Asthma Management Handbook

Managing allergic rhinitis in adults and adolescents with asthma

Recommendations

Prescribe or recommend intranasal corticosteroids for adults and adolescents with persistent allergic rhinitis or moderate-to-severe intermittent allergic rhinitis, even if the person is already taking regular inhaled corticosteroids for asthma. Intranasal corticosteroids can be used alone or in combination with an intranasal antihistamine (e.g. azelastine or levocabastine).

Table. Classification of allergic rhinitis

Pattern of symptoms

Intermittent

Persistent

Either of:

  • symptoms present <4 days per week
  • symptoms present <4 consecutive weeks

Both of:

  • symptoms present ≥4 days per week
  • symptoms present ≥4 consecutive weeks

Severity

Mild

Moderate-to-severe

No features of moderate-to-severe allergic rhinitis

Any of:

  • sleep disturbance
  • impairment of daily activities, leisure, physical activity
  • impairment of school or work
  • troublesome symptoms

Source: Bousquet J, Khaltaev N, Cruz AA et al. Allergic rhinitis and its impact on asthma (ARIA) 2008. Allergy 2008; 63(Suppl 86): 7-160. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2007.01620.x/full

Asset ID: 54

Close

Figure. Management of allergic rhinitis in adults and adolescents Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/106

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Seidman et al, 20151
  • Bousquet et al, 20082
  • Brożek et al, 20103
  • Lohia et al, 20134
  • Bousquet et al, 20165
  • Wallace et al, 20086
  • Berger and Meltzer, 20157

If symptoms are troublesome to the patient, consider initially adding an agent with a more rapid onset of action, e.g. oral H1-antihistamine, intranasal H1-antihistamine or short-term (maximum 5 days) intranasal decongestant.

Note: Warn patients not to take intranasal decongestants for more than 5 days, and only occasionally.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Bachert and Maspero, 20118
  • Bousquet et al. 20082
  • Brożek et al. 20103
  • Howarth, 19999
  • Kaliner et al. 201110
  • Wallace et al. 20086

For adults and adolescents with mild intermittent allergic rhinitis, consider starting treatment with an intranasal H1-antihistamine or second-generation less sedating oral H1-antihistamine. Do not use sedating antihistamines.

If symptoms do not improve significantly within 2 weeks, switch to an intranasal corticosteroid.

For those with seasonal allergic rhinitis, montelukast can be considered as an alternative to antihistamines.

  • Advise patients and parents about potential adverse psychiatric effects of montelukast in young people
How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Seidman et al, 20151
  • Bousquet et al, 20082
  • Brożek et al, 20103
  • Lohia et al, 20134
  • Bousquet et al, 20165
  • Wallace et al, 20086
  • Berger & Meltzer, 20157
  • Bachert & Maspero, 20018

Advise patients that intranasal corticosteroids, intranasal antihistamines or oral antihistamines will often relieve eye itching and redness associated with allergic rhinitis without the need for eye drops.

If ocular symptoms are troublesome, consider initial use of topical H1-antihistamines (e.g. azelastine, ketotifen, levocabastine or olopatadine).

If long-term treatment for ocular symptoms is necessary, consider a topical mast-cell stabiliser (e.g. cromoglycate or lodoxamide). Explain that onset of therapeutic effect may take up to 2–4 weeks.

Avoid topical alpha agonist vasoconstrictors (including in combination with antihistamines) because they can cause conjunctivitis medicamentosa.

Note: People who wear contact lenses should consult their pharmacist about which products are suitable.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Seidman et al, 20151
  • Bousquet et al, 20082
  • Brożek et al, 20103
  • Wallace et al, 20086
  • Hong et al, 201111
  • Castillo et al, 201512

Provide an allergic rhinitis treatment plan.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).​

If allergic rhinitis symptoms do not resolve within 3–4 weeks:

  • review the diagnosis
  • check adherence and intranasal administration technique
  • consider allergy testing.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If the response to an intranasal corticosteroid alone is inadequate despite regular daily use and correct spray technique, add an intranasal antihistamine and continue intranasal corticosteroid.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Seidman et al, 20151
  • Bousquet et al, 20165

For patients with asthma who need long-term regular medication for allergic rhinitis, explain that effective management of allergic rhinitis is part of their overall respiratory care. Emphasise the need to take intranasal corticosteroids consistently, and reassure patients that these medicines have a good safety profile when taken long term.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Demonstrate correct technique for using intranasal sprays and check patients’ technique regularly.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider specialist referral for patients with allergic rhinitis who have:

  • poorly controlled asthma, despite appropriate treatment, good adherence and good inhaler technique
  • other significant allergic disease (e.g. food allergies or severe eczema)
  • symptoms that suggest an alternative diagnosis (e.g. unilateral nasal symptoms, persistent nasal obstruction that does not respond to intranasal corticosteroids, or suspected chronic sinusitis).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

In pharmacies, advise people with co-occurring asthma and allergic rhinitis to consult their GP for thorough investigation if:

  • rhinitis symptoms are not well controlled by self-management with over-the-counter medicines (e.g. S2 intranasal corticosteroids, oral antihistamines)
  • they need to take rhinitis treatment for more than 4 weeks at a time
  • there are any complications (e.g. pain, loss of hearing or sense of smell, persistent cough).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

At each review, check adherence to medications and topical therapy technique, as for asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Inspect nasal mucosa one month after starting treatment then every 6 months for resolution of turbinate hypertrophy and any evidence of local crusting or bleeding. Consider referral to an ear, nose and throat surgeon for review if the patient is bothered by nasal obstruction, and turbinate hypertrophy has not responded to 12 months of regular intranasal corticosteroid treatment.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If allergic rhinitis symptoms are uncontrolled despite regular use of an intranasal corticosteroid alone or in combination with an intranasal antihistamine, consider specialist referral.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Advise patients with allergic rhinitis to avoid tobacco smoke. Explain that smoking worsens both asthma and allergic rhinitis, and can reduce the effectiveness of treatment.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider nasal irrigation with saline solution or saline nasal sprays as well as drug treatment.

Note: If patients are using saline irrigation or saline nasal spray and an intranasal medication (corticosteroid or H1-antihistamine) at the same time, they should use the saline first and wait approximately 10 minutes before using the medication. Saline can be used again after waiting at least an hour after using an intranasal corticosteroid.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider specific allergen immunotherapy in patients with allergic rhinitis or allergic asthma who have a history of proven, clinically important sensitisation to a particular allergen that cannot feasibly be avoided and for which specific allergen immunotherapy is available.

Note: Specific allergen immunotherapy should not be started unless the patient has stable asthma, including spirometry-demonstrated forced expiratory volume in 1 second (FEV1) greater than 80% predicted for subcutaneous immunotherapy and greater than 70% predicted for sublingual immunotherapy.

Note: Make sure the patient or parents understand that treatment must be long term (3–5 years), and understand the cost and risks of the treatment.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Virchow et al, 201613
  • Mosbech et al, 201414
  • Cox, 201615
  • Meadows et al, 201316
  • Durham et al, 201617
  • Passalacqua et al, 201418
  • Chelladurai et al, 201319
  • Brożek et al, 20103
  • Erekosima et al, 201420
  • Calderon et al, 201521
  • Radulovic et al, 201022
  • Canonica et al, 200923

Warn people with allergic rhinitis and allergy to ryegrass pollen (i.e. most people with springtime allergic rhinitis symptoms) that they may be at risk of thunderstorm-triggered asthma if they live in, or are travelling to, a region with seasonal high grass pollen levels – even if they have never had asthma symptoms before.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Davies, 201724
  • Girgis et al, 20005
  • Marks et al, 200125

For all patients at risk of thunderstorm-triggered asthma (e.g. because they have seasonal allergic rhinitis and/or asthma with grass pollen allergy, and are living in or travelling to an area with high grass pollen levels), provide advice on:

  • continual or prophylactic seasonal use of inhaled corticosteroids for asthma, as indicated (see recommendation below)
  • prophylactic seasonal use of intranasal corticosteroid for allergic rhinitis (see recommendation below)
  • asthma first aid for those without known asthma, including how to recognise asthma symptoms, how to get and use a reliever inhaler (ideally with spacer), and when to call an ambulance
  • avoidance – warn against being outdoors just before and during thunderstorms in spring and early summer, especially in wind gusts that precede the rain front.
How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • NACA, 201726

For people with seasonal allergic rhinitis who do not use intranasal corticosteroid treatment all year, advise intranasal corticosteroid starting 6 weeks before the pollen season (or exposure) and continuing until pollen levels abate (e.g. in Victoria, ideally 1 September–31 December).

Note: Refer to ASCIA's Pollen calendar

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • NACA, 201727

For people with asthma who are at risk of thunderstorm-triggered asthma:

  • prescribe regular inhaled corticosteroids for continuous use if indicated (most adults and older adolescents with asthma)
  • for patients for whom preventer therapy is not otherwise indicated, prescribe regular inhaled corticosteroids for at least 2 weeks before and throughout the pollen season (e.g. in Victoria, ideally 1 September–31 December)
  • provide training in correct inhaler technique, and check technique and adherence regularly
  • advise patients to carry a reliever inhaler and replace it before the expiry date
  • provide an up-to-date written asthma action plan that includes thunderstorm advice and instructs the person to increase doses of both inhaled preventer and reliever (as well as starting oral corticosteroids, if indicated) in response to flare-ups.

Notes:

Most adults and older adolescents with asthma should be using a regular inhaled corticosteroid long term.

People with asthma are particularly at risk of thunderstorm-triggered asthma if they have seasonal (springtime) allergic rhinitis (i.e. allergic to ryegrass pollen), and live in or are travelling to an area with high grass pollen levels. People with allergy to ryegrass pollen without known asthma are also at risk of thunderstorm-triggered asthma.

Refer to ASCIA’s Pollen calendar for information on local high-risk periods.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • NACA, 201727

More information

Thunderstorm-triggered asthma

Certain types of thunderstorms in spring or early summer in regions with high grass pollen concentrations in the air can cause life-threatening allergic asthma flare-ups in sensitised individuals, even if they have not had asthma before.18, 24, 28, 25, 5 People at risk of acute asthma flare-ups triggered by a thunderstorm include those with seasonal allergic rhinitis (with or without asthma), those with asthma (or a history of asthma), and those with undiagnosed asthma.24

Epidemics of thunderstorm-triggered asthma can occur when such a storm travels across a region and triggers asthma in many susceptible individuals, causing a high demand on ambulance and health services.28 However, epidemic thunderstorm asthma events are uncommon.

Data from thunderstorm asthma epidemics suggest that the risk of asthma flare-ups being triggered by a thunderstorm is highest in adults who are sensitised to grass pollen and have seasonal allergic rhinitis (with or without known asthma).24 The worst outcomes are seen in people with poorly controlled asthma. Regular treatment with an inhaled corticosteroid asthma preventer was significantly protective in a well-conducted Australian case-control study.5

Prevention and management are based on:27

  • year-round asthma control, including inhaled corticosteroid-containing preventers where indicated
  • preventive inhaled corticosteroid treatment for adults and adolescents with asthma who have known or suspected allergy to grass pollens (e.g. concomitant allergic rhinitis, a history of spring flare-ups in asthma symptoms) but are not already taking regular medication. Treatment should at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, asthma should be managed according to age group.
  • preventive intranasal corticosteroid treatment for adults and adolescents with seasonal allergic rhinitis, because it can be reasonably assumed that they are allergic to ryegrass pollen. Treatment should start at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, allergic rhinitis should be managed according to age group.
  • advice for at-risk patients to avoid being outdoors just before and during thunderstorms in spring and early summer, especially during wind gusts that precede the rain front
  • advice to ensure appropriate access to relievers during grass pollen season.
Close
Links between allergic rhinitis and asthma

Prevalence, aetiology and symptoms

Asthma and allergic rhinitis frequently coexist. At least 75% of patients with asthma also have rhinitis, although estimates vary widely.3 Patients with asthma may have both allergic and non-allergic rhinitis.

Allergic rhinitis that starts early in life is usually due to a classical IgE hypersensitivity. Adult-onset asthma or inflammatory airway conditions typically have more complex causes. Chronic rhinosinusitis with nasal polyps is not a simple allergic condition and generally needs specialist care.29

Symptoms and signs of allergic rhinitis can be local (e.g. nasal discharge, congestion or itch), regional (e.g. effects on ears, eyes, throat or voice), and systemic (e.g. sleep disturbance and lethargy). Most people with allergic rhinitis experience nasal congestion or obstruction as the predominant symptom. Ocular symptoms (e.g. tearing and itch) in people with allergic rhinitis are usually due to coexisting allergic conjunctivitis.30

Patients may mistake symptoms of allergic rhinitis for asthma and vice versa. Allergic rhinitis is sometimes more easily recognised only after asthma has been stabilised.

Effects on asthma

Allergic rhinitis is an independent risk factor for developing asthma in children and adults.31, 32, 33, 34, 35 However, the use of antihistamines in children has not been shown to prevent them developing asthma.3

The presence of allergic rhinitis is associated with worse asthma control in children and adults.36, 37, 38, 39 The use of intranasal corticosteroids in patients with concommitant allergic rhinitis and asthma may improve asthma control in patients who are not already taking regular inhaled corticosteroids.4

Both rhinitis and asthma can be triggered by the same factors, whether allergic (e.g. house dust mite, pet allergens, pollen, cockroach) or non-specific (e.g. cold air, strong odours, environmental tobacco smoke).

Food allergies do not cause allergic rhinitis. Most people with allergic rhinitis are sensitised to multiple allergens (e.g. both pollens and house dust mite), so symptoms may be present throughout the year.

Pollens (e.g. grasses, weeds, trees) and moulds are typically seasonal allergens in southern regions, but can be perennial in tropical northern regions.29 However, ryegrass is not found in tropical regions (see Thunderstorm-triggered asthma).

Pollen calendars provide information on when airborne pollen levels are likely to be highest for particular plants.

Thunderstorm-triggered asthma

Seasonal allergic rhinitis, which in Australia is typically associated with sensitisation to perennial ryegrass (Lolium perenne), is an important risk factor for thunderstorm-triggered asthma.24

Close
Treatment of allergic rhinitis in adults and adolescents

 

Table. Overview of efficacy of allergic rhinitis medicines for specific symptoms Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/102

Intranasal corticosteroids

If continuous treatment is required, an intranasal corticosteroid is the first-choice treatment unless contraindicated. Intranasal corticosteroids are more effective in the treatment of allergic rhinitis than other drug classes including oral H1-antihistamines, intranasal H1-antihistamines and montelukast.4, 3, 5 Intranasal corticosteroid are most effective when taken continuously.4

Intranasal corticosteroids are effective in reducing congestion, rhinorrhoea, sneezing and itching in adults and adolescents with allergic rhinitis.4, 3 They are also effective for ocular symptoms.11

All available intranasal corticosteroids appear to be equally effective.4

The onset of action is between 3 and 36 hours after first dose and, in practice, the full therapeutic effect takes a few days.17

The addition of an oral H1-antihistamine or leukotriene receptor antagonist to an intranasal corticosteroid is generally no more effective than intranasal corticosteroid monotherapy.5

Intranasal corticosteroids are well tolerated. Common (>1%) adverse effects include nasal stinging, itching, nosebleed, sneezing, sore throat, dry mouth, cough.40 Nose bleeds are usually due to poor spray technique or crusting. Evidence from studies mainly in adults suggests that intranasal corticosteroids do not cause atrophy of nasal epithelium.41

Intranasal corticosteroids are not generally associated with clinically significant systemic adverse effects when given in recommended doses.4, 6 Studies in adults evaluating effects on the hypothalamic-pituitary axis using morning cortisol concentrations, cosyntropin stimulation, and 24-hour urinary free cortisol excretion show no adverse effects with beclomethasone dipropionate, budesonide, ciclesonide, fluticasone propionate, fluticasone furoate, or triamcinolone acetonide.4

In patients with asthma already taking inhaled corticosteroids, both the intranasal corticosteroid dose and the inhaled corticosteroid dose should be taken into account when calculating the total daily corticosteroid dose. Drug–drug interactions (e.g. with CYP3A4 inhibitors such as such as erythromycin, clarithromycin, ritonavir and itraconazole) may change the metabolism or increase absorption of corticosteroids administered by any route, increasing the risk of adrenal suppression.40

Combination intranasal corticosteroid plus intranasal antihistamines

Combined intranasal fluticasone propionate and azelastine hydrochloride in a single device is more effective than fluticasone propionate alone for a range of nasal and ocular symptoms.4, 5, 24

The onset of therapeutic action is approximately 30 minutes after dosing.24

Oral antihistamines

Second-generation (less sedating) antihistamines (e.g. cetirizine, desloratadine, fexofenadine or loratadine) should be used in preference to older, more sedating antihistamines. Cetirizine is the most likely of the less sedating antihistamines to cause sedation, while fexofenadine and loratadine appear to be the least sedating.13

Less sedating oral H1-antihistamines are effective in managing allergic rhinitis symptoms of rhinorrhoea, sneezing, nasal itching and ocular symptoms.5, 8 They can provide adequate relief for some individuals when taken continuously or intermittently.4 Available agents appear to be equally effective.6

However, oral antihistamines are less effective than continuous intranasal corticosteroids, especially for nasal congestion.4, 2 In adults with allergic rhinitis, oral antihistamines usually produce no further improvement when added to intranasal corticosteroid treatment.4

Common (>1%) adverse effects include drowsiness, fatigue, headache, nausea and dry mouth.40 Oral antihistamines can also cause ocular dryness.12

Intranasal antihistamines

Intranasal antihistamines are at least equally effective as second-generation, less sedating oral H1-antihistamines for the treatment of allergic rhinitis, but are generally less effective than intranasal corticosteroids.3

Intranasal antihistamines are more effective than oral antihistamines for reducing nasal congestion.4 They have a rapid onset of action (15–30 minutes).4

The most common (>1%) adverse effect is local irritation.40 Bitter taste is more common intranasal antihistamines than with intranasal corticosteroids.4

Montelukast

Leukotriene receptor antagonists are no more effective than oral H1-antihistamines.3, 5 Montelukast is less effective than intranasal corticosteroid in the treatment of allergic rhinitis.4, 3 In most studies, adding montelukast to an intranasal corticosteroid was not more effective than intranasal corticosteroid alone.5

Montelukast is approved by TGA for treatment of in adults with asthma or seasonal allergic rhinitis.

It is generally very well tolerated, but has been infrequently associated with neuropsychiatric adverse effects, including suicidal ideation, in children and young people.42, 43, 44, 45, 46 A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares, depression, and aggression.46 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.46

Other nasal sprays

Ipratropium bromide spray is effective in managing persistent rhinorrhoea in patients with allergic rhinitis, but not blockage or itch.3 It is indicated for use in adults and adolescents over 12 years old.

Intranasal sodium cromoglycate is less effective than intranasal corticosteroids, but is effective in some patients for prevention and treatment of allergic rhinitis and is associated with minimal adverse effects.6

Specific allergen immunotherapy

Specific allergen immunotherapy (desensitisation) is effective in reducing allergic rhinitis symptoms (see separate topic).

Close
Non-recommended medications for allergic rhinitis

Intranasal decongestants have a limited role in the management of allergic rhinitis because they should only be used for very short courses (up to 5 days maximum). Repeated or long-term use can cause rebound swelling of nasal mucosa (rhinitis medicamentosa), which can lead to dose escalation by patients, with a risk of atrophic rhinitis. Intranasal decongestants can be considered for a patient with severe nasal congestion to gain rapid relief of symptoms until the full effect of intranasal corticosteroids is achieved.

Oral decongestants (e.g. pseudoephedrine or phenylephrine) should not generally be used in the management of allergic rhinitis. They are indicated for short-term use only (e.g. acute infectious rhinitis, or during air travel by a patient with symptomatic rhinitis, as a single tablet taken one hour before landing). They are associated with adverse effects including palpitations, tachycardia and insomnia.

Oral corticosteroids should be avoided as a treatment for allergic rhinitis. In exceptional circumstances, their use might be considered in consultation with an allergy specialist.

Topical ocular alpha agonist vasoconstrictors (including in combination with antihistamines) should not be used for allergic conjunctivitis because they can cause conjunctivitis medicamentosa.

Close
Smoking and allergic rhinitis

Smoking may worsen both asthma and rhinitis, and exposure to tobacco smoke can reduce the effectiveness of treatment in adults and children.47, 48

Close
Nasal saline irrigation for allergic rhinitis

Nasal irrigation (via a syringe, rinse bottle, spray or other device) can improve nasal symptoms, mucociliary clearance, and quality of life.49 Saline administered by spray or other devices was used at least twice daily in most studies that showed a benefit.49

Isotonic solution is preferable to hypertonic solution because it supports optimal mucociliary clearance.49 Isotonic saline is solution is inexpensive and has no known adverse effects.49 Patients can use either commercially manufactured saline solutions or home-made normal saline: 1 teaspoon (5 g) rock or sea salt in 500 mL of water (preferably bottled or boiled).

There is not enough evidence to determine:

  • whether solutions should be buffered or non-buffered, sterile or non-sterile
  • whether various additives provide any advantage
  • whether inhaling steam or an irritant decongestant (e.g. eucalyptus, menthol) before saline irrigation provides any extra benefit. However, patients are more likely to adhere to simple and convenient regimens, regardless of theoretical advantages. Caution is required with steam inhalation to avoid burns.

If patients are using both saline irrigation and an intranasal corticosteroid or intranasal H1‑antihistamine, they should perform saline irrigation first. Saline can be used again after waiting at least an hour after using an intranasal corticosteroid.

Young children are unlikely to tolerate nasal irrigation.

Close
Specific allergen immunotherapy (desensitisation)
  • Specific allergen immunotherapy should not be started unless the patient has stable asthma, including spirometry-demonstrated forced expiratory volume in 1 second (FEV1) greater than 80% predicted for subcutaneous immunotherapy and greater than 70% predicted for sublingual immunotherapy.50, 51 For patients with unstable asthma (e.g. frequent symptoms, marked variability in airflow measured by spirometry or peak flow monitor), the risks of treatment should be considered. These patients will need specialist supervision during treatment.

Options available in Australia

Two forms of specific allergen immunotherapy are available:

  • sublingual immunotherapy
  • subcutaneous immunotherapy.

Both forms of specific allergen immunotherapy require 3–5 years of treatment. Specific allergy immunotherapy can be repeated.

Although some specific allergen therapies can be prescribed by primary care health professionals, it is recommended that they are initiated under the care of an allergy specialist (allergist or clinical immunologist), where possible.

Commercial allergen preparations for immunotherapy are available in Australia for aeroallergens including house dust mite, pollens (e.g. grass, tree and weed pollens), animal dander and moulds.

Overview of efficacy

There is strong evidence that allergen immunotherapy is effective in the treatment of seasonal and perennial allergic rhinitis.15, 16, 17 There is less evidence supporting specific allergen immunotherapy in children than in adults.16 Specific allergen immunotherapy in children with seasonal allergic rhinoconjunctivitis might prevent development of asthma.52, 53

Single-allergen specific allergen immunotherapy is effective in patients sensitised to one allergen and those sensitised to multiple allergens.13, 54, 55 In selected cases more than one allergen may be administered as separate extracts. There is weak evidence for the efficacy of allergen mixes.18

A systematic review of studies directly comparing subcutaneous immunotherapy and sublingual immunotherapy in the treatment of allergic rhinoconjunctivitis and asthma found:19

  • low-grade evidence that subcutaneous immunotherapy is more effective than sublingual immunotherapy for reducing asthma symptoms and for reducing a combined measure of rhinitis symptoms and medication use
  • moderate-grade evidence that subcutaneous immunotherapy is more effective than sublingual immunotherapy for reducing nasal and/or eye symptoms.

Sublingual immunotherapy is associated with a lower rate of severe adverse effects (anaphylaxis and death) than subcutaneous immunotherapy, based on indirect comparison.3, 20, 21

Sublingual immunotherapy

Sublingual immunotherapy (self-administered at home) is effective for the treatment of allergic rhinitis in adults and children.22 23 The greatest benefits have been demonstrated in those with allergies to temperate grass pollens or house dust mite.23 Therapeutic Goods Administration (TGA)-approved indications for commercially available preparations vary according to age group.

The extract must be held under the tongue without swallowing for 2 minutes (liquid extracts) or 1 minute (tablets).

Sublingual immunotherapy is generally well tolerated.22 Local adverse effects are common in children receiving sublingual immunotherapy.3 Systemic adverse reactions, such as anaphylaxis, are very rare.3 The majority of adverse events occur soon after beginning treatment.23

TGA-approved indications

Asthma: Acarizax (house dust mite) is indicated for adults 18–65 years with house dust mite allergic asthma that is not well controlled by inhaled corticosteroids and is associated with mild-to-severe house dust mite allergic rhinitis.56 It is contraindicated in patients with FEV1 <70% predicted after adequate treatment, and for patients who have experienced a severe flare-up within the previous 3 months.56

Allergic rhinitis: Several commercial preparations of aeroallergens for sublingual immunotherapy in patients with allergic rhinitis are used in Australia, including:

  • Acarizax (house dust mite) – indicated for adults 18–65 years with persistent moderate to severe house dust mite allergic rhinitis despite symptomatic treatment.56
  • Actair (house dust mite) – indicated for the treatment of house dust mite allergic rhinitis with or without conjunctivitis in adults and adolescents over 12 years diagnosed with house dust mite allergy.57
  • Grazax (Timothy grass [Phleum pratense] pollen extract) – indicated for adults, adolescents and children older than 5 years with allergic rhinitis induced by Timothy grass58
  • Oralair tablets (mix of grass pollens) – indicated for adults and children over 5 years with grass pollen allergic rhinitis.59

Various single allergens and/or multiple allergen mixes are available for use as advised by the treating allergist, available as liquid extracts. Age restrictions vary between products.

Note: PBS status as at October 2016: Treatment with sublingual immunotherapy specific allergen preparations is not subsidised by the PBS.

Subcutaneous immunotherapy

Subcutaneous immunotherapy involves injections in which the dose is gradually increased at regular intervals (usually weekly), or until a therapeutic/maintenance dose is reached. This can take approximately 3–6 months.60 Treatment is then continued for a further 3–5 years.

Subcutaneous immunotherapy is generally not suitable for younger children (e.g. less than 7 years) because they may not be able to tolerate frequent injections.

Several commercial preparations of aeroallergens for subcutaneous immunotherapy are available in Australia, including various single allergens and/or multiple allergen mixes for use as advised by the treating allergist. Age restrictions vary between products.

Subcutaneous immunotherapy is effective for the treatment of allergic rhinitis and asthma, particularly when single-allergen immunotherapy regimens are used.20 There is strong evidence that it reduces asthma symptoms, asthma medication usage, rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and rhinitis/rhinoconjunctivitis disease-specific quality of life, in comparison to placebo or usual care.20 There is also moderate evidence that subcutaneous immunotherapy reduces rhinitis/rhinoconjunctivitis medication usage.20

Subcutaneous immunotherapy is associated with local adverse effects (e.g. injection-site swelling) and, less frequently, serious systemic adverse effects.3, 23 The most common systemic reactions are respiratory symtoms. There have been few reports of anaphylaxis.20

Note: PBS status as at October 2016: Treatment with subcutaneous specific allergen immunotherapy preparations is not subsidised by the PBS.

Close
Surgical turbinate reduction

Turbinate reduction surgery can be considered when nasal obstruction is due to turbinate hypertrophy and symptoms do not respond to medical treatment. It should not be performed in young children except after thorough investigation and review.

Inferior turbinate hypertrophy secondary to inflammation is a common cause of nasal obstruction in patients with allergic rhinitis.61 Several surgical procedures are available to correct this problem.1 The ideal surgical reduction should preserve the mucosa and physiological function.61

Short-term adverse outcomes of inferior turbinate reduction include nasal bleeding, scarring and crusting. Rarely, it may worsen symptoms when patients have non-specific rhinitic conditions or sino-nasal somatisation disorders (‘empty nose syndrome’).1 There is no evidence that turbinate surgery creates these conditions, but sino-nasal surgery may exacerbate the symptoms.

 

Close
Montelukast for adults and adolescents: psychiatric effects

Post-marketing surveillance reports led to concerns about a possible association between leukotriene receptor antagonist use and suicide risk.42 A recent case-control study reported a statistically significant association between the use of leukotriene receptor antagonists and suicide attempts in people aged 19–24 years. However, this association was no longer statistically significant after adjusting for potential confounding factors, including previous exposure to other asthma medicines and previous exposure to other medicines associated with suicide.42

Close

References

  1. Seidman, M. D., Gurgel, R. K., Lin, S. Y., et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015; 152: S1-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25644617
  2. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008. Allergy. 2008; 63: 8-160. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2007.01620.x/full
  3. Brożek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol. 2010; 126: 466-476. Available from: http://www.jacionline.org/article/S0091-6749(10)01057-2/fulltext
  4. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015; 152: S1-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25644617
  5. Girgis ST, Marks GB, Downs SH, et al. Thunderstorm-associated asthma in an inland town in south-eastern Australia. Who is at risk?. Eur Respir J. 2000; 16: 3-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10933077
  6. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008; 122: S1-S84. Available from: http://www.jacionline.org/article/S0091-6749(08)01123-8/fulltext
  7. Davies J, Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Final report. Victorian State Government Department of Health and Human Services, Melbourne, 2017.
  8. Bachert C, Maspero J. Efficacy of second-generation antihistamines in patients with allergic rhinitis and comorbid asthma. J Asthma. 2011; 48: 965-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21970671
  9. Howarth PH. Assessment of antihistamine efficacy and potency. Clin Exp Allergy. 1999; 29 Suppl 3: 87-97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10444220
  10. Kaliner MA, Berger WE, Ratner PH, Siegel CJ. The efficacy of intranasal antihistamines in the treatment of allergic rhinitis. Ann Allergy Asthma Immunol. 2011; 106: S6-s11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277531
  11. Hong J, Bielory B, Rosenberg JL, Bielory L. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: A systematic review. Allergy Asthma Proc. 2011; 32: 22-35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21262095
  12. Ousler GW, Wilcox KA, Gupta G, Abelson MB. An evaluation of the ocular drying effects of 2 systemic antihistamines: loratadine and cetirizine hydrochloride. Ann Allergy Asthma Immunol. 2004; 93: 460-4.
  13. Mann RD, Pearce GL, Dunn N, Shakir S. Sedation with "non-sedating" antihistamines: four prescription-event monitoring studies in general practice. BMJ (Clinical research ed). 2000; 320: 1184-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10784544
  14. Verkerk MM, Bhatia D, Rimmer J, et al. Intranasal steroids and the myth of mucosal atrophy: a systematic review of original histological assessments. Am J Rhinol Allergy. 2015; 29: 3-18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25590306
  15. Nasser M, Federowicz Z, Aljufairi H, McKerrow W. Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children. Cochrane Database Syst Rev. 2010; Issue 7: . Available from: https://www.ncbi.nlm.nih.gov/pubmed/20614452
  16. Berger WE, Meltzer EO. Intranasal spray medications for maintenance therapy of allergic rhinitis. Am J Rhinol Allergy. 2015; 29: 273-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26132312
  17. Bousquet J, Schunemann HJ, Hellings PW, et al. MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis. J Allergy Clin Immunol Pract. 2016; 138: 367-374.e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27260321
  18. D'Amato G, Vitale C, D'Amato M, et al. Thunderstorm-related asthma: what happens and why. Clin Exp Allergy. 2016; 46: 390-6.
  19. Chelladurai, Y., Suarez-Cuervo, C., Erekosima, N., et al. Effectiveness of subcutaneous versus sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. J Allergy Clin Immunol Pract. 2013; 1: 361-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24565541
  20. Erekosima, N., Suarez-Cuervo, C., Ramanathan, M., et al. Effectiveness of subcutaneous immunotherapy for allergic rhinoconjunctivitis and asthma: a systematic review. Laryngoscope. 2014; 124: 616-27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23832632
  21. Calderon, M. A., Kleine-Tebbe, J., Linneberg, A., et al. House dust mite respiratory allergy: an overview of current therapeutic strategies. J Allergy Clin Immunol Pract. 2015; 3: 843-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26342746
  22. Radulovic, S, Calderón, M A, Wilson, D, Durham, S. Sublingual immunotherapy for allergic rhinitis. Cochrane Database Syst Rev. 2010; Issue 12: . Available from: [https://www.ncbi.nlm.nih.gov/pubmed/21154351; full text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002893/full](https://www.ncbi.nlm.nih.gov/pubmed/21154351; full text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002893/full)
  23. Canonica, G W, Bousquet, J, Casale, T, et al. Sub-lingual immunotherapy. World Allergy Organization information position paper 2009. WAO Journal. 2009; November: 233-281. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20041860
  24. Davies J, Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Final report. Victorian State Government Department of Health and Human Services, Melbourne, 2017.
  25. Marks GB, Colquhoun JR, Girgis ST, et al. Thunderstorm outflows preceding epidemics of asthma during spring and summer. Thorax. 2001; 56: 468-71. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746065/
  26. National Asthma Council Australia. Thunderstorm asthma. An information paper for health professionals.. NACA, Melbourne, 2017.
  27. National Asthma Council Australia. Thunderstorm asthma. An information paper for health professionals. NACA, Melbourne, 2017.
  28. Victoria State Government Department of Health and Human Services,. The November 2016 Victorian epidemic thunderstorm asthma event: an assessment of the health impacts. The Chief Health Officer’s Report, 27 April 2017. Victorian Government, Melbourne, 2017.
  29. National Asthma Council Australia. Managing allergic rhinitis in people with asthma. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/allergic-rhinitis-asthma-hp
  30. Spangler DL, Abelson MB, Ober A, Gotnes PJ. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther. 2003; 25: 2245-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14512132
  31. Pallasaho, P, Juusela, M, Lindqvist, A, et al. Allergic rhinoconjunctivitis doubles the risk for incident asthma – results from a population study in Helsinki, Finland. Respir Med. 2011; 105: 1449-1456. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21600752
  32. Rochat, M K, Illi, S, Ege, M J, et al. Allergic rhinitis as a predictor for wheezing onset in school-aged children. J Allergy Clin Immunology. 2010; 126: 1170-5.e2.
  33. van den Nieuwenhof, L, Schermer, T, Bosch, Y, et al. Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma?. Allergy. 2010; 65: 1049-1055.
  34. Morais-Almeida, M, Gaspar, A, Pires, G, et al. Risk factors for asthma symptoms at school age: an 8-year prospective study. Allergy Asthma Proc. 2007; 28: 183-189.
  35. Shaaban R, Zureik M, Soussan D, et al. Rhinitis and onset of asthma: a longitudinal population-based study. Lancet. 2008; 372: 1047-1057. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61446-4/fulltext
  36. Thomas M, Kocevar VS, Zhang Q, et al. Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis. Pediatrics. 2005; 115: 129-34. Available from: http://pediatrics.aappublications.org/content/115/1/129.long
  37. Price D, Zhang Q, Kocevar VS, et al. Effect of a concomitant diagnosis of allergic rhinitis on asthma-related health care use by adults. Clin Exp Allergy. 2005; 35: 282-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15784104
  38. Oka, A., Matsunaga, K., Kamei, T., et al. Ongoing allergic rhinitis impairs asthma control by enhancing the lower airway inflammation. J Allergy Clin Immunol Pract. 2014; 2: 172-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24607045
  39. de Groot EP, Nijkamp A, Duiverman EJ, Brand PL. Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax. 2012; 67: 582-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22213738
  40. . Australian Medicines Handbook. Last modified July 2017. Australian Medicines Handbook Pty Ltd, 2017.
  41. Verkerk, M. M., Bhatia, D., Rimmer, J., et al. Intranasal steroids and the myth of mucosal atrophy: a systematic review of original histological assessments. Am J Rhinol Allergy. 2015; 29: 3-18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25590306
  42. Schumock GT, Stayner LT, Valuck RJ, et al. Risk of suicide attempt in asthmatic children and young adults prescribed leukotriene-modifying agents: a nested case-control study. J Allergy Clin Immunol. 2012; 130: 368-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22698520
  43. Wallerstedt SM, Brunlöf G, Sundström A, Eriksson AL. Montelukast and psychiatric disorders in children. Pharmacoepidemiol Drug Saf. 2009; 18: 858-864. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19551697
  44. Philip G, Hustad C, Noonan G, et al. Reports of suicidality in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 691-6.e6. Available from: http://www.jacionline.org/article/S0091-6749(09)01247-0/fulltext
  45. Philip G, Hustad CM, Malice MP, et al. Analysis of behavior-related adverse experiences in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 699-706.e8. Available from: http://www.jacionline.org/article/S0091-6749(09)01248-2/fulltext
  46. Haarman MG, van Hunsel F, de Vries TW. Adverse drug reactions of montelukast in children and adults. Pharmacol Res Perspect. 2017; 5: e00341. Available from: http://onlinelibrary.wiley.com/doi/10.1002/prp2.341/full
  47. Baena-Cagnani, CE, Gómez, RM, Baena-Cagnani, R, Canonica, GW. Impact of environmental tobacco smoke and active tobacco smoking on the development and outcomes of asthma and rhinitis. Curr Opin Allergy Clin Immunol. 2009; 9: 136-140.
  48. Marogna, M, Massolo, A, Colombo, F, et al. Children passive smoking jeopardises the efficacy of standard anti-allergic pharmacological therapy, while sublingual immunotherapy withstands. Allergol Immunopathol (Madr). 2011; 39: 60-67.
  49. Hermelingmeier, K. E., Weber, R. K., Hellmich, M., et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy. 2012; 26: e119-25. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904042/
  50. Global Initiative for Asthma (GINA),. Global strategy for asthma management and prevention (2017 update). GINA, 2017.
  51. Australasian Society of Clinical Immunology and Allergy,. Treatment plan for subcutaneous allergen immunotherapy (SCIT). ASCIA, 2013.
  52. Jacobsen, L., Niggemann, B., Dreborg, S., et al. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy. 2007; 62: 943-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17620073
  53. Zielen, S., Devillier, P., Heinrich, J., et al. Sublingual immunotherapy provides long-term relief in allergic rhinitis and reduces the risk of asthma: A retrospective, real-world database analysis. Allergy. 2017; : . Available from: www.ncbi.nlm.nih.gov/pubmed/28561266
  54. Nelson, H. S.. Allergen immunotherapy (AIT) for the multiple-pollen sensitive patient. Expert Rev Clin Pharmacol. 2016; 9: 1443-1451. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27687128
  55. Demoly, P., Passalacqua, G., Pfaar, O., et al. Management of the polyallergic patient with allergy immunotherapy: a practice-based approach. Allergy Asthma Clin Immunol. 2016; 12: 2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26759555
  56. Seqirus. Product Information: Acarizax (standardised allergen extract from the house dust mites. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  57. Stallergenes. Product Information: Actair Initiation Sublingual Tablets 100 IR & 300 IR and Actair Continuation Treatment Sublingual Tablets 300 IR (mixture of. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  58. Seqirus. Product Information: Grazax. Therapeutic Goods Administration, Canberra, 2017. Available from: https://www.ebs.tga.gov.au
  59. Stallergenes. Product Information: Oralair (allergen pollen extract of five grasses). Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  60. Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergen Immunotherapy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/patients/allergy-treatment/immunotherapy
  61. Barham, H. P., Thornton, M. A., Knisely, A., et al. Long-term outcomes in medial flap inferior turbinoplasty are superior to submucosal electrocautery and submucosal powered turbinate reduction. Int Forum Allergy Rhinol. 2016; 6: 143-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26681570