How is allergic rhinitis treated?

Objectives of treatment of allergic rhinitis

The main goal is to alleviate the symptoms of the disease. The complex of therapeutic measures includes the elimination of allergens, drug treatment, specific immunotherapy and patient education.

Indications for hospitalization

Allergic rhinitis is treated on an outpatient basis.

Elimination of allergens

Treatment of allergic rhinitis begins with the detection of possible cause-significant allergens, after elimination of which in most cases the symptoms of rhinitis decrease.

The main groups of allergens that cause allergic rhinitis

• Pollen allergens (pollen of trees, grass and weeds). In the flowering season, to eliminate allergens, it is recommended to keep the windows and doors indoors and in the car closed, use the air conditioning systems in the room, and limit the time spent on the street. After walking, it is advisable to take a shower or bath to remove pollen from the body and prevent contamination of the laundry.
• Spores of mold fungi. When allergic to spores molds are often recommended to clean rooms in which mold growth is possible, thoroughly clean air humidifiers, steam extractors, use fungicides, maintain relative humidity in the room of less than 40%.
• Ticks of house dust, insects (cockroaches, moths and fleas). In the highest concentration, house dust mite allergens are found in carpets, mattresses, pillows, upholstered furniture, clothes (mostly in the nursery), soft toys. Excrement of glue - the main allergen in the composition of house dust. Elimination measures:
  • carpets are replaced by easily washable, preference is given to wooden and leather furniture;
  • bedding is washed in hot water (at least 60 ° C) at least once a week;
  • use special anti-nodular bedding, covers on mattresses that do not pass the allergen (this helps reduce the concentration of house dust mites, but does not lead to a significant decrease in the symptoms of allergic rhinitis);
  • the relative humidity in the apartment is maintained at a level no higher than 40%;
  • use a vacuum cleaner with a built-in HEPA filter and dust collectors with thick walls (using air purifiers is not effective for removing tick allergens);
  • for the destruction of ticks, special chemical preparations are used - acaricides (for example, for carpets - a solution containing benzyl benzoate, for upholstered furniture - 3% solution of tannic acid, acaricides are effective with regular application);
  • To remove cockroaches, insecticide treatment is recommended by specially trained personnel.
• Animal allergens. Elimination measures:
  • getting rid of pets;
  • the exclusion of the animal in the child's bedroom (if it is impossible to remove);
  • weekly bathing of the animal (it helps to reduce the number of allergens, but the benefits of this event are doubtful);
  • Use of HEPA filters (reduces the number of allergens in the room, but less efficiently than removing the animal).

Of course, specific desensitization is fine, but you need at least 30 injections, and what to do if there is a multialergy. The course lasts 4 months. In contrast to bronchial asthma in allergic rhinitis in children, even accelerated specific immunotherapy according to Sieselson (36 days) is also hardly justified. Recently, local immunotherapy is gaining popularity, which is conducted by standardized allergens of house dust, cereals, herbs and begins before the peak of the season at a frequency of 3 times a week for three months by intranasal insufflation.

Clinical improvement should be expected after a long time (weeks) after elimination of allergens.

Food allergens can cause rhinorrhea in young children.

Medicamentous treatment of allergic rhinitis

If the elimination of allergens does not lead to a reduction in the severity of symptoms, drug treatment is initiated.

Anti-inflammatory drugs

Local (intranasal) glucocorticosteroids are the drugs of choice in the treatment of allergic rhinitis; they effectively reduce the severity of such symptoms as itching, sneezing, rhinorrhea and nasal congestion. These drugs, due to their anti-inflammatory effect, are more effective than intranasal cromones and systemic antihistamines. The clinical onset of intranasal glucocorticosteroids occurs on the 2-3rd day of treatment, the maximum effect occurs by the 2-3rd week and persists throughout the course of treatment. To achieve control of the disease, they are recommended for regular and prolonged use. Modern intranasal glucocorticosteroids, such as mometasone and fluticasone, are preferred for use in pediatric practice. They adequately control the symptoms of allergic rhinitis and have good tolerability. The advantages of these drugs include the possibility of their use once a day and minimal systemic absorption (<0.1 and 2%, respectively). Side effects occur in 5-10% of cases, among local effects, the most common sneezing, burning, irritation of the nasal mucosa, which are usually expressed minimally and do not require drug withdrawal. In rare cases, with improper application of intranasal glucocorticosteroids (spraying on the nasal septum area) perforation of the nasal septum is possible. In numerous studies in children, it has been shown that the use of modern intranasal glucocorticosteroids (mometasone, fluticasone) in therapeutic doses does not affect growth and the hypothalamic-pituitary-adrenal system. It has been proven that mometasone does not have systemic side effects even with prolonged (1 year) use. Taking into account the results of separate clinical studies, indicating the delay in the growth of children aged 3-9 years with beclomethasone and delayed growth of the lower limbs in children using budesonide, these glucocorticosteroids are undesirable in pediatric practice.

Prophylactic effect of mometasone on the course of seasonal allergic rhinitis is proved. When using the drug in the therapeutic dosage for 1 month before the expected flowering, the number of days free from allergic manifestations increases significantly.

To improve the effectiveness of intranasal glucocorticosteroids, it is recommended that the nasal cavity is cleared of mucus before the administration of the preparations, and the use of moisturizers is recommended.

• Mometasone is used in children from 2 years of age, prescribe 1 insufflation (50 mcg) in each half of the nose 1 time per day.
• Fluticasone is permitted for use in children from the age of 4, prescribed 1 dose (50 μg) in each half of the nose.
• Beclomethasone is used from 6 years, prescribe 1-2 inhalations (50-100 μg) 2-4 times a day, depending on the age.
• Budesonide is used in children from the age of 6, appoint 1 dose (50 mcg) in each half of the nose 1 time per day, the maximum daily dose of 200 mcg.

Mometasone (nazonex) has an optimal efficacy / safety profile in the class of intranasal glucocorticoids. Due to its pharmacological properties, the highest lipophilicity and the final viscosity, mometasone furoate quickly penetrates into the mucous membrane of the nasal cavity, practically does not flow down the back wall of the pharynx and exerts maximum effect in the inflammatory focus. This causes high local anti-inflammatory activity and systemic safety of the drug.

Systemic glucocorticosteroids (oral or parenteral) reduce the severity of symptoms of allergic rhinitis, but given the potential for systemic side effects, their use in the treatment of allergic rhinitis in children is very limited.

Antihistamines of the second generation serve as the basis for the treatment of allergic rhinitis, regardless of the degree of its severity. This is due to the fact that allergic rhinitis is a systemic disease that is often associated with other manifestations of allergy (bronchial asthma / bronchial hyperreactivity, urticaria, atopic dermatitis). In addition, clinical studies have shown that with moderate and severe forms of the disease, intranasal glucocorticosteroid monotherapy is not always effective enough (more than 50% of patients need additional antihistamines).

Antihistamines

Antihistamines of systemic action prevent and reduce such symptoms of allergic rhinitis as itching, sneezing, rhinorrhea, but less effective with regard to nasal obstruction. The possibility of developing tachyphylaxis with second-generation antihistamines is not available.

Antihistamines of the first generation (chloropyramine, mebhydroline, clemastin) in the treatment of allergic rhinitis are rarely used because of pronounced sedative and anticholinergic side effects. These drugs violate cognitive functions: concentration of attention, memory and learning ability.

Second-generation antihistamines such as desloratadine, loratadine and fexofenadine do not penetrate the blood-brain barrier and do not have a sedative effect in therapeutic doses, they do not affect attention concentration, memory and learning ability.

Cetirizine and levocetirizine pass through the blood-brain barrier to a lesser extent than antihistamines of the first generation, in therapeutic doses can cause sedation (in 15% and 5-6% of cases, respectively).

• Desloratadine is used in children 1-5 years for 1.25 mg (2.5 ml), from 6 to 11 years - 2.5 mg (5 ml) once a day in the form of a syrup, over 12 years - 5 mg 1 tablet or 10 ml of syrup) 1 time per day.
• Loratadin is used in children older than 2 years. Children with a body weight of less than 30 kg of the drug prescribed 5 mg once a day, children with a body weight of more than 30 kg - 10 mg once a day.
• Cetirizine for children from 1 to 6 years of age appoint 2.5 mg twice a day or 5 mg once a day in the form of drops, children older than 6 years - 10 mg once or 5 mg 2 times a day.
• Fexofenadine is used in children 6-12 years of age for 30 mg once a day, over 12 years - 120-180 mg once a day.

Desloratadine is the most studied antihistamine in patients with allergic rhinitis. In numerous clinical studies, desloratadine has been shown to be highly effective against all the symptoms of allergic rhinitis, including nasal congestion, as well as concomitant ophthalmic and bronchial symptoms (in patients with concomitant allergic conjunctivitis and asthma).

With respect to reducing the severity of symptoms of allergic rhinitis, antihistamines are less effective than intranasal glucocorticosteroids, and are comparable or even superior to cromones. With a mild allergic rhinitis, second-generation antihistamines can be used as monotherapy. With moderate and severe allergic rhinitis, it is justified to add second-generation antihistamines to the treatment with intranasal glucocorticosteroids.

Intranasal antihistamines (azelastine) are effective in the treatment of seasonal and all-year-round allergic rhinitis. When they are used, it can burn in the nose, a bitter and metallic taste in the mouth. Azelastine is used in children older than 5 years in the form of nasal spray for 1 insufflation 2 times a day.

Cremona

Cromoglycic acid is less effective than intranasal glucocorticosteroids, but more than a placebo in the treatment of allergic rhinitis. The drug is used in children with allergic rhinitis of the mild course in the form of nasal sprays 1-2 insufflation in each nasal passage 4 times a day. Cromoglycic acid is the drug of first choice in children under 3 years of age, the second choice in children older than 3 years. The most effective preventive use of the drug (before contact with allergens). Side effects are minimal.

Combined treatment of allergic rhinitis

For patients with moderate to severe disease or with ineffective initial treatment, a combination therapy may be prescribed, which includes intranasal glucocorticosteroids and second generation antihistamines or cromoglycic acid. Combined treatment with second-generation antihistamines and intranasal glucocorticoids contributes to the effect of using lower doses of the latter.

Drugs for the relief of symptoms

Decongestants. Intranasal vasoconstrictors (naphazoline, oxymetazoline, xylometazoline) for the treatment of allergic rhinitis in children are not recommended for use for more than 3-7 days due to the risk of systemic side effects and tachyphylaxis, which is manifested by ricochet swelling of the nasal mucosa. With prolonged use of drugs of this group, medical rhinitis occurs. It is permissible to use vasoconstrictive drugs in patients with severe nasal congestion before intranasal glucocorticosteroids are administered for no more than 1 week.

Moisturizers. This group of drugs helps to moisturize and cleanse the nasal mucosa.

The effect of different groups of drugs on individual symptoms of allergic rhinitis

Medicinal products	Sneezing	Discharge from the nose	Itching in the nose	Nasal congestion
Antihistamines	+++	++	+++	?
Intranasal GCS	+++	+++	+++	++
Cremona	+	+	+	+/-
Decoingstants				+++

Allergen-specific immunotherapy

This method of treatment consists in the introduction of increasing doses of the allergen, to which the patient has an increased sensitivity. Applied for the treatment of allergic rhinitis associated with hypersensitivity to pollen of plants and to house dust mites, and (with less effect) when sensitized to allergens of animals and mold. Allergen-specific immunotherapy is performed with ineffectiveness of elimination measures and drug treatment or with undesirable side effects from the drugs used. Applied in children older than 5 years. Duration of treatment is 3-5 years. Allergen-specific immunotherapy is carried out according to an individually designed scheme under the supervision of an allergist doctor. Patients receiving the parenteral allergen should be under the supervision of the doctor within 30-60 minutes after the injection (the possible time of development of adverse reactions).

Other treatments for allergic rhinitis

Surgery

Indications:

• irreversible forms of hypertrophy of nasal congestion, which appeared against the background of allergic rhinitis;
• true hyperplasia of the pharyngeal tonsil, which significantly disrupts nasal breathing and / or accompanied by hearing impairment;
• abnormalities of intranasal anatomy;
• pathology of the paranasal sinuses, which can not be eliminated by other means.

Patient education

• Providing detailed information about elimination activities.
• Acquaintance with modern methods of treatment and possible side effects.
• Acquaintance with various measures to prevent exacerbations of allergic rhinitis (preseasonal prophylaxis before presumed contact with the allergen).
• Carrying out allergotschool, providing methodological materials and manuals.

Surgical methods of treatment of allergic rhinitis

Chronic tonsillitis: it is proved that tonsillectomy does not lead to improvement in the clinical picture of allergic rhinitis.

Curvature of the nasal septum: indisputably, showing the removal of spines. Resection is cautious, it is only shown when combined with broncho-pulmonary syndrome and at an older age.

Hypertrophic rhinitis: surgical treatment is indicated, however it is desirable to use submucosal methods of conchotomy with a laser.

Anomalies in the area of the middle nasal passage: it is highly desirable to eliminate endoscopically or by means of a laser.

Hypertrophy in the vomer area: mandatory laser or cryoexposure.

Polyposis of nose: up to 3 years - conservative treatment, immunotherapy gives effect. After 3 years - careful removal of polyps without opening the trellis labyrinth with subsequent conservative anti-relapse therapy.

Chronic sinusitis: endonasal dissection, restoration of aeration. Removal of individual small polyps and cysts. Radical surgery - only with infectious-allergic forms at an older age.

Adenoids: with allergic rhinitis, the pharyngeal tonsil also becomes a shock organ, where inhaled allergens are delayed. This fact is confirmed by immunological and histological methods. Hypertrophy of II and III degree is an obvious indication to adenotomy, but the attitude to this operation with allergic rhinitis should be neat. Preoperative preparation is shown, the operation should be performed outside the exacerbation of rhinitis, with pollinosis - outside the flowering season. Postoperative therapy is mandatory, since it is in this group that a large percentage of relapses are observed.

Difference in the approach to surgical correction in the nasal cavity and its paranasal sinuses

We believe that in the latter case a separate classification is appropriate. This is due to some factors. Allergic rhinitis has significant features in different age groups, so the main criterion here should be the age-based approach. The course of allergic rhinitis and its etiology (allergens) are different from those in adults. Heredity, immunological status, anatomical and physiological conditions (for example, absence of frontal sinuses), age variants of the structure, creating conditions for excessive concentration of allergens and formation of focal zones of allergic inflammation are of great importance. There are other concomitant diseases of ENT organs (for example, adenoids), a different approach to surgery (for example, submucosal resection of the septum of the nose), other combinations with infections (for example, with children), functional disorders predominate, to a lesser extent organic (for example, pronounced polyposis of the nose). The possibilities of treatment due to side effects of drugs, the risk of systemic diseases and methodological difficulties in the local treatment are reflected. All this testifies to the advisability of a separate classification of allergic rhinitis in childhood.

Age classification of allergic rhinitis in childhood

Age, years	0-3	3-7	7-14
Etiology of allergy	Food Medications	Inhalation	Inhalation
Flow	Constant forms	Seasonal Permanent	Seasonal Permanent
Concomitant ENT diseases	Nose development anomalies Ethmoiditis Genyantritis	Adenoids Exudative otitis Hymoroethmoiditis	Polyposis of the nose Polyposis sinusitis Hypertrophy of the nasal conchae Fronts Sfentidity Curvature of the septum
Associated Allergic Disease	Exudative diathesis Atopic dermatitis Conjunctivitis	Asthmatic bronchitis	Bronchial asthma Atopic dermatitis
Surgery	Elimination of anomalies in the development of the nose Punctures of the maxillary sinuses	Adenotomy Ethmoidectomy Puncture of maxillary sinuses Cristotomy Endonasal maxillary sinusitis	Resection of the nasal septum Laser operations on the nasal conchaes (submucosal) Trepanopuncture of the frontal sinuses Radical operation on the maxillary sinuses

Tactics of further reference

Multiplicity of observation of a patient with allergic rhinitis:

• pediatrician - with exacerbation according to clinical indications, mainly 1 time in 5-7 days; exacerbation of 1 every 6 months;
• Allergist - outside of an exacerbation 1 time in 3-6 months.

Indications for consultation of other specialists

The patient should be referred to a specialist (allergist, otorhinolaryngologist) in the following cases:

• ineffectiveness of oral / intranasal drug treatment;
• moderate and severe persistent symptoms;
• the need for a skin testing / radioallergosorbent test to identify cause-relevant allergens in order to perform elimination activities and address the issue of allergen-specific immunotherapy.
• concomitant diseases (atopic dermatitis, bronchial asthma, chronic / recurrent rhinosinusitis);
• any severe allergic reactions that cause concern to the child and parents.

[1], [2], [3], [4], [5], [6], [7], [8]