Asthma Management Handbook

Managing allergies as part of asthma management

Recommendations

Manage allergic asthma according to the principles of asthma management in children or adults, with these considerations:

  • Assess and manage risk for thunderstorm-triggered asthma in affected regions.
  • Identify other clinically relevant allergic triggers and manage, or advise avoidance as appropriate, taking into account the cost, burden, and potential effectiveness of avoidance.
  • Manage co-occurring allergic rhinitis.
  • Consider specific immunotherapy for patients who meet all the criteria.
How this recommendation was developed

Consensus

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

Consider specific allergen immunotherapy (sublingual immunotherapy or subcutaneous 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 for specific allergen immunotherapy is available.

Make sure the patient or parents understand that long-term treatment (at least 3 years) is necessary, and understand the cost and risks of the treatment.

Notes

Both forms of specific allergen immunotherapy require at least 3 years of treatment and should initially be prescribed by an allergy specialist (allergist or clinical immunologist) where possible. Sublingual therapy for house dust mite allergic asthma is only approved for patients who also have allergic rhinitis, and whose asthma is not well controlled with inhaled corticosteroids.

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, and they will need specialist supervision during treatment.

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):

  • Australasian Society of Clinical Immunology and Allergy, 20131
  • Australasian Society of Clinical Immunology and Allergy, 19972

Omalizumab treatment can be considered for adults and adolescents aged 12 years and over, with moderate-to-severe allergic asthma despite inhaled corticosteroid treatment, and raised IgE levels.

​Note: For adults and adolescents with severe allergic asthma who may be eligible for PBS subsidy, whose asthma is not well-controlled despite optimal inhaled therapy, refer immediately for specialist assessment, because patients only become eligible for PBS subsidisation for omalizumab after at least 6 months’ care by a specialist experienced in the management of severe asthma. After treatment is established, ongoing treatment with omalizumab may be administered by a GP, with 6-monthly review of ongoing eligibility at the specialist clinic.

How this recommendation was developed

Adapted from existing guidance

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

  • Katelaris et al. 20093
  • Chung et al. 20144

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Omalizumab treatment can be considered for children aged 6 to 11 years with severe allergic asthma (documented exacerbations despite daily high-dose inhaled corticosteroids with or without another maintenance treatment) and raised IgE levels.

Note: For children with severe allergic asthma who may be eligible for PBS subsidy, whose asthma is not well-controlled despite optimal inhaled therapy, refer immediately for specialist assessment, because patients only become eligible for PBS subsidisation for omalizumab after at least 6 months' care by the same specialist.

How this recommendation was developed

Adapted from existing guidance

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

  • Chung et al. 20144
  • Katelaris et al. 20093

Benralizumab or mepolizumab can be considered as an add-on treatment for patients aged 12 years and over with severe refractory eosinophilic asthma. Benralizumab is given by subcutaneous injection every 4 weeks for the first three injections then every 8 weeks. Mepolizumab is given by subcutaneous injection every 4 weeks.

Note: For adults and adolescents with severe allergic asthma who may be eligible for PBS subsidy, whose asthma is not well-controlled despite optimal inhaled therapy, refer for specialist assessment, because patients only become eligible for PBS subsidisation for mepolizumab after at least 6 months of treatment by a specialist experienced in the management of severe asthma.

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):

  • Menzella et al. 20165
  • Powell et al. 20156
  • Farne et al. 20177

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Consider offering referral to an allergy specialist for:

  • patients with poorly controlled asthma or allergic rhinitis, despite appropriate treatment, good adherence and good inhaler technique
  • patients considering specific immunotherapy.
How this recommendation was developed

Consensus

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

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

Note: Specific allergen immunotherapy is indicated for the management of allergy, not prevention of asthma. However, early treatment before the onset of asthma may reduce the risk of asthma symptoms and asthma medication requirements.

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

Note: TGA-approved indications for commercially available preparations vary according to age group.

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):

  • Kristiansen et al. 20178
  • Valovirta et al. 20189
  • Jacobsen et al. 200710
  • Novembre et al. 200411

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More information

Allergies and asthma: links

There is a strong link between asthma and allergies:12, 13

  • The majority of people with asthma have allergies.
  • Immunoglobulin E-mediated sensitisation to inhalant allergens is an important risk factor for developing asthma, particularly in childhood.
  • In individuals with asthma, exposure to relevant allergens can worsen asthma symptoms and trigger flare-ups, including severe acute asthma.
  • Allergens are a common cause of occupational asthma.

Although atopic sensitisation increases the risk of developing asthma, most people who are allergic to inhalant allergens or food allergens do not have asthma.13 Among people with food allergies, asthma may be a risk factor for fatal anaphylaxis due to food allergens.1415 However, foods are rarely a trigger for asthma symtpoms.

Neither asthma nor allergy is a single disease – each has multiple phenotypes and is a complex of several different diseases with different aetiologies, genetic risk factors and environmental risk factors.12

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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.16 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.17

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.18

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.19, 20, 21, 22, 23 However, the use of antihistamines in children has not been shown to prevent them developing asthma.16

The presence of allergic rhinitis is associated with worse asthma control in children and adults.24, 25, 26, 27 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.28

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 asthma).

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

Thunderstorm asthma

Seasonal allergic rhinitis, which in Australia is typically associated with sensitisation to perennial ryegrass (Lolium perenne), is an important risk factor for thunderstorm asthma.30

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Thunderstorm 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 individuals sensitised to rye grass, even if they have not had asthma before.31, 32, 33, 34, 35

Sensitisation to rye grass allergen is almost universal in patients who have reported flare-ups consistent with thunderstorm asthma in Australia.

People with allergic rhinitis and allergy to ryegrass pollen (i.e. most people with springtime allergic rhinitis symptoms) are at risk of thunderstorm 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. This includes people with undiagnosed asthma, no previous asthma, known asthma.3132 Lack of inhaled corticosteroid preventer treatment has been identified as a risk factor.31

Epidemics of thunderstorm asthma can occur when such a storm travels across a region and triggers asthma in many susceptible individuals. Epidemic thunderstorm asthma events are uncommon, but when they occur can they make a high demand on ambulance and health services.363537

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).31

The worst outcomes are seen in people with poorly controlled asthma.36 Treatment with an inhaled corticosteroid asthma preventer was significantly protective in a well-conducted Australian case-control study.32

There is insufficient evidence to determine whether intranasal corticosteroids help protect against thunderstorm asthma. Intranasal corticosteroids reduce symptoms of allergic rhinitis and limited indirect evidence suggests they may protect against asthma flare-ups in people not taking inhaled corticosteroids.38

The effectiveness of specific allergen immunotherapy in protecting against thunderstorm asthma has not been evaluated in randomised clinical trials, but data from a small Australian open-label study suggest that short-term treatment with five-grass sublingual immunotherapy may have been protective in individuals.39

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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.40, 41 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.42, 43, 44 There is less evidence supporting specific allergen immunotherapy in children than in adults.43 Specific allergen immunotherapy in children with seasonal allergic rhinoconjunctivitis might prevent development of asthma.17, 10, 45

Single-allergen specific allergen immunotherapy is effective in patients sensitised to one allergen and those sensitised to multiple allergens.46, 47, 48 In selected cases more than one allergen may be administered as separate extracts. There is weak evidence for the efficacy of allergen mixes.49

A systematic review of studies directly comparing subcutaneous immunotherapy and sublingual immunotherapy in the treatment of allergic rhinoconjunctivitis and asthma found:50

  • 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.16, 51, 52

Sublingual immunotherapy

Sublingual immunotherapy (self-administered at home) is effective for the treatment of allergic rhinitis in adults and children.53, 54 The greatest benefits have been demonstrated in those with allergies to temperate grass pollens or house dust mite.54 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.53 Local adverse effects are common in children receiving sublingual immunotherapy.16 Systemic adverse reactions, such as anaphylaxis, are very rare.16 The majority of adverse events occur soon after beginning treatment.54

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.55 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.55

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.55
  • 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.56
  • Grazax (Timothy grass [Phleum pratense] pollen extract) – indicated for adults, adolescents and children older than 5 years with allergic rhinitis induced by Timothy grass57
  • Oralair tablets (mix of grass pollens) – indicated for adults and children over 5 years with grass pollen allergic rhinitis.58

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.1 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.51 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.51 There is also moderate evidence that subcutaneous immunotherapy reduces rhinitis/rhinoconjunctivitis medication usage.51

Subcutaneous immunotherapy is associated with local adverse effects (e.g. injection-site swelling) and, less frequently, serious systemic adverse effects.16, 54 The most common systemic reactions are respiratory symtoms. There have been few reports of anaphylaxis.16

Note: PBS status as at March 2019: Treatment with subcutaneous specific allergen immunotherapy preparations is not subsidised by the PBS.

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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: http://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.28, 16, 44 Intranasal corticosteroid are most effective when taken continuously.28

Intranasal corticosteroids are effective in reducing congestion, rhinorrhoea, sneezing and itching in adults and adolescents with allergic rhinitis.28, 16 They are also effective for ocular symptoms.59

All available intranasal corticosteroids appear to be equally effective.28

The onset of action is between 3 and 36 hours after first dose and, in practice, the full therapeutic effect takes a few days.60

The addition of an oral H1-antihistamine or leukotriene receptor antagonist to an intranasal corticosteroid is generally no more effective than intranasal corticosteroid monotherapy.44

Intranasal corticosteroids are well tolerated. Common (>1%) adverse effects include nasal stinging, itching, nosebleed, sneezing, sore throat, dry mouth, cough.9 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.61

Intranasal corticosteroids are not generally associated with clinically significant systemic adverse effects when given in recommended doses.28, 62 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.28

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.9

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.28, 44, 30

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

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.63

Less sedating oral H1-antihistamines are effective in managing allergic rhinitis symptoms of rhinorrhoea, sneezing, nasal itching and ocular symptoms.44, 64 They can provide adequate relief for some individuals when taken continuously or intermittently.28 Available agents appear to be equally effective.62

However, oral antihistamines are less effective than continuous intranasal corticosteroids, especially for nasal congestion.28, 65 In adults with allergic rhinitis, oral antihistamines usually produce no further improvement when added to intranasal corticosteroid treatment.28

Common (>1%) adverse effects include drowsiness, fatigue, headache, nausea and dry mouth.9 Oral antihistamines can also cause ocular dryness.66

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.16

Intranasal antihistamines are more effective than oral antihistamines for reducing nasal congestion.28 They have a rapid onset of action (15–30 minutes).28

The most common (>1%) adverse effect is local irritation.9 Bitter taste is more common intranasal antihistamines than with intranasal corticosteroids.28

Montelukast

Leukotriene receptor antagonists are no more effective than oral H1-antihistamines.16, 44 Montelukast is less effective than intranasal corticosteroid in the treatment of allergic rhinitis.28, 16 In most studies, adding montelukast to an intranasal corticosteroid was not more effective than intranasal corticosteroid alone.44

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.67, 68, 69, 70, 71 A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares, depression, and aggression.71 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.71

Other nasal sprays

Ipratropium bromide spray is effective in managing persistent rhinorrhoea in patients with allergic rhinitis, but not blockage or itch.16 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.62

Specific allergen immunotherapy

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

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Treatment of allergic rhinitis in children

 

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

Intranasal corticosteroids

Intranasal corticosteroids are effective in reducing congestion, rhinorrhoea, sneezing and itching in school-aged children with allergic rhinitis.28, 16 However, there is weaker evidence to support their efficacy in children than in adults.16 There is limited evidence to guide the treatment of allergic rhinitis in preschool children.44

The addition of an oral H1-antihistamine or leukotriene receptor antagonist to an intranasal corticosteroid is generally no more effective than intranasal corticosteroid monotherapy.44

TGA-approved indications vary between age groups. Intranasal corticosteroids indicated for children aged under 12 years include fluticasone furoate (age 2 years and over), mometasone furoate (age 3 years and over), and budesonide (age 6 years and over).

Intranasal corticosteroids are well tolerated. Evidence from studies mainly in adults suggests that they do not cause atrophy of nasal epithelium.72 Intranasal corticosteroids are not generally associated with clinically significant systemic adverse effects in children when given in recommended doses.2862 Studies in children evaluating effects on the hypothalamic-pituitary axis using morning cortisol concentrations, cosyntropin stimulation, and 24-hour urinary free cortisol excretion showed no adverse effects with ciclesonide, fluticasone propionate, fluticasone furoate, mometasone furoate, or triamcinolone acetonide.28 One knemometry study showed reduced lower leg growth rate in children using intranasal budesonide.28 In studies using stadiometry over 12 months, higher-than-recommended doses of intranasal beclomethasone dipropionate were associated with growth suppression, but fluticasone propionate and mometasone furoate showed no effects on growth compared with placebo.28

In children 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.

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.63

These antihistamines can be taken long term by children. Eighteen months of treatment with cetirizine was well tolerated in a large, prospective, multi-country, randomised controlled trial in infants with atopic dermatitis aged 12–24 months.73

Less sedating oral H1-antihistamines are effective in managing allergic rhinitis symptoms of rhinorrhoea, sneezing, nasal itching and ocular symptoms,44, 64 including in preschool children. 44 They can provide adequate relief for some individuals when taken continuously or intermittently.28 Available agents appear to be equally effective.62

However, oral antihistamines are less effective than continuous intranasal corticosteroids, especially for nasal congestion.28, 65 The addition of oral antihistamines to intranasal corticosteroids has not been demonstrated to be an effective strategy in children.74

TGA-approved indications vary between age groups. Less sedating oral antihistamines indicated for children under 12 years include cetirizine (1 year and over), loratatidine (1 year and over), desloratadine (6 months and over), and fexofenadine (6 months and over).

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.16

Intranasal antihistamines are more effective than oral antihistamines for reducing nasal congestion.28 They have a rapid onset of action (15–30 minutes).28

Montelukast

Leukotriene receptor antagonists are no more effective than oral H1-antihistamines.16, 44 Montelukast is less effective than intranasal corticosteroid in the treatment of allergic rhinitis.28, 16 In most studies, adding montelukast to an intranasal corticosteroid was not more effective than intranasal corticosteroid alone.44

Montelukast is approved by TGA for the treatment of asthma in children over 2 years, and for the treatment of 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.67, 68, 69, 70 A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares (especially in children), depression, and aggression (especially in children).71 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.71

The potential association of montelukast with behaviour-related adverse events should be mentioned to parents when commencing treatment, and treatment should be stopped if such adverse events are suspected.

Specific allergen immunotherapy

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

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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.

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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.75 Saline administered by spray or other devices was used at least twice daily in most studies that showed a benefit.75

Isotonic solution is preferable to hypertonic solution because it supports optimal mucociliary clearance.75 Isotonic saline is solution is inexpensive and has no known adverse effects.75 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.

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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.76 Several surgical procedures are available to correct this problem.77 The ideal surgical reduction should preserve the mucosa and physiological function.76

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’).77 There is no evidence that turbinate surgery creates these conditions, but sino-nasal surgery may exacerbate the symptoms.

 

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References

  1. Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergen Immunotherapy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/patients/allergy-treatment/immunotherapy
  2. Australasian Society of Clinical Immunology and Allergy. Specific allergen immunotherapy for asthma. A position paper of the Thoracic Society of Australia and New Zealand and the Australasian Society of Clinical Immunology and Allergy. Med J Aust. 1997; 167: 540-4. Available from: https://www.mja.com.au/journal/1997/167/10/specific-allergen-immunotherapy-asthma
  3. Katelaris CH, Douglass J, Gibson PG, et al. Omalizumab. Recommendations for use in the Australasian context (A consensus paper of the Thoracic Society of Australia and New Zealand). Thoracic Society of Australia and New Zealand, 2009. Available from: https://www.thoracic.org.au/clinical-documents/area?command=record&id=47
  4. Chung, K. F., Wenzel, S. E., Brozek, J. L., et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. The European respiratory journal. 2014; 43: 343-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24337046
  5. Menzella, F., Lusuardi, M., Montanari, G., et al. Clinical usefulness of mepolizumab in severe eosinophilic asthma. Therapeutics and clinical risk management. 2016; 12: 907-16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27354806
  6. Powell, Colin, Milan, Stephen J., Dwan, Kerry, et al. Mepolizumab versus placebo for asthma. **. 2015; : . Available from: http://dx.doi.org/10.1002/14651858.CD010834.pub2
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