,
– previous nasal injury or surgery,
– family history.
• Immediate-type hypersensitivity skin tests are
commonly used.
– Percutaneous testing is safer and more generally
accepted than intradermal testing, which is usually
reserved for patients requiring confirmation.
3/3/2020 8Dr/Nada Elnaidany

9. TREATMENT
• Goals of Treatment:
– Minimize or prevent symptoms,
– prevent long-term complications,
– minimize or avoid medication side effects,
– provide economical therapy,
– maintain normal lifestyle.
3/3/2020 9Dr/Nada Elnaidany

10. NONPHARMACOLOGIC THERAPY
• Avoiding offending allergens
• Reduce mold growth by humidity less than 50% and removing
obvious growth with disinfectant.
• Reducing exposure to dust mites
• Prevent poor air quality in home
• Patients with seasonal allergic rhinitis should keep windows
closed and minimize time spent outdoors during pollen seasons.
• Filter masks can be worn while gardening
3/3/2020 10Dr/Nada Elnaidany

11. PHARMACOLOGIC THERAPY
• Antihistamines
– Nonselective (first-generation or sedating
antihistamines)
– Peripherally selective (second-generation or
nonsedating antihistamines).
3/3/2020 11Dr/Nada Elnaidany

12. Antihistamines
• Relief symptom
– Decreased capillary permeability, wheal-and-flare formation, and
itching.
• Side effect
– Drowsiness Sedative effects , Adverse anticholinergic
– Loss of appetite, nausea, vomiting, and epigastric distress. Taking
medication with meals or a full glass of water may prevent
gastrointestinal (GI) side effects.
• Antihistamines should be used with caution in patients
predisposed to urinary retention and in those with increased
intraocular pressure, hyperthyroidism, and cardiovascular
disease.
3/3/2020 12Dr/Nada Elnaidany

13. Intranasal antihistamine
• Azelastine
– rapidly relieves symptoms of seasonal allergic
rhinitis.
– has systemic availability 40%.
– drying effects, headache, and diminished with time.
• Olopatadine
– less drowsiness because it is a selective H1 -receptor
antagonist.
3/3/2020 13Dr/Nada Elnaidany

14. Ophthalmic antihistamines
• for allergic conjunctivitis
– Levocabastine and bepotastine
• ophthalmic antihistamines that can be used for conjunctivitis
associated with allergic rhinitis.
– Systemic antihistamines are usually also effective.
• Ophthalmic agents are a useful addition to nasal
corticosteroids for ocular symptoms.
• They are also useful for patients whose only
symptoms involve the eyes or for patients whose
ocular symptoms persist on oral antihistamines.
3/3/2020 14Dr/Nada Elnaidany

15. Decongestants
• Topical and systemic work well in
combination with antihistamines when nasal
congestion is part of the clinical picture.
• Topical decongestants are applied directly to
swollen nasal mucosa via drops or sprays
• They result in little or no systemic absorption
3/3/2020 15Dr/Nada Elnaidany

16. Rhinitis medicamentosa
• Rhinitis medicamentosa (rebound
vasodilation with congestion) may occur with
prolonged use of topical agents (>3–5 days).
– Abrupt cessation is an effective treatment, but
rebound congestion may last for several days or
weeks.
• not occur with oral decongestants
• Nasal steroids have been used successfully
but take several days to work.
3/3/2020 16Dr/Nada Elnaidany

17. Adverse effects
of topical decongestants
• Burning, stinging, sneezing, and dryness of the nasal
mucosa.
• These products should be used only when absolutely
necessary (eg, at bedtime) and in doses that are as small
and infrequent as possible.
• Duration of therapy should be limited to 5 days or less.
• Weaning off the topical over several weeks.
• Combining the weaning process with nasal steroids may
be helpful.
3/3/2020 17Dr/Nada Elnaidany

18. Oral decongestants
• Pseudoephedrine
• oral decongestant that has a slower onset of
• Doses up to 180 mg produce no measurable change in blood
pressure or heart rate. However, higher doses (210– 240 mg) may
raise both blood pressure and heart rate.
• should be avoided in hypertensive patients unless
absolutely necessary.
• hypertensive reactions with monoamine oxidase
inhibitors.
• Pseudoephedrine can cause mild CNS stimulation, even at
therapeutic doses.
3/3/2020 18Dr/Nada Elnaidany

19. Oral decongestants
• Phenylephrine
• replaced pseudoephedrine
• Combination oral products containing a
decongestant and antihistamine are rational
because of different mechanisms of action.
Consumers should read product labels carefully
to avoid therapeutic duplication and use
combination products only for short courses.
3/3/2020 19Dr/Nada Elnaidany

20. Nasal Corticosteroids
• relieve sneezing, rhinorrhea, pruritus, and nasal
congestion with minimal side effects.
• reduce inflammation by:-
– blocking mediator release, suppressing neutrophil chemotaxis,
causing mild vasoconstriction, and inhibiting mast cell–
mediated, late-phase reactions.
• excellent choice for:-
– persistent rhinitis
– seasonal rhinitis
• Initial therapy over antihistamines along with allergen
avoidance.
3/3/2020 20Dr/Nada Elnaidany

21. Nasal Corticosteroids
• Side effects:-
– Sneezing, stinging, headache, epistaxis, and rare infections
with Candida albicans.
• Some patients improve within a few days, but peak
response may require 2 to 3 weeks.
• The dosage may be reduced once a response is achieved.
• Blocked nasal passages should be cleared with a
decongestant or saline irrigation before administration to
ensure adequate penetration of the spray.
3/3/2020 21Dr/Nada Elnaidany

22. Cromolyn Sodium
• mast cell stabilizer
• prevents antigen-triggered mast cell
degranulation
• Side effect
– local irritation (sneezing and nasal stinging).
• Dosage for persons at least 2 years of age is one
spray in each nostril three or four times daily at
regular intervals
3/3/2020 22Dr/Nada Elnaidany

23. Cromolyn Sodium
• Nasal passages should be cleared before
administration, and inhaling through the nose during
administration enhances distribution to the entire
nasal lining.
• For seasonal rhinitis,
– treatment should be initiated just before the start of the
offending allergen’s season and continue throughout the
season.
• In persistent rhinitis,
– effects may not be seen for 2 to 4 weeks;
– antihistamines or decongestants may be needed during
this initial phase of therapy.
3/3/2020 23Dr/Nada Elnaidany

24. Ipratropium Bromide
• (Atrovent) nasal spray
– Anticholinergic useful in persistent allergic rhinitis.
– Antisecretory when applied locally and provides
symptomatic relief of rhinorrhea.
– The 0.03% solution is given as two sprays (42 mcg)
two or three times daily.
• Adverse effects
– mild and include headache, epistaxis, and nasal
dryness.
3/3/2020 24Dr/Nada Elnaidany

25. Montelukast Montelukast (Singulair)
• is a leukotriene receptor antagonist approved for treatment of
persistent allergic rhinitis in children as young as 6 months and for
seasonal allergic rhinitis in children as young as 2 years.
• It is effective alone or in combination with an antihistamine.
• Dosage for adults and adolescents older than 14 years is one 10-
mg tablet daily. Children ages 6 to 14 years may receive one 5-mg
chewable tablet daily. Children ages 6 months to 5 years may be
given one 4-mg chewable tablet or oral granule packet daily.
• Montelukast is no more effective than antihistamines and less
effective than intranasal corticosteroids; therefore, it is
considered third-line therapy after those agents
3/3/2020 25Dr/Nada Elnaidany

26. IMMUNOTHERAPY
• Immunotherapy induce tolerance to the allergen
when natural exposure occurs.
• Subcutaneous or sublingual dosage forms.
• Beneficial effects of immunotherapy may result
from:-
– induction of IgG-blocking antibodies,
– reduction in specific IgE (long-term),
– reduced recruitment of effector cells,
– altered T-cell cytokine balance, T-cell anergy, and
alteration of regulatory T cells.
3/3/2020 26Dr/Nada Elnaidany

27. IMMUNOTHERAPY
• Good candidates include :-
– a strong history of severe symptoms unsuccessfully
controlled by avoidance and pharmacotherapy
– patients unable to tolerate adverse effects of drug
therapy.
• Poor candidates include:-
– patients with medical conditions that would compromise
the ability to tolerate an anaphylactic-type reaction,
– patients with impaired immune systems,
– patients with a history of nonadherence
3/3/2020 27Dr/Nada Elnaidany

28. Subcutaneous immunotherapy
• very dilute solutions are given initially once or twice
weekly.
• The concentration is increased until the maximum
tolerated dose or highest planned dose is achieved.
• This maintenance dose is continued in slowly increasing
intervals over several years, depending on clinical
response.
• Better results are obtained with year-round rather than
seasonal injections.
3/3/2020 28Dr/Nada Elnaidany

29. Sublingual immunotherapy
• is available for ragweed and certain grass allergies.
• The products are started 12 weeks before the allergen
season and continued throughout the season.
– The first dose is administered in the physician’s office to allow
observation of the patient for 30 minutes for hypersensitivity
reactions.
– The patient places the tablet under the tongue where it
dissolves; patients should not swallow for at least 1 minute.
– After the first dose is administered without incident, patients
can take immunotherapy at home, but an autoinjectable
epinephrine must be prescribed.
3/3/2020 29Dr/Nada Elnaidany

30. IMMUNOTHERAPY
• Adverse reactions
• subcutaneous immunotherapy
– mild local adverse reactions include induration and
swelling at the injection site. More severe reactions
(generalized urticaria, bronchospasm, laryngospasm,
vascular collapse, and death from anaphylaxis) occur
rarely.
– Severe reactions are treated with epinephrine,
antihistamines, and systemic corticosteroids.
• sublingual immunotherapy
– pruritus of the mouth, ears, and tongue; throat irritation;
and mouth edema
3/3/2020 30Dr/Nada Elnaidany

31. EVALUATION OF
THERAPEUTIC OUTCOMES
• Monitor patients regularly for:-
– Reduction of identified target symptoms and presence of side
effects.
– Satisfaction with the management
– Disruption to their normal lifestyle.
• The Medical Outcomes Study 36-Item Short Form Health Survey
and the Rhinoconjunctivitis
• Quality of Life Questionnaire measure symptom improvement and
parameters such as sleep quality, nonallergic symptoms (eg,
fatigue and poor concentration), emotions, and participation in a
variety of activities.
3/3/2020 31Dr/Nada Elnaidany