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nasal steroids . ( 3 , 21 , 22 ) Fluticasone propionate and azelastine are combined together in a brand name product called Dymista . The use of combination therapy is particularly beneficial in relieving symptoms of congestion when nasal steroids alone are ineffective . Patients report a significant benefit in pretreating with nasal antihistamine spray before exposure to known allergic triggers . This may be explained by the fact that , unlike nasal steroids , nasal antihistamine sprays have a very quick onset of action . ( 20 )
Studies have shown less benefit in combining an oral antihistamine with a nasal steroid and as a result , it is less often routinely recommended . In a patient with mild episodic nasal symptoms , particularly rhinitis and sneezing , an oral antihistamine may be of benefit especially in those individuals who do not like the delivery of a nasal spray and will not utilize this modality of treatment . ( 3 , 21 , 22 ) Addition of leukotriene modifiers ( montelukast ), would be a later add on treatment after nasal steroids , nasal antihistamines and oral antihistamines . ( 3 , 21 , 22 )
Special situations do come up as it relates to the treatment of rhinitis and warrant consideration . In the patient with non-allergic rhinitis , certain nasal steroids have been shown to be of benefit over others with fluticasone propionate having greater efficacy compared to other intranasal steroids for non-allergic rhinitis . In a patient with persistent rhinorrhea , nasal ipratropium bromide ( nasal Atrovent ) has been successful alone and sometimes in combination with azelastine . There are times when the rhinitis can be so severe that one may have to resort to prescribing a first-generation antihistamine or perhaps a combination oral antihistamine / anticholinergic at bedtime to control the profuse rhinorrhea that occurs . Finally , those with gustatory rhinitis may benefit from the use of nasal ipratropium bromide and nasal azelastine just prior to eating with the caveat not to exceed dosing outside the recommendations in the package insert .
Another very important group of patients to consider who often present with severe nasal symptoms are expecting mothers . Pregnant patients often have underlying allergic rhinitis and certain medications are unique in their pregnancy category B designation and are preferred . Table V summarizes these medications . ( 3 )
Special circumstances :
TABLE V . PREGNANCY CATEGORY B MEDICATIONS
Rhinocort ( budesonide ) Singulair ( montelukast ) Claritin ( loratadine ) NasalCrom ( cromolyn nasal ) Xyzal ( levocetirizine ) Zyrtec ( cetirizine )
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Allergen Immunotherapy may be continued during pregnancy at the current dose but not increased assuming current dose is not causing significant reactions .
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Decongestants are not recommended in pregnancy . ( Congenital malformations including gastroschisis and small intestinal atresia .)
»» Allegra ( fexofenadine ) has pregnancy category C designation .
It is important to note that rhinitis of pregnancy ( not allergic rhinitis ), can often occur before 34 weeks gestation , and persist until delivery with complete resolution 2 weeks after delivery . ( 3 ) This rhinitis of pregnancy is best managed by the use of saline or nasal saline irrigations and not nasal steroids . Nasal steroids have not been shown to be effective in treating rhinitis of pregnancy . ( 29 )
A word about saline … It is important to tell your patients not to use tap water in their use of preparing saline irrigations . Tap water has been shown to have amoeba and other organisms , which have resulted in CNS infections and therefore using distilled water is preferred and should be recommended . Some specialists have utilized the use of saline compounded with nasal steroid preparations through compounding pharmacies to help severe patients , particularly those with sinus disease . These have not received FDA approval , but nevertheless , may be of benefit .
ADVANCES IN IMMUNOTHERAPY FOR SPECIFIC PA- TIENTS .
As alluded to earlier , in patients with severe allergic disease who have failed medical management or in those patients who want to avoid taking medications and wish to pursue more of a long term solution , immunotherapy is an excellent choice .( 3 ) Immunotherapy has also been a very effective treatment for individuals with allergic rhinitis who have a good clinical history associated with strong skin prick test reactivity and a desire to try to get off medications and impact the long term prognosis of their disease .( 3 ) Immunotherapy used in children has been shown to decrease the progression of allergic rhinitis to asthma .( 24 ) In children with monosensitization , immunotherapy has been shown to decrease further sensitization to new allergens .( 25 , 26 ) In addition to treating allergic rhinitis , subcutaneous immunotherapy is also indicated for allergic asthma and recently atopic dermatitis . Immunotherapy has been given in many ways ; however , there are only two FDA approved means of delivery . One being standardized sublingual immunotherapy indicated for only for allergic rhinitis to grass ( Oralair , Grastek ), ragweed ( Ragwitek ), and dust mites ( Odactra ). The second being subcutaneous immunotherapy used to treat allergic rhinitis , allergic asthma , and atopic dermatitis due to indoor and outdoor allergens . Sublingual drops have not been standardized so therapeutic dosages and safety parameters have not been established and for these reasons , sublingual drops have not been approved by the FDA .
In comparing subcutaneous immunotherapy and sublingual immunotherapy , several points are worth noting . Subcutaneous immunotherapy has long been studied and has been very beneficial with a more robust clinical response and longer remission rates compared to sublingual immunotherapy .( 23 ) Sublingual immunotherapy has the benefit of home administration with less systemic reactions and no fatalities being reported .( 23 ) Studies with both subcutaneous immunotherapy and sublingual immunotherapy have yielded significant changes in the immune system causing an increase in T regulatory cells and a decrease in TH2 cells with more of a TH1 response . Initially IgE levels increase , however , after several months , IgE levels decrease following immunotherapy . Other mechanisms include the presence of IgG4 blocking antibody .
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