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Philippine Society of Allergy, Asthma and Immunology, Inc.

Room 403, 4th Flr. Medical Arts Bldg. Dr. Fe del Mundo Medical Center, 11 Banawe St.,
Quezon City
Telephone No: 712-9432

The Officers and Directors


President
Secretary
Treasurer
PRO/Historian
Honorary President
Directors

Immediate Past President

Madeleine W. Sumpaico, M.D.


Hiyasmin M. Lim, M.D.
Salvador Q. Esqueta, M.D.
Nanneth T. Tiu, M.D.
Felicidad G. Cua-Lim, M.D.
Manuel F. Ferreria, M.D.
Jovilia M. Abong, M.D.
Florecita R. Padua, M.D.
Alendry P. Caviles, Jr., M.D.
Manuel M. Po, M.D.

ALLERGIC RHINITIS

cpm 6TH eDITION

Algorithm for the Management of Allergic Rhinitis


1
Allergic
rhinitis

history + skin
prick tests
or serum
specific IgE

Allergen
avoidance

Intermittent
symptoms?

oral H1-blocker
Intranasal H1-blocker

and/or decongestant

10

Mild
symptoms?

Not in preferred order

Moderate
to severe
symptoms

Persistent
symptoms
9

Mild
symptoms?

Not in preferred order

Go to # 6

oral H1-blocker
Intranasal H1-blocker

11

and/or decongestant

Moderate
to severe
symptoms

Intranasal
CS

review the
patient after
2-4 weeks

13

in persistent rhinitis
review the patient
after 2-4 weeks
15

16

14

(chromone)

12

intranasal CS

Failure?

Go to Fig. 2

17

Improved:
continue for
one month

Figure 1

Step-up

CPM 6TH EDITION

ALLERGIC RHINITIS

1
Improved?

Step down
and continue
treatment for
one month

Failure

review diagnosis
review compliance
query infections or
other cause

increase
intranasal
CS dose
7

Itch/sneeze?

Rhinorrhea?

10

add

H1-blocker
9

add

ipratropium

blockage

11

add
decongestant
or oral CS
(short term)

12

13
Failure

Surgical
referral

* If conjunctivitis add:
oral H1-blocker
or intraocular H1-blocker
or intraocular chromosome
(or saline)
Consider specific immunotherapy
Figure 2

ALLERGIC RHINITIS

cpm 6TH eDITION

Guidelines for the Management of Allergic Rhinitis


Definition

Classification

Allergic rhinitis is clinically defined as a symptomatic


disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes
of the nose.

The new classification of allergic rhinitis:


uses symptoms and quality of life parameters
is based on duration, and is subdivided into intermittent or persistent disease

Symptoms : See Also Table 1.

is based on severity, and is subdivided into mild


or moderate-severe, depending on symptoms
and quality of life

Symptoms of allergic rhinitis include:


rhinorrhea
nasal obstruction
nasal itching

Figure 2: Classification of Allergic Rhinitis

sneezing

Clinical assessment

History
nasal discharge
blockage
sneezing

2 or more symptoms for


>1 hour on
most days

Persistent
symptoms
> 4 days per week
and > 4 weeks

Mild
Moderate-Severe

one or more items
normal sleep
abnormal sleep
normal daily
impairment of daily
activities, sport, leisure
activities, sport, leisure
normal work and
problems caused
school at work or school

Figure 1

Intermittent

symptoms
< 4 days per week
or < 4 weeks

Epidemiology
sneezers and runners

blockers

Table 1

sneezing

especially
paroxysmal

little or none

rhinorrhea

watery
anterior and
posterior

thick mucus
more
posterior

itching

yes

no

nasal
blockage

variable

often severe

diurnal
rhythm

worse during
day improving
at night

constant, day
and night, maybe
worse at night

conjunctivitis often present


Lund, J.V., et al., International Consensus Report on the
Diagnosis and Management of Rhinitis, International
Rhinitis Management Working Group. Allergy, 1994; 49
(Suppl 19) 1-34.

A. Incidence
In a series of studies from different countries,
considerable variations occur in the estimate of
prevalence of allergic rhinitis ranging from 0.5%
(Switzerland) to 28% (Finland)
Allergic rhinitis usually develops in school age or
adolescence.
Incidence (new onset) peaks between ages 10 and
15; declines after age 35.
More frequent in boys than in girls (childhood);
same frequency from adolescence.
Risk Factors
Early allergic rhinitis in persons with a family history of atopy.
More common in non-whites than in whites, in
upper than in lower classes (SIBBALD, 1993)
Birth 1-3 months before the pollen seasons increases risk of allergic rhinitis.
Allergic rhinitis more common in urban than rural
areas.

CPM 6TH EDITION

Diagnosis
The diagnosis of allergic rhinitis is based on:
a typical history of allergic symptoms
allergic symptoms are those of sneezers and runners. However, these symptoms are not necessarily
of allergic origin
diagnostic tests
- In vivo and in vitro tests used to diagnose allergic
diseases are directed towards the direction of free
or cell-bound IgE. The diagnosis of allergy has
been improved by allergen standardization providing satisfactory diagnostic vaccines for most
inhalant allergens.
- Immediate hypersensitivity skin tests are
widely used to demonstrate an IgE-mediated
allergic reaction. These represent a major diagnostic tool in the field of allergy. If properly
performed, they yield useful confirmatory evidence for the diagnosis of a specific allergy. As
there are many complexities for their performance and interpretation, it is recom-mended
that trained health professionals should carry
them out.
- The measurement of allergen-specific IgE in
serum is of importance and is of similar value to
skin tests.
- Nasal challenge tests with allergens are used
in research and, to a lesser extent, in clinical
practice. They may be useful, especially in the
diagnosis of occupational rhinitis.
Imaging is not usually necessary.

Management
A. Environmental Control and Avoidance

In most cases, allergen or irritant avoidance measures should be advised.

When possible, environmental control measures


for indoor allergens should be applied as they
may generally be inspired by the patient. This may
reduce the need for pharmacologic treatment.

Preventive Measures
First, remove all rugs, curtains and draperies from
the room except the clothes for daily use. Always
keep closet doors closed.
Clean the woodwork, window sills, screens,
closets and floor of the room. Wax the floor.
Change all mattresses and pillows in the bedroom
to solid rubber foam. No cotton, kapok, coconut

ALLERGIC RHINITIS

coir and feather (down) pillows are allowed.


Remember that spring beds may have kapok or
coconut coir stuffings at the bottom. Change
these beds to plain wooden ones with solid rubber
foam mattresses. Encase pillows and mattresses
in zippered air-tight covers
Prepare the bed using washable sheets and bedspreads (plain cotton). Do not use fuzzy bedding
such as wool, chenilles, etc. Wash covers in hot
water at least every two weeks.
Every month, remove all solid rubber foam pillows and mattresses from their covers and expose
both sides to sunlight for several hours. Change
covers before reusing.
Clean wooden and metal chairs may be used.
Plain light curtains may be used only if they are
washed weekly.
Books, leather products, stuffed toys, wood paneling and wall papers should be avoided. Wipe
walls with a mold-killing solution
The bedroom may be aired daily (windows open
but doors closed). To avoid dust from adjoining
rooms, the door must be opened only to allow
entrance and exit.
The room must be cleaned daily and given a complete cleaning weekly. The allergic patient should
avoid the room during and up to 3-4 hours after
cleaning. If the patient has to do the housecleaning and making the beds, he should always wear
a face mask.
Cleaning should include the use of a damp cloth,
mop or oil mop. Brooms and dusters should
never be used. Vacuum cleaning is strongly advised.
Preventive Measures
No smoking rule should be strongly enforced.
Do not allow the patient to use a bed other than
his own unless it has been properly prepared.
Use only washable toys. Avoid wall pennants,
macram hangings and other dust collectors.
No animal (dog, cat, bird) should be in contact
with the patient either in or out of the house unless your doctor decides otherwise.
If possible, upholstered furniture should be covered with air-tight plastic or vacuumed daily.
Dust and molds often contaminate air conditioners. It is essential that the filter and fan be cleaned
once a week. An electric fan may be used but must
be cleaned weekly.

ALLERGIC RHINITIS

cpm 6TH eDITION

B. Pharmacological Management (See Table 2)


Table 2. Effect of therapies on rhinitis symptoms


H1-antihistamines
oral
intranasal
intraocular

Sneezing

Rhinorrhea Nasal obstruction

Nasal itch

Eye symptoms

++
++
0

++
++
0

+
+
0

+++
++
0

++
0
+++

Corticosteroids
intranasal

+++

+++

+++

+++

++

Chromones
intranasal
intraocular

+
0

+
0

+
0

+
0

0
++

Decongestant
intranasal
oral

0
0

0
0

++++
+

0
0

0
0

Anti-cholinergics

++

Anti-leukotrienes

++

++

Adapted from van Cauwenberge, P., et al., Consensus statement on the treatment of allergic rhinitis, European Academy of
Allergology and Clinical Immunology. Allergy, 2000; 55(2): 0. 116-34.

Limit the number of house plants. Pollens and


mold spores become airborne when plants are
watered or disturbed.
Do not use insect sprays or powders. Children
should not play with cosmetics. Avoid substances
with strong odors such as paint, moth balls and
air fresheners.
Blankets and clothing that have been stored should
be thoroughly cleaned and ironed before use.
Bathroom and kitchen walls, floors, and sinks
should be cleaned frequently with mold-killing
solution of equal parts of water and household
bleach.
Plumbing leaks and roof leaks indicated by water
stains or peeling paints should be repaired as soon
as possible.
Correct drainage problems near the house. Prune
trees shading the house and compost collection
of leaves are potential mold sources.
Other Instructions
Reasonable exercise and outdoor exposure are
encouraged for allergic people. Unless a definite
pollen allergy is known, the person with allergic
symptoms should not limit his outdoor activities
during any season.

Although the patient should not help with the


house cleaning, he should be expected to help
with the other work in the house which do not
involve dust exposure.
C. Immunotherapy
Immunotherapy is a method employing sub
cutaneous injections of gradually increasing doses
of antigenic (allergenic materials) for the purpose of
altering the immunologic response of atopic agents.
Many studies show that immunotherapy especially
benefits patients with allergic rhinitis and bronchial
asthma.
It should be considered if:
- Pharmacotherapy is insufficient, controls symptoms or produces undesirable side effects.
- Appropriate avoidance measures of indoor al
lergens fail to control symptoms.
- There are positive skin tests or serum-specific
IgE which, correlates with rhinitis symptoms.

Reference:
Management of Allergic Rhinitis and its Impact on Asthma
(A Pocket Guide for Physicians and Nurses) 2001 - Based on
the ARIA Workshop Report in collaboration with WHO.

CPM 6TH EDITION

ALLERGIC RHINITIS

Drugs Mentioned in the Treatment Guideline


This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these
drugs can be found in PPD reference systems.
Anti-leukotrienes
Zafirlukast
Accolate
Montelukast Na
Singulair
Anticholinergics
Ipratropium Br
Atrovent
Ipratropium Br/Fenoterol
Berodual
Ipratropium Br/Salbutamol
Combivent
Antihistamines
Acrivastine
Semprex
Azelastine HCl
Azep
Cetirizine
Virlix
Zinex
Zyrtec
Chlorphenamine maleate
Antamin
Barominic
Chlor-Trimeton
Clormetamine
Drugmaker's Biotech
Chlorphenamine
Hargenan
UL Chlorphenamine
Chlorpheniramine maleate
Synestal
Chlorphenoxamine HCl
Systral
Clemastine hydrogen fumarate
Tavegyl
Tavist
Desloratadine
Aerius
Dimethindene maleate
Fenistil
Diphenhydramine HCl
Alertuss
Benadryl

Biogenerics
Diphenhydramine
Dramelin
Drugmaker's Biotech
Diphenhydramine
Europharma
Diphenhydramine
Hizon
Diphenhydramine Inj
Pharex Diphenhydramine
Disodium cromoglycate
Vividrin Nasal Spray
Hydroxyzine diHCl
Iterax
Levocetirizine
Xyzal
Loratadine
Claritin
Loradex
Loratadine/Bethamethasone
Claricort
Loratadine/Pseudoephedrine
Clarinase
Rhinase
Mebhydrolin napadisylate
Fabahistin
Mequitazine
Primalan
Olopatadine HCl
Patanol
Promethazine HCl
Phenergan
Thaprozine
Corticosteroids
Betamethasone/
Chlorphenamine maleate
Betneton
Betamethasone/
Dexchlorphenamine maleate
Celestamine
Prednisolone/
Chlorphenamine maleate
Clormetalone
Triamcinolone acetonide
Kenacort

Decongestants
Brompheniramine maleate/
Phenylephrine HCl
Dimetapp
Bromphenamine maleate/
Phenylpropanolamine
Nasatapp
Camphor/Menthol/Eucalyptol
Broncho Rub White
Camphor/Menthol/Methyl
Salicylate
Neozep Vaporizing Rub
Carbinoxamine/Phenylephrine
HCl/Phenylpropanolamine
Rhinopront
Chlorphenamine maleate/
Phenylpropanolamine HCl
Coldrex Reformulated Tab
Langex
Nafarin
Chlorphenamine maleate/
Phenylpropanolamine HCl/
Paracetamol
Alledec
Decolgen/Decolgen Forte
Nagelin
Neozep/Neozep Forte
Resttab
Chlorpheniramine maleate
Phenylpropanolamine/
Paracetamol
Colvan
Nafarin-A
Sinutab Extra Strength
Chlorphenamine/
Phenylpropanolamine/
Phenylephrine
UL Anti-Cold
Phenylpropanolamine HCl
Disudrin
Propadrin
Sinurex
Phenylpropanolamine HCl/
Paracetamol
A-P-Histallin (Reformulated)

ALLERGIC RHINITIS

Nasathera
Phenylpropanolamine HCl/
Phenyltoloxamine/
Paracetamol
Sinutab
Sodium chloride
Salinase
Nasal Preparations
Azelastine HCl
Azep
Budesonide
Budecort Nasal/NT
Cetirizine
Virlix
Zyrtec
Fluticasone propionate
Flixotide Aqueous
Nasal Spray
Fusafungine
Locabiotal 1%
Mometasone furoate
Nasonex AQ Nasal
Spray
Rinelon
Oxymetazoline HCl
Drixine Nasal Spray/
Ped Drops
Nasivin
Sodium chloride
Salinase
Xylometazoline HCl
Otrivin

cpm 6TH eDITION

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