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Allergic rhinitis is a costly disease associated with significant morbidity. It impacts the quality of life of millions of individuals, particularly in industrialized nations, and it is on the rise. Lost productivity and total healthcare expenditure exceeds several billion dollars annually in the United States, with an estimate of >$6 billion spent on prescription medications alone. It is also associated with asthma and other atopic conditions, sinusitis, otitis media, and sleep apnea. Primary care physicians should be well adept at recognizing and initiating empiric first-line therapy for chronic rhinitis. Allergen avoidance, topical nasal steroids, and antihistamines may be sufficient for some patients. In most cases, referral to a board-certified allergy specialist for skin testing and targeted management is indicated. It is essential to make sure that patients abstain from using antihistamines at least 1 week prior to reporting to the allergist for skin testing in order to avoid false-negative results. Traditional subcutaneous allergen immunotherapy, when performed by an experienced allergist, affords relief in >75% of cases. The growing armament of treatment options for refractory allergic rhinitis includes oral and sublingual immunotherapy, recombinant allergens, conjugated DNA vaccines, and anti-immunoglobulin E monoclonal antibody.
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PMID:Allergic rhinitis. 2191 95

Rhinitis is a symptomatic inflammatory disorder of the nose with different causes such as allergic, nonallergic, infectious, hormonal, drug induced, and occupational and from conditions such as sarcoidosis and necrotizing antineutrophil cytoplasmic antibodies positive (Wegener's) granulomatosis. Allergic rhinitis affects up to 40% of the population and results in nasal (ocular, soft palate, and inner ear) itching, congestion, sneezing, and clear rhinorrhea. Allergic rhinitis causes extranasal untoward effects including decreased quality of life, decreased sleep quality, obstructive sleep apnea, absenteeism from work and school, and impaired performance at work and school termed "presenteeism." The nasal mucosa is extremely vascular and changes in blood supply can lead to obstruction. Parasympathetic stimulation promotes an increase in nasal cavity resistance and nasal gland secretion. Sympathetic stimulation leads to vasoconstriction and consequent decrease in nasal cavity resistance. The nasal mucosa also contains noradrenergic noncholinergic system, but the contribution to clinical symptoms of neuropeptides such as substance P remains unclear. Management of allergic rhinitis combines allergen avoidance measures with pharmacotherapy, allergen immunotherapy, and education. Medications used for the treatment of allergic rhinitis can be administered intranasally or orally and include oral and intranasal H(1)-receptor antagonists (antihistamines), intranasal and systemic corticosteroids, intranasal anticholinergic agents, and leukotriene receptor antagonists. For intermittent mild allergic rhinitis, an oral or intranasal antihistamine is recommended. In individuals with persistent moderate/severe allergic rhinitis, an intranasal corticosteroid is preferred. When used in combination, an intranasal H(1)-receptor antagonist and a nasal steroid provide greater symptomatic relief than monotherapy. Allergen immunotherapy is the only disease-modifying intervention available.
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PMID:Chapter 5: Allergic rhinitis. 2279 78

The goals of treatment are prevention of fatalities, hospitalizations, and emergency department visits, along with achieving good long-term control of asthma, with reduction of symptoms, maintenance of normal activity level, prevention of exacerbations, and accelerated loss of pulmonary function (forced expiratory volume in 1 second [FEV(1)]) as well as avoiding harm from therapies. Treatment often is initiated based on severity of symptoms, physical examination findings, and, for some patients, the FEV(1) or peak expiratory flow rates. Comorbidities such as gastroesophageal reflux disease and laryngopharyngeal reflux, rhinitis or rhinosinusitis, sleep apnea, recurrent infections, smoking, and substance abuse should be addressed. Two treatment modalities are indicated only for individuals with allergic asthma: allergen-specific immunotherapy, commonly known as allergy shots, and omalizumab. Allergen immunotherapy is effective in decreasing symptoms and medication use in selected patients with mild-to-moderate allergic asthma. In addition, patients receiving allergen immunotherapy for allergic rhinitis may have a decreased risk of developing asthma. Omalizumab, a recombinant humanized monoclonal anti-IgE antibody indicated for persistent moderate-to-severe allergic asthma, has been shown to improve asthma-related quality of life, decrease clinically significant exacerbation rates, number of courses of oral corticosteroids, and reduce the severity of exacerbations. It is administered every 2-4 weeks subcutaneously, and improvement should be ascertained after 4-6 months.
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PMID:Chapter 12: Asthma: principles of treatment. 2279 85

The goals of treatment are prevention of fatalities, hospitalizations, and emergency department visits, along with achieving good long-term control of asthma, with reduction of symptoms, maintenance of normal activity level, prevention of exacerbations and accelerated loss of pulmonary function (forced expiratory volume in the first second of expiration [FEV1]), and avoidance of harm from therapies. Treatment is often initiated based on the severity of symptoms, physical examination findings, and, for some patients, the FEV1 or peak expiratory flow rates. Comorbidities such as gastroesophageal reflux disease and laryngopharyngeal reflux, rhinitis or rhinosinusitis, sleep apnea, recurrent infections, smoking, and substance abuse should be addressed. Two treatment modalities are indicated only for individuals with allergic asthma: allergen-specific immunotherapy (commonly known as allergy shots), and biologic therapies that target type-2 (T2) inflammation. Allergen immunotherapy is effective in decreasing symptoms and medication use in select patients with mild-to-moderate allergic asthma. In addition, patients who receive allergen immunotherapy for allergic rhinitis may have a decreased risk of developing asthma. Omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab are monoclonal antibodies that target T2 inflammation and are indicated for either moderate-to-severe or severe asthma. These have been well studied to improve asthma symptoms and have specific characteristics unique to each individual medication. A focus on adherence can be considered in choosing therapy because it is not clear which biologic to choose in T2 high asthma at this time.
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PMID:Asthma in adults: Principles of treatment. 3169 Mar 79