Allergic Rhinitis

Question 1

Classification of Allergic Rhinitis

Answer 1

Frequency
- Intermittent
- < 4x per week
- Persistent
- >= 4x per week for >= 4 consecutive weeks
Severity
- Mild - Not troublesome. No sleep disturbance. No impairment of daily activities or school / work performance.
- Moderate or severe. Troublesome. Sleep / work / school performance impairment.

Question 2

Management of Allergic Rhinitis

Answer 2

Mild
- Oral or intranasal antihistamine.
Moderate or severe
- Oral or intranasal antihistamine + Intranasal corticosteroid.
Marked rhinorrhoea? - Add intranasal ipratropium (Atrovent) 44microg ii BN TDS PRN
Persistent ocular symptoms? Antihistamine eye drop.
Coexisting asthma?consider Monteleukast (Singulair)
Consider referral to allergy specialist for consideration of allergen immunotherapy.
Trial treatment with follow up in 4 weeks and review compliance if nil improvement in symptoms.
No use of intranasal decongestants recommended. Not to be used more than 3-5 days. Can cause Rhinitis medicamentosa which can take several weeks to reverse.

Question 3

Oral antihistamines in Allergic Rhinitis

Answer 3

cetirizine (Zyrtec) 10mg PO OD
Loratadine (Claritin) 10mg PO OD
Fexofenadine (Telfast) 120mg PO OD
Desloratadine (Aerius) 5mg PO OD

PO Antihistamines less effective that intranasal antihistamines

Question 4

Intranasal antihistamines for Allergic Rhinitis

Answer 4

Faster onset of action and more effective for alleviation of nasal obstruction than PO antihistamines.

Azelastine (Azep)1mg/mL nasal spray 1 both nostrils BD
Levocabastine (Zyrtec) 0.5mg/ml nasal spray 2 both nostrils up to QID.

Note: Combining PO and intranasal antihistamine does not confer additional benefit.

Question 5

Intranasal Corticosteroids for Allergic Rhinitis

Answer 5

Consider in moderate to severe disease

Do not provide immediate relief. Usual benefit within a few days of consistent use

Use high dose for 4 weeks then reduce to maintenance dose.

All have equal efficacy to one another and are first line

Beclometasone (Beconase) 100microg i both nostrils BD x 4 weeks. Reduce to OD post
Fluticasone Furoate (Avamys) 55microg i BN OD x 4 weeks then halve dose
Mometasone (Nasonex) 100microg BN OD x 4 weeks then halve dose.

Question 6

Combination Intranasal antihistamine + Corticosteroid treatment for allergic rhinitis

Answer 6

Useful either for mod/severe disease or for mild symptoms not responding to antihistamines.

Dymista (Azelastine 137microg + Fluticasone Proprionate 50mirog) i BN BD.
Olopatadine / Mometasone 665/25microg ii BN BD

Question 7

Eye Drops for Allergic Conjunctivitis

Answer 7

Use drugs with both anti-histamine and mast-cell stabilising properties s per below
- Azelastine (eyezep) 0.05% i BE up TO QID PRN
- Ketotifen (Zatidor) 0.025% i BE BD PRN
- Olapatadine (Patanol) 0.1% i BE BD PRN

Anti-histamine only eye drop
- Levocabastine (Zyrtec) 0.05% i BE QID PRN

Mast-cell stabiliser only eye drop
- Cromoglycate (Cromo-fresh) 2% 1 BE 6 times daily PRN
- Lodoxamide (Lomide) 0.1% 1 BE QID PRN