AR is characterised by nasal and non-nasal symptoms triggered by allergen exposure, causing rhinorrhea, sneezing, nasal blockage, and itching. AR commonly co-occurs with asthma (25% of AR patients have asthma, and 50% of asthma patients have AR), often alongside other conditions like atopic disease, sinusitis, conjunctivitis, and otitis media, complicating treatment.^1,2

AR can be categorised as seasonal, perennial, or both, although changing climates and multiple sensitisations can complicate these distinctions. Intermittent AR involves symptoms for <4 days per week or <4 consecutive weeks, while persistent AR involves symptoms for >4 days per week for at least a month. Studies reveal that perennial or persistent AR has a more significant impact on patients' quality of life than seasonal AR, with house dust mites being a primary cause.^1,2

A study found that 66% of individuals with persistent or perennial AR experience severe sleep problems. These patients woke up an average of 3.8 times each night, with 92% taking 15 minutes or more to fall asleep (22.2% taking over an hour). Nighttime awakenings led to difficulties falling back asleep for 40.8% of respondents, and 69.2% faced morning tiredness. Sleep-related issues significantly affected daily functioning, with 85.5%-95.0% of those with sleep problems reporting disruptions. Additionally, work and activity impairment were observed in 53.3% and 47.1%, respectively. Individuals with both AR and asthma experienced more frequent and burdensome sleep issues, further impacting daily life and productivity.¹

What pharmacotherapies are recommended?

The International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis 2023 (ICAR-AR 2023) recommends the following:³

• Reducing exposure to allergens can be beneficial in controlling AR symptoms. Both physical and chemical interventions may help reduce allergen levels in the environment, particularly for patients sensitive to specific allergens like Fel d 1 (the major feline allergen).
• Intranasal antihistamines (INAH) are effective and safe, making them suitable as first- or second-line therapy for AR. They provide rapid relief and are especially effective for nasal congestion and ocular symptoms.
• Intranasal corticosteroids (INCS) sprays are the primary treatment for AR due to their superior efficacy in managing nasal symptoms. Prophylactic use before the pollen season is beneficial. However, in children, the lowest effective dose should be used to avoid potential growth effects.
• Oral decongestants are generally not recommended for routine AR treatment but can be used in combination with oral AHs for short-term relief of severe nasal congestion. This combination should be considered carefully, particularly in patients with comorbidities.
• Intranasal decongestants offer short-term relief during acute AR flares. However, their chronic use is discouraged due to the risk of rhinitis medicamentosa (rebound congestion).
• Leukotriene receptor antagonists (LTRAs) are effective for controlling both asthma and AR symptoms in patients with both conditions, LTRAs are not recommended as monotherapy for AR due to safety concerns and the availability of alternatives.
• Disodium cromoglycate, an intranasal cromolyn, can reduce sneezing, rhinorrhea, and nasal congestion, serving as a second-line option when other treatments are ineffective.
• Intranasal anticholinergics primarily help control rhinorrhea and can be used as an add-on treatment for patients with persistent rhinorrhea despite initial therapy.
• Nasal saline is a safe and effective first-line treatment for AR. It can be used alone or in combination with other medications, with hypertonic saline possibly more effective in children.
• Probiotics: Probiotics may serve as an adjunct treatment for patients with symptomatic AR, but the magnitude of their benefit remains uncertain due to variations in study results.
• Combination Therapies: Various combination therapies are available for AR treatment, including combinations of oral AHs and decongestants, which may provide relief for acute symptoms. However, caution is advised, especially for patients with certain medical conditions.
• Combination oral AHs and INCS has not consistently shown additional benefits compared to INCS alone.
• Combination LTRAs and oral AHs is not recommended as first-line therapy due to safety concerns but may be considered in specific cases.
• Combination INCS and INAH is effective as second-line therapy, but use may be limited by cost and prescription requirements.
• Combination INCS and LTRAs can be considered in patients with both AR and asthma, but safety concerns limit its use in AR without asthma.
• Combination INCS and intranasal decongestant is recommended as a short-term option for patients with refractory AR.
• Combination INCS and intranasal ipratropium bromide may potentially be effective for controlling rhinorrhea, especially in refractory AR, although more research is needed to confirm its benefits.

These treatment options allow healthcare professionals to tailor AR management to individual patient needs, considering factors like symptom severity, comorbidities, and patient preferences.

References

1. Romano MR, et al.The impact of perennial allergic rhinitis with/without allergic asthma on sleep, work and activity level. Allergy Asthma Clin Immunol, 2019.
2. Husna MSN, et al. Allergic Rhinitis: A Clinical and Pathophysiological Overview. Front Med, 2022.
3. Wise SK, et al. International consensus statement on allergy and rhinology: Allergic rhinitis - 2023. Int Forum Allergy Rhinol, 2023.