Antihistamines intranasal

Moderate-severe persistent intranasal corticosteroids are the drug of choice. Antihistamines, intranasal decongestants, and sodium cromoglicate are alternatives if steroids are contraindicated, or can be used as add-on drugs. Ipratropium bromide is useful for people with persistent watery effusion. 

Perennial rhinitis is common in both adults and children and is usually treated with intranasal corticosteroids, intranasal ipratropium bromide, antihistamines, intranasal cromones, and decongestants. Treatment-related adverse effects are common and monotherapy is often inadequate. There are few published studies of the comparative efficacy of rhinitis treatments. 

Antihistamines and intranasal corticosteroids are considered first-line therapy for allergic rhinitis, whereas decongestants, mast cell stabilizers, leukotriene modifiers, and systemic corticosteroids are secondary treatment options. 

Patients who may benefit from allergen immunotherapy include those who do not tolerate traditional drug therapy (e.g., nosebleeds with intranasal steroids or sedation with antihistamines), suffer from severe symptoms, have comorbid conditions (e.g., asthma or sinusitis), fail drug therapy, or prefer not to take long-term medication. 

Pharmacotherapy has an important role in managing AR symptoms (Table 59-2). Intranasal corticosteroids, systemic and topical antihistamines and decongestants, mast cell stabilizers, and immunotherapy all are beneficial in treating symptoms of AR.9 Antihistamines and intranasal corticosteroids are considered first-line therapy for AR, whereas decongestants, mast cell stabilizers, leukotriene modifiers, and systemic corticosteroids are secondary treatment options10-12 (Fig. 59-2). Whenever exposure to allergens can be predicted (e.g., SAR or visiting homes with a pet), medications should be used pro-phylactically to maximize effectiveness.11... 

Locally acting antihistamines act more quickly than oral agents but need to be administered intranasally at least twice daily due to the potential for removal by nasal secretions.13 Azelastine, an intranasal antihistamine, is as effective as systemic antihistamines in the treatment of perennial and seasonal AR. 

Intranasal (Local) Antihistamines V V V V First-line therapy... 

Intranasal anticholinergic agents (e.g., ipratropium) reduce the severity and duration of rhinorrhea but have no effect on other nasal symptoms.11,12,21 Ipratropium reduces cholinergic hyperreactivity and cholinergically mediated histamine- and antigen-induced secretion. Intranasal ipratropium acts locally, with only minimal systemic absorption. Clinical trials demonstrated that ipratropium bromide 0.3% reduced rhinorrhea in adults and children with PAR.11,12 Intranasal ipratropium is an option for patients in whom rhinorrhea is refractory to topical intranasal corticosteroids and/or antihistamines.8,12 Intranasal ipratropium is available only by prescription, and the dose is two sprays nasally two to three times daily.15 Adverse effects are minimal, but dry nasal membranes have been reported.11,12... 

Oral pseudoephedrine should not be used in children under 1 year of age due to safety concerns. Intranasal ipratropium can be used as intermittent therapy for mild rhinitis or as add-on therapy in more severe cases. AIT is recommended for persistent rhinitis, particularly severe disease, because studies have shown that children respond better than adults. Montelukast is indicated for children 2 years of age and older with SAR and for infants 6 months of age and older with PAR. Studies evaluating leukotriene receptor antagonists as monotherapy or in combination with antihistamines have contradictory results.33... 

Patients with severe symptoms or those that persist despite intranasal corticosteroid treatment are treated with a combination of intranasal corticosteroid and antihistamine. 

Is the patient taking antihistamines and/or intranasal steroids Is the patient experiencing adverse effects (e.g., sedation from antihistamines or nasal itching, burning, or bleeding from intranasal corticosteroids) ... 

Develop a plan to assess the effectiveness of the antihistamine and/or intranasal corticosteroid therapy after 3 months. 

Intranasal corticosteroids are the most effective treatment for allergic rhinitis during pregnancy. Beclomethasone and budesonide have been used most. Nasal cromolyn and first-generation antihistamines (chlorpheniramine, tripelennamine, and hydroxyzine) are also considered first-line therapy. Loratadine and cetirizine have not been as extensively studied. 

Azelastine (Astelin) is an intranasal antihistamine that rapidly relieves symptoms of seasonal allergic rhinitis. However, patients should be cau-... 

Although leukotriene antagonists represent a new therapeutic alternative, published studies to date have shown them to be no more effective than peripherally selective antihistamines and less effective than intranasal corticosteroids. However, combined use with antihistamines is more effective than antihistamine treatment alone. 

Salib RJ, Howarth PH. Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis. Drug Saf 2003 26 863-93. 

In case of an obstruction of the nasal airways, the swelling should first be reduced and then the patient should apply the anti-inflammatory medication to ensure its necessary distribution over the complete mucosa. Antihistamines in addition to oral therapy may also be applied locally, intranasally or conjunctivally. The combination of all three substance groups (H, antihistamines, topic glucocorticoids and antileukotrienes) as a pretreatment as well as a symptomatic treatment during immunotherapy increases the chances of success of hyposensitization in our experience [unpubl. data]. 

When HI antihistamines and intranasal pharmacotherapy insufficiently control symptoms or produce undesirable side effects. 

Chou, K.J., and M.D. Donovan. 1997. Distribution of antihistamines into the CSF following intranasal delivery. Biopharm Drug Disp 18 335. 

Antihistamines and intranasal corticosteroids are the first-line treatments for allergic rhinitis. Sodium cromoglicate, ipratropium bromide and decongestants, are alternative or add-on treatments. Drug treatment should be selected according to the severity, frequency and duration of symptoms ... 

Mild intermittent use an oral non-sedating (e.g. cetirizine or loratidine) or intranasal antihistamine (e.g. azelastine) as required. Consider using an intranasal decongestant in the short term (7 days maximum) if blockage is a problem. But this does not apply to Mr AJ as he has used this for a number of weeks and it is already causing rebound symptoms. 

Mild persistent or moderate-severe intermittent use an oral or intranasal antihistamine, or an intranasal corticosteroid (e.g. beclometasone or fluticasone). Intranasal decongestants and sodium cromoglicate are useful add-on drugs. 

The reasons for not including or only briefly mentioning this subject may include (1) a misconception that symptoms of allergic rhinitis are trivial and can be easily alleviated with the use of oral antihistamines and/or intranasal corticosteroids (2) an underestimation of the effect of allergic rhinitis on the quality of life, and (3) a lack of controlled trials of education in allergic rhinitis. 

Medications. Medications used for treatment should be explained to the patient. Instruction of how to correctly use intranasal corticosteroids should be given [145]. Intranasal steroids provide better control when used regularly than on an as needed basis. Such explanations increase compliance. The mode of action of antihistamines and nasal decongestants on nasal symptoms should be clarified. The side-effects and safety of long-term use of the newer antihistamines and intranasal steroids should be explained. 

For seasonal allergic rhinitis, begin treatment before allergen exposure. Nonsedating agents should be tried first. If ineffective or too expensive for the patient, the older agents may be used. For perennial allergic rhinitis, use an intranasal steroid as an alternative to or in combination with systemic antihistamines. 

For seasonal allergic rhinitis, an intranasal antihistamine, aze-lastine, is available. Azelastine has been used successfully in patients who did not respond to loratadine. Using the nasal route offers an alternative to switching to another oral antihistamine. Patient satisfaction has been varied because while the product produces rapid symptom relief, patients complain of drying effects, headache, and diminished effectiveness over time. Patients should be warned of the medication s potential to produce drowsiness, as its systemic availability is approximately 40%. " ... 

There is a case of torsade de pointes possibly due to spiramycin with the sedating antihistamine mequitazine. The situation with erythromycin and loratadine is unclear as one study found that the combination caused a very slight increase in QT interval. Both azithromycin and erythromycin raise fexofenadine levels, but this had no effect on the QT interval, or on adverse events. Azelastine, cetirizine, desloratadine, and intranasal levocabastine seem to be free of clinically relevant interactions with macrolides. 

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