Allergic Rhinitis Treatment Guidelines ALLERGIC RHINITIS: ATTESTATION. Effective Date: December 28, 2009 Reasn fr Attestatin: Annual review and update f existing guideline Key Guideline Updates/Revisins: Additin f fllwing treatment ptins -- Azelastine hydrchlride (Astepr) Mntelukast (Singulair) fr sme patients with asthma
Allergic Rhinitis Treatment Guidelines page 2 f 9 ALLERGIC RHINITIS Allergic rhinitis is an IgE-mediated inflammatry disease invlving the nasal mucsa membranes in which symptms result frm a cmplex allergen-driven mucsal inflammatin and may be characterized by early-phase and late-phase respnses. Symptms may be episdic, seasnal r perennial. Repeated expsures ( priming ) may result in a slwer rate f symptm reslutin. Allergic cnjunctivitis is frequently a cmrbidity with allergic rhinitis (see Cnjunctivitis guideline). Refer Out Less than 2 years ld Currently taking ral sterids fr severe allergic reactin Currently taking allergen immuntherapy Asthmatics with exacerbatin symptms (see Asthma Mnitring guideline) Differential Diagnsis Viral Upper Respiratry Illness (use VURI guideline) Gradual nset f symptms f general malaise, laryngitis, injectin f the cnjunctiva, and headache Vasmtr rhinitis (Idipathic rhinitis) Persistent nasal cngestin that des nt have a crrelatin t specific allergen expsures with rapid nset f nasal cngestin and nticeable pstnasal drip Atrphic rhinitis nasal airways are clear, mucsa is dry Rhinitis medicamentsa rebund nasal cngestin due t persistent nasal decngestant use Bacterial sinusitis (use Sinusitis guideline) Freign bdy Deviated septum Nasal plyps Assciated with nasal cngestin, rhinrrhea and ansmia Nasal r sinus tumrs/cancer -- Symptms may include recent nset gastresphageal reflux (GERD), pain, decreased sensatin f face, palate, teeth Clinical Presentatin Patient may cmplain f: Nasal cngestin, sneezing and clear rhinrrhea r pstnasal drainage, chrnic sniffling Itching f the nse, eyes, palate, and ears
Allergic Rhinitis Treatment Guidelines page 3 f 9 Cughing (may be mre prevalent in the mrning) Sre/scratchy thrat r itchy palate Sinus pressure Puffiness, redness, and watering f eyes may ccur Reprt sensitivity t specific allergen: dust, pllen, mld, etc. Seasnal, perennial r episdic symptms Family histry f allergies On exam: Pale, bggy nasal mucsa with clear thin secretins Enlarged nasal turbinates which may bstruct airway flw, Muth-breathing (allergic gape) Allergic shiners, perirbital edema, cbblestne appearance f the cnjunctiva with erythema Dennie s lines (lwer eyelid creases) Nasal salute Enlarged tnsils and adenids, pharyngeal cbblestne appearance Treatment Optins ($ = <$25, $$ = $25-50, $$$ = $50-100, $$$$ = $100-150, $$$$$ = >$150)
Allergic Rhinitis Treatment Guidelines page 4 f 9 Treatment Optin Advantages Disadvantages Nasal Saline Imprves mucus clearance Nne Enhances ciliary beat activity Remves antigens, bifilm r inflammatry mediatrs May prvide prtective effect n sin-nasal mucsa Intranasal Mst effective mntherapy Onset f actin may be up t Crticsterids First line fr mderate t severe 12 hurs (INS) (e.g., symptms Maximum efficacy may nt be Fluticasne) Effective in cntrlling sneezing, itching, rhinrrhea, and nasal cngestin achieved fr up t 2 weeks cnsider cncmitant use f ral antihistamines Secnd generatin ral antihistamines (e.g., lratadine) Preferred ver 1 st generatin t minimize sedatin, perfrmance impairment, and antichlinergic effects Cnsider fr patients unable r unwilling t use INS May be used alne in mild and episdic AR Nne Treatment Optin Advantages Disadvantages Intranasal Significant rapid nset f actin Less effective than INS fr Antihistamines Apprpriate fr use in episdic AR nasal symptms (e.g., Azelastine) Effectiveness equal t r superir t ral 2 nd generatin antihistamines with clinically significant effect n nasal cngestin Bitter taste Oral Decngestants (e.g., pseudephedrine) Leuktriene receptr antagnists (LTRA) (e.g., Mntelukast) Reduces nasal cngestin May be used in cmbinatin with antihistamines fr mre effective relief f nasal cngestin than with an antihistamine alne N significant difference in efficacy between LTRA and ral antihistamines Cmbinatin therapy with an antihistamine may prvide an alternative treatment fr patients with cmrbid asthma wh are unrespnsive t r nt cmpliant with INS Cmbinatin prducts (antihistamine/decngestants like Allegra-D) d nt prvide the ability t discntinue ne r the ther as symptms imprve. Many cmbinatin have replaced pseudephedrine with phenylephrine Efficacy f phenylephrine has nt been well established Less effective than INS Reprted neurpsychiatric events with these drugs have included agitatin, aggressin, anxiusness, irritability, restlessness and insmnia. Patients have als experienced tremrs, dream abnrmalities, hallucinatins, depressin and suicidality, including suicide.
Allergic Rhinitis Treatment Guidelines page 5 f 9 Antihistamine r Dsing Frequency Cnsideratins/ Pregnancy Categry Lratadine (e.g., Claritin) ($) 6 years and adults: 10mg by muth nce a day 2-5 years: 5 mg by muth nce a day Categry B Cetirizine (e.g., Zyrtec) ($) 12 years and adults: 10mg by muth nce a day 6-11 years: 5mg by muth nce a day Categry B Nt recmmended fr nursing mthers 2-5 years (use liquid): 2.5mg (2.5 ml) by muth nce a day May be mre sedating than lratadine Chlrpheniramine ($) 12 years and adults: 4mg by muth every 4-6 hurs (Max 24mg/24hurs) 6-11 years: 2 mg by muth every 4-6 hurs (Max 12mg/24 hurs) 2-5 years: 1 mg by muth every 4-6 hurs (Max 4mg/24 hurs) Categry B Preferred drug during the first trimester May cause sedatin/drwsiness first generatin antihistamine Antihistamine r Dsing Frequency Cnsideratins/ Pregnancy Categry Fexfenadine (e.g., Allegra) (60 mg $$; 180mg $$$) 12 years and adults: 60mg by muth tw times a day r 180mg by muth nce a day 6-11 years: 30mg by muth tw times a day 2-5 years: 30 mg (5 ml) by muth tw times a day Categry C Suspensin recmmended fr <6 years ld 30 day supply May refill x 2 Deslratadine (e.g., Clarinex) ($$$$) 12 years and adults: 5mg by muth nce a day 6 11 years: 2.5 mg by muth nce a day 2 5 years (use syrup): 1.25 mg (2.5mL) by muth nce a day Categry C Nt recmmended fr nursing mthers 30 day supply May refill x 2 Azelastine (Astepr) ($$$) Azelastine (Astellin) ($$$$) 12 years and adults: 1-2 sprays in each nstril tw times a day 12 years and adults: 1-2 sprays in each nstril tw times a day 5-11 years: 1 spray in each nstril tw times a day Categry C Intranasal antihistamine, nt sterid 137 mcg/inhalatin nasal spray 30 day supply May refill x2
Allergic Rhinitis Treatment Guidelines page 6 f 9 Intranasal Crticsterid Sprays (30 day supply; May refill x2) Intranasal Crticsterid Fluticasne (Flnase) 0.05 mg/inh Intranasal Spray ($$) Mmetasne (Nasnex) 50 mcg/inh Intranasal Spray ($$$) Triamcinlne (Nasacrt AQ) 55 mcg/inh Intranasal Spray ($$$) Dsing Frequency 12 years and adults: 2 sprays in each nstril nce a day 4-11 years: 1 spray in each nstril daily 12 years and adults: 2 sprays in each nstril nce a day 2-11 years: 1 spray in each nstril daily 13 years and adults: 2 sprays in each nstril nce a day 6-12 years: 1-2 spray in each nstril daily 2-5 years: 1 spray in each nstril daily Pregnancy Categry Categry C Categry C Categry C
Allergic Rhinitis Treatment Guidelines page 7 f 9 Intranasal Crticsterid Budesnide (Rhincrt AQ) 32 mcg/inh Intranasal Spray ($$$$) Dsing Frequency 13 years and adults: 1 t 4 sprays in each nstril nce a day 6-12 years: 1-2 sprays in each nstril nce a day Pregnancy Categry Categry B Other Optins Medicatin Dsing Cnsideratins Pregnancy categry C Pseudephedrine ($) Oxymetazline ($) Nasal Saline Crmlyn Sdium ($) 18 years: 60 mg (immediate release) every 6 hurs as needed r 120 mg (sustained release) every 12 hurs as needed 12-17 years: 1 mg/kg PER DOSE every 6 hurs as needed; d nt exceed 60 mg per dse r 240 mg per day Age 6 years -- 2 sprays bth nstrils every 12 hurs fr n mre than 3 days Nasal wash (e.g., Sinus Rinse r generic) Use 2 times a day, as needed Saline spray (e.g., Ocean, Ayr r generic) every 2 hurs while awake fr patients wh are reluctant t use nasal wash 2 years: ne spray t each nstril every 4-6 hurs Fr relief f nasal cngestin All studies regarding efficacy perfrmed using 240 mg daily dsage D nt use in patients with cmrbid cardiac r crnary artery cnditins D nt use in patients with histry f hypertensin r bld pressure reading abve 135/85 mm Hg Pregnancy categry C Fr relief f nasal cngestin May be used with cautin if HTN well-cntrlled <135/85 Gd ptin fr thse wh cannt take INS but less effective than INS Mst effective when started befre symptms begin; nset f actin 4-7 days Pregnancy categry B; cautin in nursing mthers
Allergic Rhinitis Treatment Guidelines page 8 f 9 Leuktriene Inhibitr fr patients with asthma cmrbidity wh are unrespnsive t r nn-cmpliant with INS Mntelukast (Singulair) ($$$$) 15 years t Adult: 10mg by muth nce a day in the evening 6-14 years: 5mg by muth nce a day in the evening 2-5 years: 4mg by muth nce a day in the evening Pregnancy categry B If initiating treatment (patient has never been n Mntelukast) recmmend fllwing up in 2 weeks at MC r a primary care prvider t evaluate effectiveness and any side effects that may have presented. Patient Educatin Envirnmental cntrl measures fr pllens, fungi/mlds, dust mites, pet dander, and insects. Minimize expsure t ther irritants like smke, perfumes, csmetics, hair spray, and ther drs Suggest develpment f a rhinitis actin plan that includes what medicatins t use fr specific symptms and when t seek medical attentin in cnjunctin with Primary Care Prvider Prvide instructins n use f intranasal sprays (Key pints) Shake the bttle well Blw nse until clear befre administering medicatin Tilt head slightly frward, place the nasal applicatr int the nstril making sure t keep the bttle upright ( Lk at yur tes and spray yur nse ) Breathe nrmally when spraying the medicatin Wipe the applicatr with a clean tissue after use Fllw-Up Seek immediate medical attentin fr difficulty breathing, wheezing, shrtness f breath, chest discmfrt. Fllw up with MinuteClinic r primary care prvider in 14 days if n imprvement in symptms. Initiatin f Mntelukast: Fllw up with MinuteClinic r primary care prvider in 2 weeks t evaluate effectiveness and any side effects that may have develped.
Allergic Rhinitis Treatment Guidelines page 9 f 9 References 1. ARIA At-A-Glance Pcket Reference. 1 st ed. 2007. Available: http://www.whiar.rg/dcs/aria_glance_wm.pdf. 2. Bruntn SA, Frmer LM. Treatment ptins fr the management f perennial allergic rhinitis, with a fcus n intranasal crticsterids. Suthern Medical Jurnal. 2007;100(7):701-708. 3. Heier B, Ortiz G, Williams DM. The rle f nnprescriptin antihistamines in the treatment f allergic rhinitis. Washingtn, DC: American Pharmacists Assciatin. 2007. 4. Institute fr Clinical Systems Imprvement. Health care guideline: diagnsis and treatment f respiratry illness in children and adults. Blmingtn, MN: Authr, Jan 2007. 5. Quillen DM, Feller DB. Diagnsing rhinitis: Allergic vs. nnallergic. American Family Physician. 2006;73(9):1583-1590. 6. Wallace DV, Dykewicz MS, eds. The diagnsis and management f rhinitis: An updated practice parameter. Jurnal f Allergy and Clinical Immunlgy. 2008 August (Suppl);122(2):S1-S84. 7. Wrld Health Organizatin (WHO). Allergic rhinitis and its impact n asthma. Natinal Guideline Clearinghuse. 2008. 8. Yawn B, Knudtsn M. Treating asthma and cmrbid allergic rhinitis in pregnancy: A review f the current guidelines. Jurnal f the American Bard f Family Medicine. 2007;20(3):289-298.