Treatment of allergic rhinitis

Pharmacotherapy of allergic rhinitis has its own peculiarities:

• the effect of drugs for the treatment of allergic rhinitis after their abolition quickly passes, so with a persistent form, treatment should be continuous;
• tachyphylaxis (rapidly developing tolerance) with long-term use of drugs does not happen. The only exception is the vasoconstrictor and H1 receptor blockers of histamine I generation, which can cause tolerance (sensitivity to the drug used);
• medications are usually administered orally or intranasally;
• the active use of glucocorticoids is usually not recommended because of the risks of developing severe side effects.

In the presence of conjunctivitis in the above scheme it is necessary to include a blocker of H1 receptors of histamine or cromones in the form of eye drops.

Non-drug treatment of allergic rhinitis

Treatment of allergic rhinitis includes allergen-specific immunotherapy and pharmacotherapy.

Allergen-specific immunotherapy is a treatment with increasing doses of an allergen, which is most often injected subcutaneously (less often intranasally or sublingually). Data on the efficacy and safety of subcutaneous immunotherapy are contradictory. It is believed that immunotherapy is most effective in children and adolescents with monovalent sensitization and a mild course of the disease.

It must be carried out strictly according to the indications.

Indications for subcutaneous specific immunotherapy:

• insufficient effectiveness of pharmacotherapy;
• refusal of the patient from medical treatment;
• manifestation of undesirable effects of drugs;
• period of stable clinical and functional remission:
• accurate identification of the allergen.

A subcutaneous immunotherapy should be performed by an allergist specialist in the conditions of a specialized allergological cabinet.

Quite often, alternative therapies are used, such as homeopathy, acupuncture, phytotherapy. However, to date, there is no scientific evidence to support the effectiveness of these methods.

Medicamentous treatment of allergic rhinitis

The tactics of drug treatment depend on the severity of the disease and includes certain groups of medicines.

For the treatment of allergic rhinitis use antihistamines.

• Preparations of the first generation: chloropyramine, clemastine, mebhydroline, promethazine, diphenhydramine,
• Preparations of the second generation: acrivastine, cetirizine, loratadine, ebastin,
• Preparations of the third generation: desloratadine, feksofenadn. Antihistamines of the 1st generation (competitive antagonists of histamine H1 receptors) have a number of disadvantages. The main undesirable properties of this group of drugs are short-term action, marked sedation, development of tachyphylaxis, which requires frequent changes of one drug to another (every 7-10 days). In addition, these drugs have atropine-like effects (dry mucous membranes, delay urination, exacerbation of glaucoma).

Antihistamines of the second generation are highly selective blockers of histamine H1 receptors. These drugs do not have a sedative effect, or it is insignificant, do not have anticholinergic action, tachyphylaxis does not occur with their administration, the drugs have a long-term effect (they can be taken once a day). Modern blockers of H1-receptor histamine are effective against the relief of many symptoms, such as rhinorrhea, sneezing, itching in the nose and nasopharynx, eye symptoms. Compared with antihistamine drugs of the 1st generation, antihistamines of the 2nd generation are more effective and safe. In this group of drugs, one of the most effective and fast acting is ebastine. In addition, it has a 24-hour effect, which makes it possible to use it not only as an "ambulance", but also as a drug for routine therapy of allergic rhinitis.

Antihistamines of the third generation are highly selective blockers of histamine H2-receptors. New, but already well-proven desloratadine is an active metabolite loratadine. Desloratadn to date - the most powerful of the existing antihistamines. In therapeutic doses, it has antihistamine, anti-allergic and anti-inflammatory effects. By the strength of blocking the main mediators of allergic inflammation, the effectiveness of desloratadine is comparable to dexamethasone. The effect of the drug is manifested as early as 30 minutes after ingestion and lasts for 24 hours. Against the background of desloratadine, there was a significant decrease in nasal congestion in allergic rhinitis.

Fexofenadine is a fast acting and effective antihistamine. Quickly absorbed, the concentration in the blood plasma is maximal 1-5 hours after ingestion, the effect after a single dose is maintained for 24 hours. In therapeutic doses (up to 360 mg), fexofenadine does not adversely affect the psychomotor and cognitive functions.

Local antihistamines: azelastine, dimethindene-phenylephrine are released as a nasal spray and eye drops. These drugs are recommended for mild forms of the disease (nasal forms stop the rhinorrhea and sneezing) and to eliminate the symptoms of allergic conjunctivitis. Advantages of these drugs: rapid onset of the effect (after 10-15 min) and good tolerability. Azelastine and levocabastine are used 2 times a day after the toilet bowl.

Glucocorticoids used for the treatment of allergic rhinitis: beclomethasone, mometasone, fluticasone, hydrocortisone, prednisolone, methylprednisolone. Local glucocorticoids are the most effective means of treating all forms of allergic rhinitis. Their high efficiency is due to the pronounced anti-inflammatory effect and influence on all stages of the development of allergic rhinitis. They reduce the number of mast cells and the secretion of mediators of allergic inflammation, reduce the number of eosinophils, T-lymphocytes, inhibit the synthesis of prostaglandins and leukotrienes, inhibit the expression of adhesion molecules. All these effects lead to a decrease in the tissue edema and normalization of nasal breathing, a decrease in the secretion of mucous glands, a decrease in the sensitivity of the receptors of the nasal mucosa to irritating effects. This, in turn, causes the cessation of rhinorrhea and sneezing, suppression of specific and nonspecific nasal hyperreactivity. Patients are well tolerated by modern preparations of glucocorticoids. When they are used, the atrophy of the nasal mucosa and the inhibition of mucociliary transport do not occur. The bioavailability of the drugs in this group is very low, which ensures their systemic safety. Rare side effects in the form of dryness in the nose, the formation of crusts or short nosebleeds are reversible and are usually associated with an overdose of the drug. Glucocorticoids are effective not only for allergic rhinitis, but also for allergic diseases, primarily bronchial asthma.

The first representative of the group of local intranasal glucocorticosteroids beclomethasone, which is used for the treatment of allergic rhinitis and bronchial asthma since 1974. Beclethamasone is considered the "gold standard" of basic therapy for allergic rhinitis. In nazis with allergic rhinitis intranasal forms of beclomethasone reduce the severity of the asthmatic component. Nabobek is a dosage spray containing an aqueous suspension of beclomethane, has a convenient mode of application: 2 times a day. The drug acts on the receptors of the nasal mucosa, does not dry or irritate it, which allows you to quickly and effectively eliminate the main symptoms. The incidence of side effects is low. Aldecine (a drug beclomethasone) otorhinolaryngologists and allergists are widely used in clinical practice for 10 years already. The drug has proved to be an effective and safe remedy for the treatment of allergic rhinitis, nasal pollinosis and bronchial asthma. The presence of two nozzles (for the nose and mouth) makes the use of the drug more convenient. A small amount of active substance (50 μg) in 1 standard dose allows individual selection of the necessary daily dose for adults and children.

Mometasone begins to act within the first 12 hours after admission. The use of mometasone once a day allows to stop all symptoms of allergic rhinitis, including nasal congestion, for 24 hours, which increases the patient's condition. In connection with low bioavailability (less than 0.1%), the use of mometasone guarantees high systemic safety (it is not determined in the blood even at a 20-fold excess of the daily dose). Mometasone does not cause dryness in the nasal cavity, since it includes a moisturizer. With prolonged use (12 months), mometasone does not cause atrophy of the nasal mucosa, but, on the contrary, helps restore its normal histological structure. The drug is approved for use by children from two years of age.

Fluticasone has a pronounced anti-inflammatory effect. In medial doses, he does not have systemic activity. It has been established that fluticasone significantly reduces the production of inflammatory mediators of the early and late phase of allergic rhinitis. Nasal spray fluticasone has a quick soothing and cooling effect on the nasal mucosa: it reduces congestion, itching, runny nose, unpleasant sensations in the area of the paranasal sinuses and a feeling of pressure around the nose and eyes. The preparation is produced in vials supplied with a convenient dispensing sprayer. Apply the drug 1 time per day.

Systemic glucocorticoids (hydrocortisone, prednisolone, methylprednieolon) are used to treat severe forms of allergic rhinitis during a short period of acute exacerbation with ineffectiveness of other methods. Scheme of treatment is selected individually.

Stabilizers of membranes of mast cells: kromony (kromoglikat) and ketotifen. Stabilizers of mast cell membranes are used to prevent intermittent allergic rhinitis or to eliminate intermittent symptoms of the disease, since these drugs do not have sufficient effect on nasal obstruction. The membrane-stabilizing effect of these drugs develops slowly (within 1-2 weeks), another significant drawback is the need for 4 single-dose, which creates significant inconvenience for patients. It should be noted that the cromones do not have side effects. This allows them to be used in children and pregnant women.

Vasoconstrictors: naphazoline, oxymetazoline, tetrisolin, xylometazoline. Vasoconstrictors (alpha-adrenoceptor agonists) are used in the form of drops or sprays. They effectively and quickly restore nasal breathing for a short time. With short courses of treatment (up to 10 days) they do not cause irreversible changes in the mucous membrane of the nasal cavity. However, with a longer use develops the syndrome "rebound": there is a persistent edema of the mucous membrane of the nasal concha, abundant rhinorrhea, a change in the morphological structure of the mucous membrane of the nasal cavity.

M-cholinoreceptor blockers: ipratropium bromide. The drug has virtually no systemic anticholinergic activity, locally blocks M-cholinergic receptors, reducing rhinorrhea. Applied for the treatment of moderate and severe forms of persistent allergic rhinitis in the complex therapy.

Mucolytics: acetylcysteine and carbocysteine are expedient for prescribing with prolonged intermittent forms.

Given that allergic inflammation is a chronic process, therapeutic efforts should be focused on the proper selection of basic therapy. The drugs of basic therapy can be glucocorticoids and cromones.

Vasoconstrictors and blockers of histamine H1-receptors for allergic rhinitis are used as symptomatic agents. The exception is the light forms of seasonal (intermittent) allergic rhinitis, when only these groups of drugs can be used.

Further management

Patients with allergic rhinitis need a dispensary observation of an otorhinolaryngologist and an allergist. This is associated with a risk of development in patients with allergic rhinitis polypous rhinosinusitis, bronchial asthma. Patients should visit the otorhinolaryngologist 1-2 times per year.