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Drugs in Allergic Rhinitis

#H1 antihistamines are effective for treating nasopharyngeal itching, sneezing, watery rhinorrhea, and ocular itching, tearing, erythema.

*Side effects associated with older H1 antihistamines include sedation, visual disturbance, urinary retention, and arrhythmias

#Newer H1 antihistamines:( terfenadine (Seldane) astemizole (Hismanal))

*These agents exhibit less sedation associated with their reduced ability to cross the blood brain barrier.
*However, there are very important drug-drug interactions associated with this category.
  • For example, macrolide antibiotics such as erythromycin, clarithromycin (Biaxin), ketoconazole-class broad-spectrum antifungal drugs, inhibit terfenadine (Seldane) or astemizole (Hismanal) metabolism.
  • Toxic levels of terfenadine (Seldane) or astemizole (Hismanal) may induce potentially fatal cardiac arrhythmias.
  • These new H1 antihistamines are contraindicated for concurrent use with macrolide antibiotics and ketoconazole-class and fungal drugs or in the presence of impaired hepatic function or inpatients predisposed to arrhythmias.

#Topical alpha-adrenergic agonists:

*Phenylephrine (Neo-Synephrine) or oxymetazoline (Afrin) reduce nasal congestion/obstruction.
  • Efficacy duration: limited due to rebound rhinitis and systemic effects which may include insomnia, irritability, and hypertension -- the latter which is seen more commonly with oral alpha adrenergic agonists.

#Oral alpha-adrenergic agonists may be useful in diminishing antihistamine-mediated sedation while improving antihistamine efficacy in relieving congestion. However, there is a concern that these agents due to their potentially hypertensive effects, may precipitate adverse cardiovascular effects, such as stroke. Recently, there has been an effort to remove such "pressor" agents from common over-the-counter cold medications.

#Cromolyn sodium: This agent is a liquid provided as a nasal metered-does spray. Cromolyn sodium (Intal) is not associated with side effects and typically is used prophylactically to reduce episodic allergen nasal mast cell activation. This agent may be used as part of a anti-asthma drug regimen.

#ntranasal glucocorticoids:

*Intranasal glucocorticoids are the most potent drugs available for management of established rhinitis (seasonal or perennial) and including vasomotor rhinitis
  • Topical-to-systemic activity greater for: flunisolide (AeroBid) or budesonide (Rhinocort), compared to beclomethasone (Banceril) or triamcinolone (Aristocort).
*Despite the different route of administration, intranasal-administered glucocorticoids exhibit the same efficacy but with reduced systemic side effects compared to same agent administered orally.
*Side effects include local irritation, which is the most frequent side effect to Candida over-growth which is an unusual side effect
*Topical high potency glucocorticoids exhibit superior efficacy compared antihistamines during pollen season.

#Immunotherapy (hyposensitization): This approach is based on repeated, subcutaneous injections of gradually increasing allergen (specific for the symptom complex) over a period of 3-5 years.

*Contraindications include significant cardiovascular disease and unstable angina
*Cautious use applies to patients receiving beta adrenergic blockers (due to difficulty in managing possible anaphylactoid responses to treatment)

**Clinical Management Sequence:

1.Identification of allergens confirmed by allergens-specific IgE skin testing and/or serum assay.
2.Avoidance of offending allergen
3.Mild symptoms: prophylaxis with topical cromolyn sodium or single (bedtime) dose of chlorpheniramine (Chlor-Trimeton) or astemizole (Hismanal) or terfenadine (Seldane) (decision based on side effects and presence of other concurrent medications or disease.
4.Prominent symptoms: Topical beclomethasone (Banceril) or if needed budesonide (Rhinocort) or flunisolide (AeroBid)
5.Management failure: immunotherapy

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