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Small and Kim Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S3

http://www.aacijournal.com/content/7/S1/S3 ALLERGY, ASTHMA & CLINICAL


IMMUNOLOGY

REVIEW Open Access

Allergic rhinitis
Peter Small1*, Harold Kim2,3

Abstract
Allergic rhinitis is a common disorder that is strongly linked to asthma and conjunctivitis. It is usually a
long-standing condition that often goes undetected in the primary-care setting. The classic symptoms of
the disorder are nasal congestion, nasal itch, rhinorrhea and sneezing. A thorough history, physical
examination and allergen skin testing are important for establishing the diagnosis of allergic rhinitis.
Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment.
Allergen immunotherapy is an effective immune-modulating treatment that should be recommended if
pharmacologic therapy for allergic rhinitis is not effective or is not tolerated. This article provides an
overview of the pathophysiology, diagnosis, and appropriate management of this disorder.

Introduction rhinitis and asthma frequently coexist. Therefore, aller-gic


Rhinitis is broadly defined as inflammation of the nasal rhinitis and asthma appear to represent a combined
mucosa. It is a common disorder that affects up to 40% of airway inflammatory disease, and this needs to be con-
the population [1]. Allergic rhinitis is the most com-mon sidered to ensure the optimal assessment and manage-
type of chronic rhinitis, affecting 10 to 20% of the ment of patients with allergic rhinitis [1,3].
population, and evidence suggests that the prevalence of Comprehensive and widely-accepted guidelines
the disorder is increasing. Severe allergic rhinitis has been for the diagnosis and treatment of allergic rhinitis
associated with significant impairments in quality of life, were pub-lished in 2007 [1]. This article provides an
sleep and work performance [2]. overview of the recommendations provided in these
In the past, allergic rhinitis was considered to be a dis- guidelines as well as a review of current literature
order localized to the nose and nasal passages, but cur- related to the pathophysiology, diagnosis, and
rent evidence indicates that it may represent a component appropriate manage-ment of allergic rhinitis.
of systemic airway disease involving the entire respiratory
tract. There are a number of physiolo-gical, functional and Pathophysiology
immunological relationships between the upper (nose, In allergic rhinitis, numerous inflammatory cells, includ-ing
nasal cavity, paranasal sinuses, pharynx and larynx) and mast cells, CD4-positive T cells, B cells, macro-phages,
lower (trachea, bronchial tubes, bronchioles and lungs) and eosinophils, infiltrate the nasal lining upon exposure to
respiratory tracts. For example, both tracts contain a an inciting allergen (most commonly air-borne dust mite
ciliated epithelium consisting of goblet cells that secrete fecal particles, cockroach residues, ani-mal dander,
mucous, which serves to filter the incoming air and protect moulds, and pollens). The T cells infiltrating the nasal
structures within the air-ways. Furthermore, the mucosa are predominantly T helper (Th)2 in nature and
submucosa of both the upper and lower airways includes release cytokines (e.g., interleukin [IL]-3, IL-4, IL-5, and IL-
a collection of blood vessels, mucous glands, supporting 13) that promote immunoglo-bulin E (IgE) production by
cells, nerves and inflamma-tory cells. Evidence has shown plasma cells. IgE produc-tion, in turn, triggers the release
that allergen provocation of the upper airways not only of mediators, such as histamine and leukotrienes, that are
leads to a local inflamma-tory response, but also to responsible for arteriolar dilation, increased vascular
inflammatory processes in the lower airways, and this is permeability, itch-ing, rhinorrhea (runny nose), mucous
supported by the fact that secretion, and smooth muscle contraction [1,2]. The
mediators and cytokines released during the early phase
1
Sir Mortimer B. Davis Jewish General Hospital, Division of Allergy & of an immune response to an inciting allergen, trigger a
Clinical Immunology, Montreal Quebec, Canada further cellular
Full list of author information is available at the end of the article

2011 Small and Kim; licensee BioMed Central Ltd. This is an open access article distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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inflammatory response over the next 4 to 8 hours visits [1,6]. Therefore, screening for rhinitis is recom-
(late-phase inflammatory response) which results in mended, particularly in asthmatic patients since
recurrent symptoms (usually nasal congestion) [1,4]. studies have shown that rhinitis is present in up to
95% of patients with asthma [7-10].
Classification A thorough history and physical examination are the
Rhinitis is classified into one of the following cornerstones of establishing the diagnosis of allergic rhi-
categories according to etiology: IgE-mediated nitis (see Table 2). Allergy testing is also important for
(allergic), auto-nomic, infectious and idiopathic confirming that underlying allergies cause the rhinitis
(unknown). Although the focus of this article is [1]. Referral to an allergist should be considered if
allergic rhinitis, a brief description of the other forms the diagnosis of allergic rhinitis is in question.
of rhinitis is provided in Table 1.
Traditionally, allergic rhinitis has been categorized as History
seasonal (occurs during a specific season) or perennial During the history, patients will often describe the fol-
(occurs throughout the year). However, not all patients fit lowing classic symptoms of allergic rhinitis: nasal con-
into this classification scheme. For example, some allergic gestion, nasal itch, rhinorrhea and sneezing. Allergic
triggers, such as pollen, may be seasonal in cooler conjunctivitis (inflammation of the membrane covering the
climates, but perennial in warmer climates, and patients white part of the eye) is also frequently associated with
with multiple seasonal allergies may have symptoms allergic rhinitis and symptoms generally include redness,
throughout most of the year [4]. Therefore, allergic rhinitis tearing and itching of the eyes [1].
is now classified according to symptom duration An evaluation of the patients home and work/school
(intermittent or persistent) and severity (mild, moderate or environments is recommended to determine potential
severe) (see Figure 1) [1,5]. Rhinitis is con-sidered triggers of allergic rhinitis. The environmental history
intermittent when the total duration of the epi-sode of should focus on common and potentially relevant aller-
inflammation is less than 6 weeks, and persistent when gens including pollens, furred animals, textile flooring/
symptoms continue throughout the year. Symptoms are upholstery, tobacco smoke, humidity levels at home, as
classified as mild when patients are generally able to well as other potential noxious substances that the patient
sleep normally and perform normal activities (including may be exposed to at work or at home. The use of certain
work or school); mild symptoms are usually intermittent. medications (e.g., beta-blockers, acetylsalicylic acid
Symptoms are categorized as mod-erate/severe if they [ASA], non-steroidal anti-inflammatory drugs [NSAIDs],
significantly affect sleep and activ-ities of daily living angiotensin-converting enzyme [ACE] inhibi-tors, and
and/or if they are considered bothersome. It is important to hormone therapy) as well as the recreational use of
classify the severity and duration of symptoms as this will cocaine can lead to symptoms of rhinitis and, therefore,
guide the manage-ment approach for individual patients patients should be asked about current or recent
[1]. medication and drug use [1].
The history should also include patient questioning
Diagnosis and investigations regarding a family history of atopic disease, the impact of
Allergic rhinitis is usually a long-standing condition that symptoms on quality of life and the presence of
often goes undetected in the primary-care setting. Patients comorbidities such as asthma, mouth breathing, snoring,
suffering from the disorder often fail to recog-nize the sleep apnea, sinus involvement, otitis media (inflamma-
impact of the disorder on quality of life and functioning tion of the middle ear), or nasal polyps. Patients may
and, therefore, do not frequently seek medi-cal attention. attribute persistent nasal symptoms to a constant cold
In addition, physicians fail to regularly question patients and, therefore, it is also important to document the fre-
about the disorder during routine quency and duration of colds [1].

Table 1 Etiological classification of rhinitis [1]


Description
IgE-mediated (allergic) IgE-mediated inflammation of the nasal mucosa, resulting in eosinophilic and Th2-cell infiltration of the nasal lining
Further classified as intermittent or persistent
Autonomic Drug-induced (rhinitis medicamentosa)
Hypothyroidism
Hormonal
Non-allergic rhinitis with eosinophilia syndrome (NARES)
Infectious Precipitated by viral (most common), bacterial, or fungal infection
Idiopathic Etiology cannot be determined
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Intermittent Persistent
x Symptoms < 6 weeks x Symptoms continue
throughout the year

Mild Moderate-Severe

x Normal sleep x Abnormal sleep, or


x No impairment of daily x Impairment of daily
activities, sport, leisure activities, sport, leisure, or
x Normal work/school x Problems at work/school, or
x No bothersome symptoms x Bothersome symptoms

Figure 1 Classification of allergic rhinitis according to symptom duration and severity. Adapted from Small et al., 2007 [1], Bousquet
et al., 2008 [5]

Table 2 Components of a complete history and physical examination for suspected rhinitis [1]
History Physical examination
Personal Outward signs
Nasal itch Mouth breathing
Rhinorrhea Rubbing the nose/transverse nasal crease
Sneezing Frequent sniffling and/or throat clearing
Eye involvement Allergic shiners (dark circles under eyes)
Seasonality Nose
Triggers Mucosal swelling, bleeding
Family Pale, thin secretions
Allergy Polyps or other structural abnormalities
Asthma Ears
Environmental Generally normal
Pollens Pneumatic otoscopy to assess for Eustachian tube dysfunction
Animals Valsalvas maneuver to assess for fluid behind the ear drum
Flooring/upholstery Sinuses
Mould Palpation of sinuses for signs of tenderness
Humidity Maxillary tooth sensitivity
Tobacco exposure Posterior oropharynx
Medication/drug use Postnasal drip
Beta-blockers Lymphoid hyperplasia (cobblestoning)
ASA Tonsillar hypertrophy
NSAIDs Chest and skin
ACE inhibitors Atopic disease
Hormone therapy Wheezing
Recreational cocaine
use Quality of life
Rhinitis-specific
questionnaire Comorbidities
Asthma
Mouth breathing
Snoring
Sinus involvement
Otitis media
Nasal polyps
Conjunctivitis
Response to previous medications
Second-generation oral antihistamines
Intranasal corticosteroids

ASA: acetylsalicylic acid; NSAIDs: non-steroidal anti-inflammatory drugs; ACE: angiotensin-converting enzyme; OTC:
over-the-counter Adapted from Small et al., 2007 [1]
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Before seeking medical attention, patients often attempt Diagnostic tests


using over-the-counter or other medications to manage Although a thorough history and physical examination are
their symptoms. Assessing patient response to such required to establish the clinical diagnosis of rhinitis,
treatments may provide information that can aid in the further diagnostic testing is usually necessary to confirm
diagnosis and subsequent management of allergic rhinitis. that underlying allergies cause the rhinitis. Skin-prick
For example, symptom improvement with newer, second- testing is considered the primary method for identifying
generation antihistamines (e.g., deslorata-dine [Aerius], specific allergic triggers of rhinitis. Skin prick testing
fexofenadine [Allegra], loratadine [Clari-tin]) is strongly involves placing a drop of a commercial extract of a spe-
suggestive of an allergic etiology. However, it is important cific allergen on the skin of the forearms or back, then
to note that response to first-generation antihistamines pricking the skin through the drop to introduce the extract
(e.g., brompheniramine mal-eate [Dimetane], into the epidermis. Within 15-20 minutes, a wheal-and-
chlorpheniramine maleate [Chlor-Tri-polon], clemastine flare response (an irregular blanched wheal surrounded by
[Tavist-1]) does not imply an allergic etiology since the an area of redness) will occur if the test is positive. Testing
anticholinergic and sedative properties of these agents is typically performed using the aller-gens relevant to the
reduce rhinorrhea and may improve sleep quality patients environment (e.g., pollen, animal dander, moulds
regardless of whether the inflammation is allergic. and house dust mites). A reason-able alternative to skin
Previous response to intranasal corticosteroids may also prick testing is the use of aller-gen-specific IgE tests (e.g.,
be suggestive of an allergic etiology, and likely indicates radioallergosorbent tests [RASTs]) that provide an in vitro
that such treatment will continue to be benefi-cial in the measure of a patients specific IgE levels against particular
future [1]. allergens. However, skin prick tests are generally
Important elements of the history for patients with considered to be more sen-sitive and cost effective than
suspected allergic rhinitis are summarized in Table 2. allergen-specific IgE tests, and have the further advantage
of providing physicians and patients with immediate
Physical examination results [1,6].
The physical examination of patients with suspected
allergic rhinitis should include an assessment of out- Pengobatan
ward signs, the nose, ears, sinuses, posterior Tujuan pengobatan untuk rhinitis alergi adalah
menghilangkan gejala. Pilihan terapi yang ada untuk
orophar-ynx (area of the throat that is at the back of
mencapai tujuan ini meliputi tindakan penghindaran,
the mouth), chest and skin (see Table 2). Outward antihistamin oral, kortikosteroid intranasal, antagonis
signs that may be suggestive of allergic rhinitis reseptor leukotrien, dan imunoterapi alergen (lihat Gambar
include: per-sistent mouth breathing, rubbing at the 2). Terapi lain yang mungkin berguna pada pasien terpilih
nose or an obvious transverse nasal crease, meliputi dekongestan dan kortikosteroid oral. Jika gejala
frequent sniffling or throat clearing, and allergic pasien tetap ada walaupun ada pengobatan yang tepat,
shiners (dark circles under the eyes that are due to rujukan ke ahli alergi harus dipertimbangkan. Seperti yang
disebutkan sebelumnya, alergi rhinitis dan asma mewakili
nasal congestion). Examination of the nose typically penyakit inflamasi jalan nafa, oleh karena itu, pengobatan
reveals swelling of the nasal mucosa and pale, thin asma juga merupakan pertimbangan penting pada pasien
secretions. An internal endo-scopic examination of dengan rhinitis alergi.
the nose should also be consid-ered to assess for
structural abnormalities and nasal polyps [1]. Penghindaran alergi
The ears generally appear normal in patients with Pengobatan lini pertama rhinitis alergi melibatkan
allergic rhinitis; however, assessment for Eustachian penghindaran alergen yang relevan (mis., Tungau debu
rumah, jamur, hewan piaraan, serbuk sari) dan iritan (mis.,
tube dysfunction using a pneumatic otoscope should Asap tembakau). Pasien yang alergi terhadap tungau
be considered. Valsalvas maneuver (increasing the debu rumah harus diinstruksikan untuk menggunakan
pressure in the nasal cavity by attempting to blow penutup alergen yang kedap air untuk seprai dan menjaga
out the nose while holding it shut) can also be used kelembaban relatif di rumah di bawah 50% (untuk
to assess for fluid behind the ear drum [1]. menghambat pertumbuhan tungau). Paparan serbuk sari
The sinus examination should include palpation of the dapat dikurangi dengan menjaga jendela tetap tertutup,
sinuses for evidence of tenderness or tapping of the menggunakan AC, dan membatasi jumlah waktu yang
dihabiskan di luar rumah selama puncak musim serbuk
maxillary teeth with a tongue depressor for evidence of
sari. Bagi pasien yang alergi terhadap bulu binatang,
sensitivity. The posterior oropharynx should also be pengangkatan hewan dari rumah dianjurkan dan biasanya
examined for signs of post nasal drip (mucous accumu- menghasilkan penurunan gejala yang signifikan dalam
lation in the back of the nose and throat), and the chest waktu 4-6 bulan.
and skin should be examined carefully for signs of con-
current asthma (e.g., wheezing) or dermatitis [1].
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dampak negatif pada kognisi dan fungsi otak, oleh karena


itu, mereka tidak dianjurkan secara rutin untuk mengobati
Penghindaran alergen rhinitis alergi [1,6]

Kortikosteroid intranasal
Kortikosteroid intranasal juga merupakan pilihan terapi
lini pertama untuk pasien dengan gejala persisten ringan
atau moderat / berat dan dapat digunakan sendiri atau
Antihistamin oral dikombinasikan dengan antihistamin oral. Bila digunakan
secara teratur dan benar, kortikosteroid intranasal efektif
mengurangi peradangan pada mukosa hidung dan
memperbaiki patologi mukosa. Penelitian dan
metaanalisis telah menunjukkan bahwa kortikosteroid
intranasal lebih unggul dari antihistamin dan antagonis
Kortikosteroid intranasal reseptor leukotrien dalam mengendalikan gejala rhinitis
alergi, termasuk kongesti hidung, dan rhinorrhea [11-14].
Mereka juga telah terbukti memperbaiki gejala mata dan
mengurangi gejala jalan napas yang lebih rendah pada
pasien asma bersamaan dan rhinitis alergi [15-17].
Antagonis reseptor Kortikosteroid intranasal yang tersedia di Kanada
leukotrien ditunjukkan pada Tabel 3 dan mencakup fluticasone
furoate (Ava-mys), beklometason (Beconase), fluticasone
propionate (Flonase), triamcinolone acetonide (Nasacort),
mometa-sone furoate (Nasonex), ciclesonide (Omnaris)
imunoterapi alergen dan budesonida (Rhinocort). Karena penggunaan
semprotan nasal yang tepat diperlukan untuk
mendapatkan respons klinis yang optimal, pasien harus
diberi konseling mengenai penggunaan alat intranasal
Gambar 2 A algoritma stepwise yang telah di sederhanakan
yang tepat ini. Idealnya, kortikosteroid intranasal paling
untuk pengobatan rhinitis alergi. Catatan: pengobatan bisa
baik dimulai sesaat sebelum terpapar alergen yang
digunakan secara sendiri atau kombinasi.
relevan dan, karena efek puncaknya mungkin memerlukan
waktu beberapa hari untuk berkembang, mereka harus
Namun kepatuhan terhadap rekomendasi ini buruk, oleh digunakan secara teratur [4].
karena itu, penggunaan filter partikulat efisiensi tinggi Efek samping yang paling umum dari intranasal
(PET) menyaring dan membatasi hewan dari kamar tidur kortikosteroids adalah iritasi dan sengatan hidung.
atau ke luar rumah mungkin diperlukan untuk mengurangi Namun, efek samping ini biasanya dapat dicegah dengan
tingkat alergen. Tindakan untuk mengurangi paparan mengarahkan semprotan sedikit menjauh dari septum
alergen meliputi pembersihan dengan fungisida, menjaga hidung [1]. Bukti menunjukkan bahwa intravena
kelembapan udara sampai kurang dari 50%, dan filtrasi folomethasone, tapi bukan kortikosteroid intranasal
PET. Strategi penghindaran ini dapat secara efektif lainnya, dapat memperlambat pertumbuhan pada anak-
memperbaiki gejala rhinitis alergi, dan pasien harus anak dibandingkan dengan plasebo; Namun, penelitian
disarankan untuk kerja sama untuk hasil yang optimal [1]. jangka panjang yang menguji dampak dari intranasal
beklometason terhadap pertumbuhan itu kurang [18-21].
Antihistamin
Obat anti histamin oral generasi kedua yang lebih baru, Penting untuk dicatat bahwa sebagian besar pasien
tidak sedatif, (desloratadine [Aerius], fexofenadine dengan rinitis alergi yang hadir ke dokter unmum dengan
[Allegra] dan loratadine [Claritin]) adalah terapi gejala sedang sampai parah dan memerlukan
farmakologi lini pertama yang direkomendasikan untuk kortikosteroid intranasal. Bousquet et al. mencatat
semua pasien dengan rhinitis alergi (lihat Tabel 3 untuk peningkatan hasil pada pasien dengan gejala sedang
daftar antihistamin generasi kedua dan rejimen dosis yang sampai berat yang ditangani dengan kombinasi obat ini
direkomendasikan). Obat ini telah ditemukan untuk secara [22].
efektif mengurangi bersin, gatal dan rhinorrhea bila
diminum secara teratur pada saat gejala maksimal atau Antagonis reseptor leukotrien
sebelum terpapar alergen. Meskipun antihistamin
penenang yang lebih tua (generasi pertama) (misalnya, Antagonis reseptor leukotrien (AsRLT) montelu-kast dan
diphenhydramine, chlorpheniramine) juga efektif dalam zafirlukast juga efektif dalam pengobatan rhinitis alergi;
mengurangi gejala, mereka telah ditunjukkan ke Namun, obat ini tidak seefektif kortikosteroid intranasal
[23-25]. Meskipun satu penelitian jangka pendek
menemukan kombinasi AsRLT dan antihistamin seefektif
kortikosteroid intranasal [26]
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Tabel 3 Gambaran umum pilihan terapi farmakologi dari rhinitis alergi


Dosis dewasa Dosis anak
Antihistamin oral (generasi
kedua)
5-10 mL (1-2 sendok teh) sekali sehari (formulasi anak-
Cetirizine (Reactine) 1-2 tablet (5 mg) sekali sehari anak)
1 tablet (10 mg) sekali sehari
2.5-5 mL (0.5-1.0 sendok teh) sekali sehari ( formulasi anak-
Desloratadine (Aerius) 1 tablet (5 mg), sekali sehari anak)
Saat ini tidak ada indikasi untuk anak di bawah umur 12
Fexofenadine (Allegra) 1 tablet (60 mg) tiap 12 jam (12-jam tahun
formulasi)
1 tablet (120 mg), sekali sehari (24-jam formulasi)
5-10 mL (1-2 sendok teh) sekali sehari (formulasi anak-
Loratadine (Claritin) 1 tablet (10 mg), sekali sehari anak)
Intranasal corticosteroids
Beclomethasone (Beconase) 1-2 semprot (42 g/semprot) EN, dua kali sehari 1 semprot (42 g/semprot) EN, dua kali sehari
semprot (64 g/semprot) EN, sekali sehari atau 1 2 semprot (64 g/semprot) EN, sekali sehari atau 1
Budesonide (Rhinocort) 2 semprot EN, semprot EN, dua kali
Dua kali sehari sehari (jangan melebihi 256 g)
Ciclesonide (Omnaris) 2 semprto (50 g/semprot) EN, sekali sehari Tidak ada indikasi untuk anak di bawah umur 12 tahun
Fluticasone furoate (Avamys) 2 semprot (27.5 g/semprot) EN, sekai sehari 1 semprot (27.5 g/semprot) EN, sekali sehari
Semprot (50 g/semprot) EN, sekali sehari atau
Fluticasone propionate 2 tiap 12 1-2 semprot (50 g/semprot) EN, sekali sehari
(Flonase) jam (untuk rhinitis berat)
Mometasone furoate 2 semprot (50 g/semprot) EN, sekali sehari 1 semprot (50 g/semprot) EN, sekali sehari
(Nasonex)
Triamcinolone acetonide 2 semprot (55 g/semprot) EN, sekai sehari 1 semprot (55 g/semprot) EN, sekali sehari
(Nasacort)
Leukotriene receptor
antagonists
Saat ini tidak di perbolehkan untuk anak-anak dibawa
Montelukast 1 tablet (10 mg), sekali sehari umur 15 tahun
EN: each nostril.

penelitian jangka panjang telah menemukan kortikosteroid suntikan perawatan dosis maksimal yang dapat ditoleransi
intranasal agar lebih efektif daripada kombinasi untuk setiap 3 sampai 4 minggu selama 3 sampai 5 tahun.
mengurangi gejala malam hari dan hidung [12,27]. Penting Setelah periode ini, banyak pasien mengalami efek
untuk dicatat bahwa di Kanada, montelu-kast (Singulair) perlindungan yang berkepanjangan dan, karena itu,
adalah satu-satunya ARLT yang diindikasikan untuk pertimbangan dapat diberikan untuk menghentikan terapi.
mengobati alergi rhinitis pada orang dewasa. Persiapan musim yang dikelola setiap tahun juga tersedia
AsRLT harus dipertimbangkan saat antihistamin oral dan [1,6]. Persiapan bahasa juga diharapkan disetujui di
/ atau kortikosteroid intranasal tidak dapat ditoleransi Kanada dalam waktu dekat. Ini akan memberi pasien
dengan baik atau tidak efektif dalam mengendalikan gejala pilihan terapi yang efektif. Meskipun pasien akan mampu
rhinitis alergi. Jika kombinasi terapi farmakologi dengan mengatur sendiri formulasi sublingual, pemantauan ketat
antihistamin oral, kortikosteroid intranasal dan AsRLT tidak oleh dokter masih diperlukan.
efektif atau tidak dapat ditoleransi, imunoterapi alergen
harus dipertimbangkan [1,6]. Imunoterapi alergen harus disediakan untuk pasien yang
di dalamnya tindakan penghindaran optimal dan makula
Imunoterapi alergen macet tidak cukup untuk mengendalikan gejala atau tidak
Imunoterapi alergen melibatkan pemberian subkutan dapat ditoleransi dengan baik. Karena bentuk terapi ini
secara bertahap meningkatkan jumlah alergen yang membawa risiko reaksi anafilaksis, seharusnya hanya
relevan dengan pasien sampai tercapai dosis yang efektif dilakukan oleh dokter yang cukup terlatih dalam
dalam mendorong toleransi imunologis ke aller-gen. pengobatan alergi dan yang siap untuk mengatasi
Bentuk terapi ini terbukti efektif untuk pengobatan rhinitis kemungkinan anafilaksis yang mengancam jiwa [1].
alergi yang disebabkan oleh serbuk sari dan tungau debu, Algoritma stepwise yang disederhanakan untuk
namun memiliki kegunaan yang terbatas dalam mengobati pengobatan rhinitis alergi diberikan pada Gambar 2.
jamur dan alergi bulu binatang [1]. Perhatikan bahwa rinitis alergi ringan dan intermiten pada
Biasanya, imunoterapi alergen diberikan secara tahunan umumnya dapat dikelola secara efektif dengan tindakan
dengan kenaikan inkremental mingguan dalam dosis penghindaran dan antihista oral. Namun, seperti yang
selama 6-8 bulan, diikuti oleh disebutkan sebelumnya, kebanyakan pasien dengan
rhinitis alergi memiliki gejala tingkat sedang sampai parah,
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oleh karena itu, akan memerlukan kortikosteroid Conclusions


intranasal. Allergic rhinitis is a common disorder that can signifi-cantly
impact patient quality of life. The diagnosis is made
Pilihan terapeutik lainnya
Dekongestan oral dan intranasal (mis., Pseudoephe-drine, through a comprehensive history and physical
phenylephrine) bermanfaat untuk mengurangi gangguan examination. Further diagnostic testing using skin-prick
hidung pada pasien dengan rhinitis alergi. Namun, profil tests or allergen-specific IgE tests is usually required to
efek samping yang terkait dengan dekongestan oral (e., confirm that underlying allergies cause the rhinitis. The
Agitasi, insomnia, sakit kepala, palpitasi) dapat membatasi therapeutic options available for the treatment of aller-gic
penggunaan jangka panjang mereka. Selanjutnya, obat ini rhinitis are effective in managing symptoms and are
dikomunikasikan pada pasien dengan hipertensi yang
generally safe and well-tolerated. Second-generation oral
tidak terkontrol dan penyakit arteri koroner berat.
Penggunaan dekongestan intranasal yang antihistamines and intranasal corticosteroids are the
berkepanjangan membawa risiko rinitis medicamentosa mainstay of treatment for the disorder. Allergen immu-
(meningkatkan sumbatan hidung) dan oleh karena itu, notherapy as well as other medications such as deconge-
agen ini tidak boleh digunakan lebih dari 5 sampai 10 hari. stants and oral corticosteroids may be useful in select
Kortikosteroid oral juga terbukti efektif pada pasien cases.
dengan rhinitis alergi parah yang tidak tahan terhadap
pengobatan dengan antihistamin oral dan kortikosteroid
intranasal. [1,4] Key take-home messages
Allergic rhinitis is linked strongly with asthma and
Meskipun tidak seefektif kortikosteroid intranasal, sodium conjunctivitis.
cromoglycate (Cromolyn) telah terbukti mengurangi Allergen skin testing is the best diagnostic test to
bersin, rhinorrhea dan gatal pada hidung dan oleh karena confirm allergic rhinitis.
itu merupakan pilihan terapi yang bias dinadalkan untuk Intranasal corticosteroids are the mainstay of
beberapa pasien. Omalizumab antibodi anti-IgE juga treat-ment for most patients that present to
terbukti efektif pada rinitis alergi musiman dan asma [1].
physicians with allergic rhinitis.
Terapi bedah mungkin membantu pasien terpilih dengan
rhinitis, poliposis, atau penyakit sinus kronis yang tidak Allergen immunotherapy is an effective immune-
tahan terhadap perawatan medis. Sebagian besar modulating treatment that should be recommended
intervensi bedah dapat dilakukan dengan anestesi lokal if pharmacologic therapy for allergic rhinitis is not
atau pasien rawat jalan. effec-tive or is not tolerated.
Penting untuk dicatat bahwa rinitis alergi dapat
berlangsung selama kehamilan dan, akibatnya, mungkin
memerlukan perawatan farmakologi. Rasio manfaat, risiko Acknowledgements
dari obat farmakologi untuk rhinitis alergi perlu This article has been published as part of Allergy, Asthma & Clinical
dipertimbangkan sebelum merekomendasikan terapi Immunology Volume 7 Supplement 1, 2011: Practical guide for allergy
and immunology in Canada. The full contents of the supplement are
medis kepada wanita hamil. Intranasal sodium
available online at http://www.aacijournal.com/supplements/7/S1
cromoglycate dapat digunakan sebagai terapi lini pertama
untuk rhinitis alergi pada kehamilan karena tidak ada efek Author details
teratogenik yang telah dicatat dengan kromon pada 1
Sir Mortimer B. Davis Jewish General Hospital, Division of Allergy & Clinical
manusia atau hewan. Antihistamin generasi pertama juga Immunology, Montreal Quebec, Canada. 2University of Western Ontario,
dapat dipertimbangkan untuk rhinitis alergi pada London, Ontario, Canada. 3McMaster University, Hamilton, Ontario, Canada.
kehamilan dan, jika diperlukan, chlorpheniramine dan
Competing interests
diphenhydramine harus direkomendasikan mengingat Dr. Peter Small has received consulting fees or honoraria from
catatan keselamatan jangka panjang mereka. Namun, GlaxoSmithKline, Graceway Pharmaceuticals, King Pharma,
pasien harus diberi tahu risiko sedasi dengan obat ini. Jika Merck Frosst, Novartis, and Nycomed.
korteks corti-costeroid intranasal diperlukan selama Dr. Harold Kim is the past president of the Canadian Network for
kehamilan, pemberian semprotan nasidinason atau Respiratory Care and co-chief editor of Allergy, Asthma and Clinical
budesonida harus dianggap sebagai terapi lini pertama Immunology. He has received consulting fees and honoraria for continuing
education from AstraZeneca, GlaxoSmithKline, Graceway
karena catatan keamanannya yang lebih panjang.
Pharmaceuticals, King Pharma, Merck Frosst, Novartis, and Nycomed.
Memulai atau meningkatkan imunoterapi alergen selama
kehamilan tidak dianjurkan karena risiko anafilaksis pada Published: 10 November 2011
janin. Namun, dosis perawatan dianggap aman dan efektif
selama kehamilan [1]. References
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