Pharmacotherapeutic strategies for allergic rhinitis: Matching treatment to symptoms, disease progression, and associated conditions

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Abstract:

The selection of specific pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, most prominent symptoms, symptom severity, patient preference, cost, and comorbid conditions. Guidelines focus on immediate symptoms and monotherapy. However, given the often variable course of disease, understanding symptom patterns, and recommending intervention transitions among agents and classes (and from alternative single and combination medications) can aid in optimization of treatment. This review focuses on considerations for combination therapy for AR, particularly in the context of step-up and step-down treatment, and individual symptoms and comorbidities that may benefit from such treatment (e.g., asthma). Relevant clinical studies for treatment of AR and of AR with comorbid asthma and information on treatment guidelines were identified through MEDLINE searches from inception through 2012. Search terms and phrases included “allergic rhinitis,” “asthma,” “treatment guidelines,” and “stepwise treatment.” Stepped methodology is individualized according to patient-specific factors and severity of disease. A possible step-up/step-down approach might move through five stages: step 1, for mild intermittent symptoms, intranasal or oral antihistamine, as needed; step 2, daily intranasal antihistamine (an oral antihistamine or leukotriene antagonist may be considered as an alternative); step 3, daily intranasal corticosteroids (INS); step 4, combination INS and intranasal antihistamines; step 5, further add-on therapy options in severe cases. A step-up/step-down approach to AR pharmacotherapy based on patient response may hold the potential for optimal control of AR symptoms while minimizing side effects and cost of treatment.

Keywords: Antihistamine; asthma; combination therapy; congestion; corticosteroids; decongestant; intranasal steroid; montelukast; ocular symptoms; stepwise treatment

Document Type: Research Article

DOI: http://dx.doi.org/10.2500/aap.2013.34.3676

Affiliations: Allergy & Asthma Medical Group & Research Center, San Diego, California, USA

Publication date: July 1, 2013

More about this publication?
  • Allergy and Asthma Proceedings is a peer reviewed publication dedicated to distributing timely scientific research regarding advancements in the knowledge and practice of allergy, asthma and immunology. Its primary readership consists of allergists and pulmonologists.

    The goal of the Proceedings is to publish articles with a predominantly clinical focus which directly impact quality of care for patients with allergic disease and asthma.

    Featured topics include asthma, rhinitis, sinusitis, food allergies, allergic skin diseases, diagnostic techniques, allergens, and treatment modalities. Published material includes peer-reviewed original research, clinical trials and review articles.

    Articles marked "F" offer free full text for personal noncommercial use only.

    The journal is indexed in Thomson Reuters Web of Science and Science Citation Index Expanded, plus the National Library of Medicine's PubMed service.
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