Medical Care
The management of allergic rhinitis consists of 3 major categories of treatment, (1) environmental control measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy.
Environmental control measures and allergen avoidance: These involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allerg. However, global environmental control without identification of specific triggers is inappropriate.
Pollens and outdoor molds
Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist (see Causes).
Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.
Despite all of these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal molds may be difficult.
Indoor allergens
Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure. Bed linens should be washed every 2 weeks in hot (at least 130Β°F) water to kill any mites present. Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.
Indoor environmental control measures for mold allergy focus on reduction of excessive humidity and removal of standing water. The environmental control measures for dust mites can also help reduce mold spores.
For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping it entirely out of the bedroom can be of some benefit. Cat allergen levels in the home can be reduced with high-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may be impractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.
Occupational allergens: As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.
Nonspecific triggers: Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoor pollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of these situations or triggers if they seem to aggravate symptoms.
Pharmacotherapy: See Medication.
Immunotherapy (desensitization): A considerable body of clinical research has established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements. Success rates have been demonstrated to be as high as 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observed for 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefully consider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits of immunotherapy against the risks and benefits of the other management options.
Indications: Immunotherapy may be considered more strongly with severe disease, poor response to other management options, and the presence of comorbid conditions or complications. Immunotherapy is often combined with pharmacotherapy and environmental control.
Administration: Administer immunotherapy with allergens to which the patient is known to be sensitive and that are present in the patient's environment (and cannot be easily avoided). The value of immunotherapy for pollens, dust mites, and cats is well established. The value of immunotherapy for dogs and mold is less well established.
Contraindication: A number of potential contraindications to immunotherapy exist and need to be considered. Immunotherapy should only be performed by individuals who have been appropriately trained, who institute appropriate precautions, and who are equipped for potential adverse events.
DRUG TREATMENT : Patients with intermittent symptoms are often treated adequately with oral antihistamines. The newer, second-generation (ie, nonsedating) antihistamines are usually preferable to avoid sedation and other adverse effects associated with the older, first-generation antihistamines. Ocular antihistamine drops (for eye symptoms), intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short courses of oral corticosteroids (reserved for severe, acute episodes only) may also provide relief.
1. SECOND GENERATION ANTIHISTAMINES :
- CITIRIZINE
- LEVOCETIRIZINE
- FEXOFENADINE
- LORATADINE
- DESLORATADINE
2. LEUKOTRIENE RECEPTOR ANTAGONISTS :
- MONTELUKAST
- ZAFIRLUKAST
- ZILEUTON
3. FIRST GENERATION ANTIHISTAMINES :
- CHLORPHENIRAMINE MALEATE
- DIPHENHYDRAMINE
- HYDROXYZINE
4. IMMUNOTHERAPY
- HISTAGLOBE INJ - 1 AMP. EVERY WEEK FOR 3 WEEKS. THEN 4TH AFTER 6 WEEKS AND THEN EVERY 6 MONTHS FOR SEVERAL YEARS IS VERY EFFECTIVE FOR NONSPECIFIC ALLERIES.