Page 81 - rp-may-2020

CPD ACTIVITY
79
RET AIL PHARMA C Y • MA Y 2020
persistent allergic rhinitis (they are only
first line for intermittent mild allergic
rhinitis). Antihistamines are particularly
effective in allergic rhinoconjunctivitis
and histamine related symptoms such as
itching, rhinorrhoea, sneezing and eye
symptoms (Table 1). They are far less
27
effective for nasal congestion.
First generation oral antihistamines
(cyproheptadine, dexchlorpheniramine,
pheniramine, promethazine) may have
pronounced sedative effects so should
be avoided in the treatment of allergic
rhinitis. The less sedating antihistamines
28
can be taken long term with no loss of
efficacy, and have a good safety profile.
28
While all antihistamines are effective,
non-responders to one antihistamine may
respond favourably to another.
29
Intranasal antihistamines are as effective
as oral antihistamines, but not as effective
as INCS. Onset of action of intranasal
30
antihistamine is within 15 minutes, so they
may be useful in cases of acute onset
of symptoms.
22
Antihistamine-mast cell stabiliser eye
drops such as ketotifen and olopatadine,
and antihistamine eye drops including
azelastine and levocabastine are effective
in conjunction with INCS and oral
antihistamines for ocular symptoms.
Leukotriene receptor antagonist
The leukotriene receptor antagonists (LRA)
montelukast should not be used as first-
line treatment for allergic rhinitis. It is less
31
effective than intranasal corticosteroids,
and possibly comparable to oral
antihistamines. In combination with an
22
oral antihistamine, LRAs are more effective
than oral antihistamine alone.
22
Montelukast may be beneficial in
concomitant seasonal allergic rhinitis
and asthma, especially exercise-induced
bronchoconstriction or aspirin exacerbated
respiratory disease. It has been found
32
to improve nasal and bronchial symptoms
with a reduction of reliever use.
5
Anticholinergics
Intranasal anticholinergics such as
ipratropium bromide may be effective
in controlling watery rhinorrhoea, but
are ineffective against sneezing and
nasal congestion.
4
Cromones
Mast cell stabilisers such as sodium
cromoglycate play only a minor role in
the treatment of allergic rhinitis. Sodium
cromoglycate must be used four times
a day and has relatively small effects on
nasal symptoms when compared with
antihistamines and INCS.
Decongestants
Oral and intranasal decongestants
may be used in cases of severe nasal
blockage for a few days. However,
they have no effect on other symptoms
of allergic rhinitis. Prolonged use of
topical decongestants for more than five
days may cause rebound congestion
(rhinitis medicamentosa).
Combination of an oral decongestant
and antihistamine provides decongestant
efficacy superior to that of either
drug alone.
33
Immunotherapy
Allergen specific immunotherapy should
be considered for patients with moderate
or severe persistent allergic rhinitis that is
not responsive to usual treatments. Patients
are desensitised by receiving increasing
doses of allergen either in injections as
subcutaneous immunotherapy or in tablets
and drops as sublingual immunotherapy.
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Medicine class
Itch/sneeze
Nasal discharge
Nasal blockage
Eye symptoms
Intranasal
corticosteroids
+++
+++
++
++
Oral/intranasal
antihistamines
++
++
+/-
++ (oral)
- (intranasal)
Oral/intranasal
decongestants
-
-
+ (oral)
+++ (intranasal)
Cromoglycate
+
+
+/-
-
Ipratropium
-
+++
-
-
Montelukast
-
+
++
++
Table 1.
Symptomatic treatment of allergic rhinitis in adults.
20
Medicine class
Active ingredient
Trade names
Daily maintenance dose
Intranasal
corticosteroids (INCS)
Beclomethasone
dipropionate
Beconase Allergy &
Hayfever 12 Hour
two sprays twice daily.
Budesonide
Rhinocort Hayfever,
Rhinocort, Budamax
One or two sprays once
daily.
Ciclesonide
Omnaris
two sprays once daily.
Fluticasone propionate
Flixonase Nasule Drops,
Flixonase Allergy &
Hayfever 24 Hour
one spray once daily.
Fluticasone furoate
Avamys
one spray once daily.
Mometasone furoate
Nasonex Allergy
Aqueous Nasal Spray,
Metaspray, Sensease
Nasal Allergy Relief
Nasal Spray, Azonaire
Hayfever & Allergy
Prevention & Relief
Nasal Spray
one spray once daily.
Intranasal corticosteroid
/antihistamine
Fluticasone propionate/
azelastine
Dymista
one spray twice daily.
Intranasal antihistamines
Azelastine
Azep
one spray twice daily.
Levocabastine
Livostin, Zyrtec
Levocabastine
two sprays twice daily.
Oral less-sedating
antihistamines
Cetirizine
Zyrtec, Alzene, Zilarex
one daily.
Desloratadine
Aerius
one daily.
Fexofenadine
Telfast, Amcal Fexo,
Fexotabs, Tefodine,
Xergic
one daily.
Loratadine
Claratyne, Allereze,
Lorano
one daily.
Intranasal
anticholinergics
Ipratropium
Atrovent Nasal, Atrovent
Nasal Forte
two to three times daily.
Cromones
Sodium cromoglycate
Rynacrom Metered
Dose Nasal Spray
one spray four times
daily.
Leukotriene receptor
antagonists
Montelukast
Singulair, Lukair,
Montelair, Respikast
10mg daily.
Table 2.
Medicines for treatment of allergic rhinitis in adults.
+++ very effective, ++ moderately effective, + marginally effective, +/- little or no effect, - ineffective