Beruflich Dokumente
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GUIDELINE PAPER
Department of General Practice, University of Aberdeen, Foresterhill Health Centre, Westburn Road,
Aberdeen, AB25 2AY, UK
b Respiratory Dept, St. Josephs Hospital, 515 Rue St. Etienne, La Malbaie, Quebec, Canada
c S
avida Medicina Apoiada, SA, Rua do Bolh
ao 109, 4000-112 Porto, Portugal
d University of Minnesota Medical School, 240 Williamson Hall, 231 Pilsbury Drive S.E., Minneapolis, MN
55455-0213, USA
e Division of Community Health Sciences: GP Section, University of Edinburgh, 20 West Richmond Street,
Edinburgh, UK
f Pharm D, Cagliari, Italy
g National Respiratory Training Centre, The Athenaeum, 10 Church Street, Warwick, UK
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Summary
The association between the upper and lower airways has been
recognised for almost 2000 years. Epidemiological data suggest that most asthma
patients also suffer from allergic rhinitis, and that both diseases share similar trigger
factors and pathophysiology. This IPCRG Guideline on the management of rhinitis in
primary care is fully consistent with the ARIA guidelines. It highlights the treatment
goals and the classication of the condition according to symptom frequency
(intermittent or persistent) and severity (mild or moderate-severe). It covers the
need for allergen avoidance, pharmacologic therapy including immunotherapy,
alternative therapies, management of ocular symptoms, the management of coexisting allergic rhinitis and asthma, and the need for follow-up and ongoing care
for patients with rhinitis.
2005 General Practice Airways Group. Published by Elsevier Ltd. All rights
reserved.
Background
1471-4418/$30.00 2005 General Practice Airways Group. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.pcrj.2005.11.002
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Strong evidence
Moderate evidence
Limited evidence
- No scientic evidence
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Introduction
The association between the upper and lower
airways has been recognized for almost two
millennia, ever since Galen recommended in 200AD
that purging the nostrils of secretions would relieve
the lungs. By the late 19th century Charles Blackley
had linked hay fever and asthma [6].
It is therefore striking that until recently
asthma guidelines have referred minimally to the
importance of rhinitis in patients with asthma.
The 1997 UK asthma guidelines did not even
mention the word rhinitis [7]. The updated 2003
UK guidelines mention its role in helping to make a
diagnosis of asthma, state that immunotherapy for
rhinitis sufferers might reduce the rate of onset of
asthma, and state that many patients with asthma
may have rhinitis but that there is no evidence
that rhinitis treatment improves asthma outcomes
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Treatment Goals
Goals for the treatment of rhinitis assume accurate
diagnosis and assessment of severity as well as any
link with asthma in an individual patient. Goals
include:
Unimpaired sleep
Ability to undertake normal daily activities,
including work and school attendance, without
limitation or impairment, and the ability to
participate fully in sport and leisure activities
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No troublesome symptoms
No or minimal side-effects of rhinitis treatment
Classication
The classication of allergic rhinitis depends on
the duration of symptoms (Intermittent or
Persistent) together with the severity and effect
on the patients daily life (Mild or ModerateSevere) (Figure 1) [10]. The classication of
rhinitis determines the treatment needed. Those
with mild disease which is intermittent in nature
require less intensive therapy [10].
Pharmacologic therapy
Pharmacologic treatment of allergic rhinitis
depends on both the classication of severity and
the individual patients symptoms as described
in Figure 1. Table 1 provides treatment options
based on the severity of the disease. The choice
of pharmacologic treatment may be individualized
based on the patients particular combination of
symptoms. Medications for allergic rhinitis have
no long-lasting effect following discontinuation.
Therefore, in persistent disease, maintenance
treatment is required. Table 2 provides detailed
notes on the treatments available in rhinitis.
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Oral H1-blocker
Intranasal H1-blocker AND/OR
Decongestant
Intranasal glucocorticosteroid
Intranasal saline
Cromone
Antileukotriene (preferred in patients with coexisting asthma)
Consider specialist referral for specic immunotherapy
Oral H1-blocker
Intranasal H1-blocker
Decongestant AND/OR
Intranasal saline
Oral H1-blocker
Intranasal H1-blocker AND/OR
Decongestant
Intranasal saline
Intranasal glucocorticosteroid
Cromone
Antileukotriene (preferred in patients with
coexisting asthma)
Consider specialist referral for specic
immunotherapy
Intranasal glucocorticosteroid
Oral H1-blocker
Decongestant
Intranasal saline
Antileukotriene (preferred in patients with coexisting asthma)
Consider specialist referral for specic immunotherapy
Review patient after 24 weeks.
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Table 2
Local H1 antihistamines
(Intranasal, introcular)
Intranasal corticosteroids
Generic Name
2nd Generation:
1st Generation:
Mechanism of Action
-Blockage of H1 receptor
Side Effects
2nd Generation:
Cetirizine
Chlorpheniramine
Ebastine
Clemastine
Fexofenadine
Hydroxyzine
Comments
-new generation oral H1-antihistamines
are preferred for their favorable
efcacy/safety ratio and
pharmacokinetics
- rapidly effective (less than 1hr) on nasal
and ocular symptoms
- poorly effective on nasal congestion
-no cardiotoxicity
Loratadine
Mizolastine
Ketotifen
Mequitazine
Acrivastine
Azelastine
New Products:
Desloratadine
Levocetirizine
Oxatomide
Others:
-Cardiotoxic:
Astemizole
Terfenadine
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Azelastine
- blockage of H1 receptor
Levocabastine
Beclomethasone
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone
Oral/IM corticoster-oids
Dexamethasone
Hydrocortisone
- reduce nasal
hyperreactivity
D. Price et al.
Methylpredisolone
Prednisolone
Prednisone
Triamcinolone
Betamethasone
Deazacort
Generic Name
Cromoglycate
Mechanism of Action
- mechanism of action
poorly known
Side Effects
- minor local side effects
Comments
- intraocular cromones are very
effective
- intranasal cromones are less effective
and their effect is short-lasting
- overall excellent safety
Ephedrine
- sympathomimetic drugs
- hypertension
Phenylephrine
- relieve symptoms of
nasal congestion
- palpitations
Nedocromil
Oral decongestants
Pseudoephedrine
Intranasal decongestants
- restlessness
- agitation
- tremor
- insomnia
- headache
- dry mucous membranes
- urinary retention
- exacerbation of glaucoma or
thyrotoxicosis
- same side effects as oral
decongestants but less intense
- rhinitis medicamentosa (a
rebound phenomenon
occurring with prolonged use
over 10 days)
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Epinephrine
- sympathomimetic drug
Naphtazoline
- relieve symptoms of
nasal congestion
Table 2 (Continued )
Oxymethazoline
Phenylephrine
Tetrahydrozoline
Xylometazoline
Intranasal anticholinergics
Antileukotrienes
Montelukast
anticholinergics block
almost exclusively
rhinorrhea
- almost no systemic
anticholinergic activity
- well tolerated
Pranlukast
Zarlukast
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Intranasal glucocorticosteroids
Intranasal glucocorticosteroids are currently the
most effective class of medications available
for the treatment of allergic and non-allergic
rhinitis [28]. The effectiveness of intranasal
glucocorticosteroids is based on their local activity
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Chromones
Anticholinergics
Anticholinergic agents can help reduce anterior
watery rhinorrhea but they have no effect on nasal
blockage or the other symptoms of allergic rhinitis
[10]*** .
Antileukotrienes
Antileukotrienes are a new class of medication for
the treatment of allergic rhinitis as well as asthma
and have been shown to be effective in improving
both asthma and rhinitis outcomes [45]*** . They
modulate inammation. They have an efcacy
comparable to that of oral antihistamines although
appear to have a greater effect on nasal obstruction
[46]* . Antileukotrienes may have an additive effect
with antihistamines [47,48]* .
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Allergen-specic
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eimmunotherapy
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(vaccination)
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Decongestants
Short courses (less than 10 days) of topical
decongestants may be useful in reducing severe
nasal blockage when starting administration of
other medications. Both oral and intranasal
decongestants may be used in the treatment of
nasal congestion associated with allergic rhinitis.
Nasal decongestant sprays have a greater effect
on nasal obstruction than oral decongestants.
However, the use of nasal decongestant sprays
is limited by rebound congestion, the potential
for irreversible tissue hypertrophy [43]*** , and a
decreasing duration of effect after 10 days of use
[44]*** . Rhinitis medicamentosa constitutes nasal
hyper-reactivity, mucosal swelling, and tolerance,
that is induced, or aggravated, by the overuse
of topical decongestants with or without a
preservative.
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Alternative therapies
The use of complementary and alternative
therapies (e.g. homeopathy, herbal medicines,
acupuncture) for the treatment of rhinitis is
increasing. In the ARIA document [10], a literature
review found insufcient evidence to support the
efcacy of alternative therapy. Since then there
have been further publications, but the design of
the trials or the outcome measures used make
it impossible to reach a denitive conclusion
regarding their use in the management of allergic
rhinitis.* A recent Cochrane Review concluded that
there was insufcient evidence to assess reliably
the role of homeopathy in asthma [54]. There is an
urgent need for well-designed, large, randomised,
controlled and properly-powered clinical trials to
evaluate the efcacy and safety of alternative
therapies in the management of allergic diseases.
Herbal medicine can induce pharmacologic
interactions with medications used in the
treatment of allergic rhinitis or other illnesses [55].
Healthcare professionals should ask their patients
about the use of herbal products and consider the
possibility of herb-drug interactions [56].
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Route of administration
Medications for allergic rhinitis are most
commonly given either intranasally or orally.
The advantage of intranasal administration,
particularly of glucocorticosteroids, is that high
local concentrations of the drug can be achieved
with minimal systemic side effects [57]*** . The
health care professional should advise patients
on the proper method to administer intranasal
glucocorticosteroids, including the importance of
directing the spray laterally rather than medially
in the nose, using the left hand for the right side
of the nose and vice versa.
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Referral
Referral should be considered for any patient
who shows persistent failure to respond to the
therapeutic options for their classication of
rhinitis or whose symptoms are suggestive of
other conditions (see Allergic Rhinitis Diagnosis
Questionnaire, Tables 3 and 4 in the IPCRG
Guidelines: Diagnosis [2]).
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Acknowledgements
The authors would like to thank S Conn, J Leder, S
Louw, and M Stubbe stergaard who contributed to
earlier versions of this document.
Funding: During the development of these
guidelines, the IPCRG received unrestricted
educational grants from Altana, AstraZeneca,
Boehringer Ingelheim, EAMG, GlaxoSmithKline,
Merck Sharp and Dohme, Mitsubishi Pharma,
Novartis, UCB Pharma, and Zambon. These funds
were used for the purpose of funding face-to-face
meetings and also to support a secretariat.
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