KEYSTONE, COLO. — Nasal corticosteroids remain the first line of treatment for most patients with seasonal allergic rhinitis, according to Dr. Harold S. Nelson.
“Nasal steroids started before the beginning of the season [work well],” Dr. Nelson said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine. “If people come in during the season and are symptomatic, using 20 mg prednisone three times a day to depress the inflammation greatly enhances the effectiveness of the nasal steroid.”
The use of antihistamines as a first line of treatment for seasonal allergic rhinitis is an antiquated approach, said Dr. Nelson, professor in the division of allergy and clinical immunology at National Jewish Medical and Research Center in Denver, which sponsored the meeting. “[They] are something you use for the person who has intermittent symptoms.”
Antihistamine-decongestant combinations, and cromolyn sodium nasal solution started 9 weeks before the onset of symptoms, each provide moderate relief, though cromolyn sodium is short acting and has to be taken six times a day, Dr. Nelson said.
Intranasal corticosteroids also outperform antihistamines when the two are compared on an as-needed (PRN) basis for the reduction of allergic inflammation, Dr. Nelson said (Arch. Intern. Med. 2001;161:2581–7).
Recent findings have shown that seasonal treatment that combined antihistamine and a nasal steroid (levocetirizine as an add-on to fluticasone) was of marginal value and led the authors to deem the practice “inappropriate” (Clin. Exp. Allergy 2006;36:676–84).
There is nothing in the drug pipeline that is better than current therapy for allergic rhinitis, Dr. Nelson said. The Food and Drug Administration is considering a request to approve the combination of montelukast and loratadine, which has been shown to be superior to either drug alone for alleviating nasal obstruction and itchy, sneezy, and runny symptoms (J. Allergy Clin. Immunol. 2000;105:917–27).
According to Dr. Nelson, the choices, from least to most effective, are:
▸ Leukotriene-receptor antagonists (less than 10% relief, compared with placebo).
▸ Antihistamines, anticholinergics (rhinorrhea only), decongestants (obstruction only), and nasal corticosteroids started during season (less than 20% relief).
▸ Cromolyn (six times per day) started before season, antihistamine/decongestant combinations (20%–40% relief).
▸ Nasal corticosteroids started before season or after 4 weeks, allergen immunotherapy (greater than 40% relief).
The use of antihistaminesas a first line of therapy for seasonal allergies is an antiquated approach. DR. NELSON