AR affects between 10% and 40% of the global population and is often underdiagnosed. The impact of AR extends beyond mere discomfort, significantly impacting productivity and quality of life (QoL).

The consequences of AR include exacerbations of asthma, comorbidities like rhinosinusitis and otitis media, increased susceptibility to viral illnesses, interference with taste and smell, as well as poor sleep quality.¹

Poor sleep quality linked to AR can lead to chronic fatigue, daytime sleepiness, and learning difficulties - especially in children. Additionally, AR can exacerbate mood disorders such as depression and impair concentration.¹

Clinical assessment essential to diagnose AR

The diagnosis of AR relies on clinical assessment, including a detailed history of symptoms and allergen exposure, along with laboratory tests indicating allergic sensitisation. Symptoms of AR include nasal signs such as rhinorrhoea, sneezing, nasal blockage, and itching, as well as non-nasal symptoms such as allergic conjunctivitis, and cough.¹

Clinical examination, including signs of atopy, evaluation of the inferior turbinate, and assessment of concomitant allergic diseases, is crucial for diagnosis. Imaging, particularly plain film sinus X-rays, has no place in diagnosis, while computed tomography scanning should be reserved for suspected chronic sinus disease.¹

The seven pillars of AR management

Effective AR management  should incorporate the following seven pillars:¹

1. Education: Inform patients that AR is a chronic disease and provide information of the various treatment options.
2. The importance of adherence allergen avoidance: Common outdoor allergens are pollens and fungal spores, while the major indoor allergens include house dust mites, pets, moulds and cockroaches.
3. Nasal douching/irrigation and rinses: Irrigation with saline, either hypertonic or isotonic, is a cost-effective method to remove allergens, irritants, and mucus, improving clearance.
4. Pharmacological treatment: Evidence-backed options include intranasal corticosteroids [INCS], intranasal antihistamines [INAH], combination INCS/INAH and leukotriene receptor antagonists.
5. Patient evaluation for allergen immunotherapy (AIT): The only disease-modifying treatment for AR, alleviates short- and long-term symptoms, reducing medication dependency and hindering AR-to-asthma progression. Indicated for patients inadequately managed with pharmacotherapy, those who have high-dose requirements, to reduce the risk of adverse events and aversion to prolonged medication use, in children to prevent sensitisations and asthma, and for individuals with pollen-food syndrome.
6. Measuring response to therapy: Visual analogue scales or AR control tests, can be used to assess treatment response and control. They are quick and to use in clinical practice.
7. Referral to a specialist: Is warranted for patients who have a poor response to treatment, those who require AIT or aeroallergen assessment, patients who experience atypical symptoms or have nasal abnormalities, severe comorbidities, and immune deficiency, as well as in patients who have severe ocular involvement.

Recommended pharmacotherapies

INCS are recommended as first-line therapy for all forms of AR, effectively targeting a broad range of symptoms. Their intermittent use is recommended for seasonal disease, while continuous use is suitable for perennial disease. Efficacy assessment should occur two- to four-weeks into treatment, and if symptoms persist, combining an INCS with an AH is recommended.¹

INCS are effective in reducing the release of inflammatory mediators, providing symptomatic relief when used consistently or in extended treatment blocks. They pose a lower risk of systemic side effects compared to oral and inhaled CS due to lower doses and bioavailability.¹

Short-term use of INCS drops is acceptable for severe congestion, but long-term usage, especially compared to nasal sprays, is strongly discouraged due to higher systemic bioavailability and increased likelihood of systemic side effects.

Depot intramuscular steroid injections are not recommended due to associated complications.¹

Systemic antihistamines, particularly H1-AH, effectively counteract the effects of histamine during allergic reactions. They address itching, sneezing, and rhinorrhoea but have limited efficacy against congestion. The use of first-generation H1-AH, with poor receptor selectivity and significant side effects, are strongly discouraged.¹

Second- and third-generation formulations are safer and more efficacious, with reduced sedation. The SAARWG recommends exclusively using newer generation AH, with careful consideration based on individual patient profiles. Topical INAHs are fast-acting and are more effective than oral AH in AR control. They are also safe and effective for children with AR.¹

Conclusion

The updated recommendations from the SAARWG provide a comprehensive and tailored approach to managing AR. The seven pillars of AR management outlined by SAARWG emphasise education, allergen avoidance, nasal irrigation, pharmacological treatment, AIT, monitoring response, and specialist referral when necessary.

The inclusion of combination mometasone/olopatadine nasal spray as a cost-effective option represents a significant advancement. The dual action of olopatadine's mast-cell-stabilising properties and mometasone's potent anti-inflammatory effects offers a promising therapeutic approach. Clinical studies confirm its efficacy in improving nasal and ocular symptoms, underscoring its rapid onset and sustained effectiveness.

References

Richards GA, McDonald M, Gray CL, et al. Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group. S Afr Fam Pract (2004), 2023.