Intranasal Steroid

• Intranasal steroids are the most effective

treatment for reducing nasal inflammation
and improving conjunctival symptoms

• Therefore, it is important to explain to the

patient that the dose of nasal steroids is in
microgram quantities and for most of the
common molecules there is minimal systemic
bioavailability
• It is best to use the spray in the morning,
putting it next to the toothbrush to aid
memory. A second dose can be used in the
evening if needed, or if the morning one was
forgotten.
Spraying the nasal septum and sniffing the
spray straight back into the throat should be
avoided.
 Begin treatment early and take it
daily

Nasal steroids have been shown to take at least

several days to reach full effectiveness and
maximal effect may not be apparent for 2 weeks

For patients with intermittent symptoms (e.g.

those allergic to pollens) it has been
demonstrated that if therapy with topical nasal
corticosteroids is begun a week or two before
symptoms are expected, symptoms have delayed
onset and reduced severity.
• Thus, it can be useful to ask patients with known
seasonal allergic rhinitis to make a note of when
their symptoms started in the current year so
that in the following year they can start the
treatment earlier.
• Daily treatment helps to prevent this low-grade
ongoing subclinical allergic inflammation in the
nasal lining increasing to a threshold at which
symptoms occur and, thus, reduces the rate and
severity of exacerbations
• BSACI guidelines suggest that in more severe
disease nasal corticosteroids and
antihistamines may be used
• together and the combination of nasal
corticosteroid plus nasal antihistamine (e.g.
azelastine plus fluticasone) has been reported
to be more effective than either alone.
Management of allergic rhinitis
 Management of allergic rhinitis
Patients with intermittent allergic rhinitis
• Caused by seasonal allergens, as the
season wanes and pollen levels in the
atmosphere reduce, treatment can be
gradually reduced, if the symptoms are
completely controlled, and stopped
once the season is over.
Patients with persistent allergic rhinitis
• such as those allergic to perennial
allergens (e.g. house dust mite, animals
or indoor moulds) or those with mixed
seasonal and perennial allergies, need
longer term therapy.
• Once complete control of symptoms
has been achieved, a gradual ‘step
down’ can be attempted. The
treatment should be continued for at
least three to six months after
complete symptom control.
• If symptoms recur, the treatment
should be restarted, usually for longer
periods (e.g. 6–12 months or even for
life).
 Allergen avoidance

Studies involving concomitant multiple strict

allergen control measures showed that it is
possible to achieve a significant reduction in
allergen exposure and, consequently, in
symptoms.

However, in real life situations, avoiding

aeroallergens to an extent where it would
make a difference in patients’ symptoms is
difficult to reach. With pollen allergy, closing
windows at night, driving with closed windows
or wearing wrap-around glasses outdoors can
prevent symptom exacerbation.
 Immunotherapy
Allergen-specific immunotherapy
is the treatment in which a
patient’s immune system is
rendered tolerant to an allergen
by giving increasing doses of the
allergen in a controlled fashion.
Few seasonal allergic rhinitis
patients warrant immunotherapy
treatment; it should only be
considered when allergic rhinitis
is debilitating and poorly
controlled by pharmacotherapy

Immunotherapy is currently
available for allergic rhinitis
caused by pollen, moulds, house
dust mite and animal allergens.
 Subcutaneous
Sublingual immunotherapy
immunotherapy
• involves allergen • is considered to be much
injections at regular time safer. The initial dose is
intervals in a hospital by given under supervision,
trained medical staff. With but can then be continued
treatment lasting several on a daily basis at home
years, patient
commitment to attending
hospital appointments is
essential.
Management in specific patient
groups

Allergic
Children with
rhinitis in
allergic rhinitis
pregnancy
 Children with allergic rhinitis
• Children metabolise drugs less well than adults because the
liver enzymes mature slowly and only reach maximal levels at
around ten years of age. However, renal clearance is well
developed.
• Of the OTC preparations, this means cetirizine is preferable,
rather than loratadine.
• A nasal steroid with low systemic bioavailability should be
used at the lowest possible dose to control symptoms,
particularly nasal congestion and obstruction.
• In older children where liver metabolic enzymes are
increasing, it may be preferable to use fluticasone,
which is cleared by first metabolism, rather than
beclomethasone that is not and, consequently, may
accumulate.
• Furthermore, fluticasone is available for children
from four years of age, while beclomethasone is only
available for children from six years of age.
 Allergic rhinitis in pregnancy
• Regular nasal douching may be helpful. Of the
antihistamines, both loratadine and cetirizine are
recommended because they appear to have good
safety records because they have been widely used
in pregnant women. Similarly, beclomethasone and
fluticasone appear safe.
• Local application of chromones , are probably the
safest drug choice for use in the first three months of
pregnancy because systemic absorption is negligible.
 Conclusion
• The treatment of allergic rhinitis involves non-
sedating H1 -antihistamines to reduce
rhinorrhoea and nasal itching, and
corticosteroids to reduce allergic inflammation
and nasal blockage.
• They should be used on a daily basis rather
than on ad hoc when symptoms are bad.