Allergic Rhinitis

Nurulfalahin Daud @ Ibrahim

SEMESTER MAR – AUG 2025

 Introduction

▪ Rhinitis is inflammation of the lining of the nose and contiguous parts of the upper respiratory
tract.
▪ Allergic rhinitis is an allergen-induced, immunoglobulin E (IgE)-mediated inflammatory
condition of the lining of the nose and upper respiratory tract.
 ▪ Family history of atopy (AR, eczema, asthma, and food
allergies)

▪ Elevated serum IgE levels (especially before the age of 6)

> 100 IU/ml

ETIOLOGY & ▪ Positive skin test results

RISK FACTORS ▪ Exposure to particulate air pollution

▪ Maternal smoking
▪ Presence of allergen specific IgE
▪ Birth during the pollen season
 Initial contact with the allergen

Production of T-helper lymphocyte type 2 (Th-2) –

directed response

Production of specific IgE antibodies

The trigger allergen bound to IgE that is fixed to

mast cells in the nasal mucosa
PATHOPHYSIOLOGY
Release of various cells, mediators, and
intermediate substances (including cytokines)

These mediators bind to receptors in the nose and cause:

• Nasal congestion (vasodilation, mucosal oedema, hypertrophy)
• Rhinorrhoea (mucous secretion and vascular permeability)
• Sneezing
• Nasal itchiness
• Watery eyes
 Early Phase & Late Phase allergic response to
subsequent exposures

Occurs within minutes of subsequent

exposure

Histamine stimulates more

mast cells, as well as
macrophages, eosinophils,
and basophils to produce
more substances : cysteine Begin as soon as 2 hours after the early
leukotrienes and phase
prostaglandin D2
Late phase involves a
second release of many
mediators of the early
phase.
 Signs and
Symptoms • Ocular manifestations (itch, redness, tearing, chemosis,
periorbital edema)
• Sleep disturbances often with fatigue, asthenia, malaise,
and irritability
• Impaired performance at work or school)
 CATEGORIES OF ALLERGIC RHINITIS

• Seasonal
• Symptoms due to seasonal aeroallergens
• Present only during specific portions of the year, with length of the exposure
dependent on geographic and climate conditions

• Perennial
• Symptoms presents throughout the year due to environmental aeroallergens
such as indoor allergens – dust mites

• Episodic
• Symptoms presents only during intermittent exposure to allergen trigger –
exposure to a friend’s pet
 CATEGORIES OF ALLERGIC RHINITIS

Symptoms of sleep disturbance, interference with daily activities –

leisure or sport, impairment of school or work, troublesome
symptoms

• Mild
• None of the symptoms present

• Moderate-severe
• Present of any of the above symptoms

• Intermittent
• Symptoms present < 4 days/ week or < 4 consecutive weeks

• Persistent
• Symptoms present ≥ 4 days/ week and ≥ 4 consecutive weeks
Treatment
Goal of treatment:

• To minimize the frequency and severity of symptoms

• To prevent comorbid disorders and complications

• To improve the patient’s quality of life

• To improve work attendance and productivity and/or school attendance

and performance

• To minimize adverse effects of therapy

 FIRST LINE AGENTS

▪ Corticosteroids
▪ Antihistamines

ADJUNCTIVE OR SECONDARY CHOICE AGENTS

▪ Decongestants
PHARMACOLOGIC
▪ Mast cell stabilizers
THERAPY ▪ Leukotriene receptor antagonists
▪ Antimuscarinic agents
▪ Omalizumab
▪ Immunotherapy
▪ Complementary and alternative medicine (CAM) therapy
 Intranasal corticosteroid
• The most effective therapy for AR especially for nasal congestion,
due to its anti-inflammatory properties.
• Provide very good relief for sneezing, itching, rhinorrhoea, nasal
Corticosteroids congestion and ocular symptoms.
• Superior to intranasal antihistamine.
• Eg: fluticasone, mometasone, budesonide
• No evidence of any single product is superior in efficacy
• Patients’ preference based on cost, availability, odour and
aftertaste.

Oral corticosteroid
• May be used in severe nasal congestion, particularly due to rhinitis
medicamentosa.
• Given as a short course of therapy
Correct administration technique of intranasal
medication
 • It is very effective for sneezing, itching, rhinorrhoea.

• Provide some benefit for nasal congestion and ocular

symptoms.

• Administered either by oral or intranasal route.

Antihistamines
• Intranasal administration is more effective than oral
administration for the nasal congestion, but less effective
for the ocular symptoms.
 Oral antihistamine agents
Second generation:
First generation:
• Cetirizine
• Diphenhydramine
• Loratadine
• Chlorpheniramine
• Desloratadine
• Levocetirizine

The use of first generation antihistamine is The second-generation antihistamines have less
currently discourage due CNS and antimuscarinic activity than the first-generation agents.
antimuscarinic side effects.

Able to decrease rhinorrhoea

 • Only for nasal congestion.

• Posses α1 adrenergic agonist activity, which causes

vasoconstriction in the nasal mucosa.

• Decongestants can be given alone, either by the oral

Decongestants or by the intranasal route.

• Eg:
• Pseudoephedrine
• Phenylephrine
Side effects of oral decongestants:

• Elevation of blood pressure

Affects cardiovascular and
• Insomnia
CNS function
Caution is warranted when they are used in patients
• Nervousness with cardiac disease (dysrhythmias, angina pectoris,
heart failure), hypertension, cerebrovascular
• Irritability disease, bladder outlet obstruction (including BPH),
glaucoma (especially closed angle),
• Anxiety hyperthyroidism, and possibly diabetes
 Intranasal decongestant

• Phenylephrine

• Oxymetazoline

• Naphazoline

• Provides rapid and effective relief of nasal congestion.

• Should be limited to short term use. Usual recommendation is to use them for no more than 3
consecutive days.

• Continuous use of intranasal decongestants often causes a paradoxical rebound phenomenon of

persistent nasal congestion, called rhinitis medicamentosa

• Rarely cause systemic side effects. Local side effects of intranasal decongestant:
• Stinging
• Burning
• Dryness
• Sneezing
 The drug binds to mast cells and prevent the
release of mediators.

Moderately effective compared to INCSs and oral

or intranasal antihistamine.

Mast Cell It can be used effectively on an as-needed basis for

episodic exposures to allergen.
Stabilizer
Most useful for patient with mild and intermittent
symptoms.

Disadvantage: four times daily

Eg: Cromolyn
 Leukotriene contribute to nasal congestion in the
late phase.

Mostly good benefit for nasal congestion and

rhinorrhoea, some benefit for ocular symptoms,
less for nasal itch and sneezing compared to
INCSs and antihistamines.
Leukotriene
Receptor Montelukast is the only LTRA approved for
treatment of AR.
Antagonist (LRTA)
The combination of montelukast with an oral
antihistamine may have improved efficacy over
either agent alone, according to some sources;
however, even the combination is probably not
better than INCSs
 Eg: Intranasal ipratropium

Have minimal systemic absorption

Its use is limited to those patients whose rhinorrhea

has not been controlled by other therapy
Antimuscarinic (antihistamines and/or INCSs)
agent There are two strengths available, 0.03%(children age 6
years old and above) and 0.06%.
 A monoclonal antibody that bind to IgE.

Its use is best limited to those with concurrent asthma and AR.

Approved for moderate to severe persistent asthma with a

Omalizumab positive skin test or in vitro reactivity to a perennial
aeroallergen and symptoms that are inadequately controlled
with inhaled corticosteroids in patients ages 6 years and older.

Administered by subcutaneous injection.

Dosage is determined by the patient’s circulating IgE levels.

Very costly.
Non-pharmacological
Treatment
 ALLERGEN AVOIDANCE MEASURES

Identify the allergen

Indoor allergen:
• Limit outdoor exposure especially during high pollen conditions and during mold /fungi release
• Wear a face mask during activities that disturb soil and decaying vegetation
• Keep windows and doors closed
• Use air conditioning, but maintain clean equipment

Indoor allergens
• Use air conditioning
• Maintain humidity below 50%, and maintain clean equipment
• Clean frequently to prevent mold growth – dilute bleach with detergent
• Avoid exposed food and garbage to deter insects
• Clean kitchen frequently
• Minimise carpeting, fabric covered furniture, and fabric wall/ window covering
• Cover bedding with allergen-proof, zippered cases
• Keep pets out of bedroom and bath cats weekly if possible
 To improve sneezing and nasal congestion.

Less effective than intranasal corticosteroids.

It can be used either alone or as add-on therapy.

Saline
Mode of administration:
• Drop
• Spray
• Irrigation
AR in special
populations
 Second generation H1 antihistamine for mild or intermittent
symptoms.

Intranasal corticosteroids for moderate-severe or persistent

manifestation.
- Mometasone
- Fluticasone
- Triamcinolone
Paediatric
Can be given as combination of INCS and antihistamine when
necessary.

First generation antihistamine is discouraged due to the possible

detrimental effects on school performance and learning.
 Nasal saline irrigations are safe, effective, and improve the response
to most other modes of therapy

External adhesive strips can be used to help keep the nares open,
especially during sleep

Pregnant Second-generation antihistamines are generally

considered safe.
women
FDA pregnancy category B:
• Budesonide
• Cromolyn
• Montelukast
• Ipratropium
Thank you