AR, caused by immunoglobulin E mediated reactions to aeroallergens such as dust mites and pollen, is usually a chronic condition that often goes undetected in the primary care setting. AR is often misdiagnosed as a common cold.2,3

A positive family history is the best predictor of allergic rhinitis.

A positive family history (father or mother with allergic rhinitis) is the best predictor of AR. The predominant features of AR are nasal obstruction (94%), followed by nasal discharge (82%), facial congestion (85%) and facial pain-pressure fullness (85%).2,5

A thorough history, physical examination and allergen skin testing are recommended to make a diagnosis of AR.3

Classification

Historically AR was classified as either seasonal or perennial, however in 2008, the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative changed the categorisation of AR to:5

Intermittent:
• <4 days a week, or
• <4 consecutive weeks Persistent:   • >4 days a week, and
• >4 consecutive weeks

Mild:
• Sleep disturbance
• Impairment of daily activities, leisure and/or sport
• Impairment of school or work
• Symptoms present but not troublesome.

Moderate/severe:
• Sleep disturbance
• Impairment of daily activities, leisure and/or sport
• Impairment of school or work
• Troublesome symptoms.

More recently, two new types of rhinitis have been added to the classification, namely occupational rhinitis, and local AR.3

Occupational rhinitis is defined as an inflammatory disease of the nose characterised by intermittent or persistent symptoms such as airflow limitation, hypersecretion, sneezing and pruritis. These symptoms must be attributable to a particular work environment (eg people who work in laboratories or food-processing plants and veterinarians).3

Local AR is characterised by a localised allergic response in the nasal mucosa in the absence of systemic atopy.3

ARIA guidelines

Current ARIA guidelines (2016) recommend the following treatment:6

Step 1: Nonsedating antihistamine (oral, intranasal, ocular), leukotriene receptor antagonists, or chromones (intranasal, ocular) for mild symptoms
Step 2: Intranasal corticosteroid (INCS) for moderate to severe symptoms and/or persistent AR
Step 3: INCS plus intranasal azelastine for patients with uncontrolled symptoms at step 2 (current or historical). Combination of INCS and intranasal antihistamine (INAH) – depending on the doctor’s experience, other therapeutic strategies could be used. Free combination of INAH/oral AH plus INCS. Fixed combination of INCS plus INAH
Step 4: Oral CS as a short course and an add-on treatment
Step 5: Consider referral to a specialist and allergen immunotherapy.

Fixed combination therapy

Segall et al conducted a 52 week follow up study to evaluate the safety and efficacy of fixed combination of olopatadine hydrochloride and mometasone furoate, in patients with persistent AR. This was a randomised, double-blind, parallel-group study, which included 601 participants (ages ≥ 12 years).7

Participants were randomised 4:1:1 to twice daily olopatadine 665μg and mometasone 25μg or two vehicle formulations (placebo [pH3.7 and pH7). The primary safety endpoint was monitored through adverse events (AE), laboratory assessments, vital signs, and physical examinations at weeks 30 and 52.7

Total Nasal Symptom Score (rTNSS) and instantaneous Total Nasal Symptom Score (iTNSS), Physician-assessed Nasal Symptom Scores (PNSS), and quality of life were assessed for olopatadine hydrochloride and mometasone furoate versus placebo.7

At week 52, treatment-emergent AEs occurred in 51.7%, 41.4% and 535% of patients in the two placebo groups, respectively. No clinically meaningful differences were observed in treatment-emergent AE incidences or other safety assessments across treatments.7

At weeks six and 30, olopatadine hydrochloride and mometasone furoate provided significant and clinically meaningful improvements in average rTNSS and iTNSS versus placebo pH 3.7.7

Similarly, at week 52, olopatadine hydrochloride and mometasone furoate provided significant and clinically meaningful improvements in rTNSS, and iTNSS versus placebo pH 3.7, with significant improvements in each individual symptom.7

PNSS and quality of life were significantly improved versus placebo pH 3.7 at weeks six and 30, but these greater improvements did not reach statistical significance at week 52.7

The authors concluded that twice daily olopatadine hydrochloride and mometasone furoate was well-tolerated and provided statistically significant and clinically meaningful improvements in persistent nasal symptoms versus placebo over 52 weeks and demonstrated a favourable safety profile and efficacy.7

REFERENCES:

1. Scadding GK, Smith PK, Blaiss M, et al. Allergic Rhinitis in Childhood and the New EUFOREA Algorithm. Front. Allergy, 2021. https://doi.org/10.3389/falgy.2021.706589
2. Bousquet J, Anto JM, Bachert, et al. Allergic rhinitis. Nature Reviews Disease Primers, 2020.
3. Small P, Keith PK, and Kim H. Allergic Rhinitis. Allergy, Asthma and Clinical Immunology, 2018.
4. WebMD. Is It a Common Cold or Allergies? https://www.webmd.com/cold-and-flu/cold-guide/common-cold-or-allergy-symptoms
5. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy 63 (Suppl. 86), 8–160 (2008).
6. Klimek L, Bachert C, Pfaar O, et al. ARIA guideline 2019: treatment of allergic rhinitis in the German health system. Allergol Select, 2019.
7. Segall N, Prenner B, Lumry W, et al. Long-term safety, and efficacy of olopatadine-mometasone combination nasal spray in patients with perennial allergic rhinitis. Allergy Asthma Proc, 2019.