Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology

Figures & data

Figure 1 The treatment strategy by pharmacotherapy in allergic rhinitis.

Table 1 Characteristics of Commonly Used Second-Generation Oral Antihistamines

Drugs	Characteristics
	Age Recommendation	Onset of Action (Hours)	Plasma Protein Binding (%)	Plasma Half-Life (Hours)	Food-Drug Interaction	Use in Pregnancy and Lactation	Sedative Effect	Dose Adjustment Requirements
Bilastine^Citation17	≥6 years	<1	90	14.5	Yes	Special precaution	Non-sedating	None
Cetirizine^Citation18	≥2 years	0.7	93	10.0	Yes	Special precaution	Minimal sedating	Renal impairment Elderly
Desloratadine^Citation19	≥6 months	1	87	27.0	No	Special precaution	Non-sedating	Renal impairment Hepatic impairment
Fexofenadine^Citation20	≥2 years	2	70	14.4	Yes	Special precaution	Non-sedating	Renal impairment Hepatic impairment
Levocetrizine^Citation21	≥6 months	1	91	8.0	No	Special precaution	Non-sedating	Renal impairment
Loratadine^Citation22	≥2 years	1	97	8.4	Yes	Special precaution	Non-sedating	Renal impairment Hepatic impairment

Box 1 Practical Considerations for the Use of Oral Antihistamines

Second-generation oral antihistamines are superior to first-generation oral antihistamines. Generally, all second-generation oral antihistamines are non-sedating, and safe. However, certain drugs can be minimally sedating, and patients must be counselled accordingly. Recommended as first-line therapy for mild-to-moderate AR. Combination with INCS can be used for moderate-to-severe AR or refractory symptoms. Play a role at primary- and secondary-care settings. Response should be reassessed at 2 weeks to decide whether to maintain, step-up or step-down treatment.

Abbreviations: AR, allergic rhinitis; INCS, intranasal corticosteroids.

Table 2 Characteristics of Commonly Used Intranasal Corticosteroids

Intranasal Sprays	Characteristics
	Age Recommendation	Onset of Action	Systemic Bioavailability (%)	Pregnancy Grade*
Beclomethasone	≥6 years	Few days	44	C
Budesonide	≥6 years	Within 10 hours	34	B
Fluticasone furoate	≥2 years	Within 8 hours	0.5	C
Fluticasone propionate	≥4 years	Within 12 hours	<2	C
Fluticasone propionate- azelastine hydrochloride	≥12 years	Within 30 minutes	40 (azelastine) 1.2 (fluticasone)	C
Mometasone	>2 years	Within 12 hours	<1	C
Triamcinolone	≥2 years	Few days	22	C

Notes: *Pregnancy grade refers to the US FDA pregnancy risk category. Category B is no demonstrable risk to the fetus in animal studies with no adequate and well-controlled studies in humans and Category C is an adverse demonstrable effect to the fetus in animal studies with no adequate and well-controlled studies in humans.

Box 2 Practical Considerations for the Use of Intranasal Corticosteroids with/Without Intranasal Antihistamines

INCS effectively relieves both early- and late-phase symptoms. Indicated in mild, moderate, and severe AR. INCS can be used as first-line therapy as an alternative to second-generation oral antihistamines, subject to patients’ preferences. INCS–INA combinations can be used in moderate and severe AR, refractory symptoms or when quicker symptom resolution is desired. Play a role at primary- and secondary-care settings. Response should be reassessed at 2 weeks to decide whether to maintain, step-up or step-down treatment.

Abbreviations: AR, allergic rhinitis; INA, intranasal antihistamines; INCS, intranasal corticosteroids.

Box 3 Practical Considerations for the Use of Systemic Corticosteroids

Not indicated as a standard treatment of AR. Risks outweigh benefits. Can be used in the secondary-care setting for severe and therapy-resistant symptoms, especially for AR with comorbid bronchial asthma or nasal polyposis. When required, only short course of systemic corticosteroids (not exceeding 5 days) should be given. Refrain from use in the primary-care setting due to safety concerns.

Abbreviation: AR, allergic rhinitis.

Box 4 Practical Considerations for the Use of Oral and Intranasal Decongestants

Both oral and intranasal formulations are effective for the rapid relief of nasal obstruction, but adverse effects are more common with oral decongestants. Weigh the risks of oral decongestants against their potential benefits prior to use. Contraindicated in patients with heart disease, hypertension, benign prostatic hypertrophy, thyroid disease, and diabetes. Short-term use for severe AR in primary- and secondary-care settings. Limit use to less than a week to avoid rhinitis medicamentosa.

Abbreviation: AR, allergic rhinitis.

Box 5 Practical Considerations for the Use of Leukotriene Receptor Antagonists

Montelukast is the most studied leukotriene receptor antagonist in AR and hence the most commonly prescribed drug. Indicated in moderate-to-severe AR at both primary- and secondary-care settings. Effective for the symptom of nasal obstruction. Less effective than INCS as monotherapy. Useful as add-on therapy to INCS and oral antihistamine, particularly for AR patients with bronchial asthma and to treat night-time symptoms of AR. Response should be reassessed at 2 weeks to decide whether to maintain, step-up or step-down treatment.

Abbreviations: AR, allergic rhinitis; INCS, intranasal corticosteroids.

Box 6 Practical Considerations for the Use of Biologics

Not approved by the Malaysian regulatory body to treat AR. The most commonly used biologic in AR management is omalizumab. Effective to treat uncontrolled AR and allergic bronchial asthma. Can be used in the secondary-care setting for selected patients. High-cost limits its widespread use.

Abbreviation: AR, allergic rhinitis.

Box 7 Practical Considerations for the Use of Immunotherapy

Both SCIT and SLIT are indicated for moderate-to-severe AR, refractory to other treatment. Both SCIT and SLIT are effective and safe for use in children and adults. SLIT is safer and well tolerated with less risk of systemic adverse effects than SCIT. The use of rescue medication may be necessary at the initiation of immunotherapy. Due to their adverse effects, the use of immunotherapy is only recommended in the secondary-care setting. The recommended treatment duration of AIT is a minimum of 3 years.

Abbreviations: AR, allergic rhinitis; AIT, allergen immunotherapy; SCIT, subcutaneous immunotherapy; SLIT, sublingual immunotherapy.

Box 8 Practical Considerations for the Use of Intranasal Sodium Cromoglycate

Safe for use in children and pregnant women. Effectiveness increases with higher dosage and dosing frequency. Less effective than INCS. Recommended as treatment for symptoms of rhinorrhea, sneezing and itchiness in pregnant women or in patients who cannot tolerate INCS. Response should be reassessed at 2 weeks to decide whether to maintain, step-up or step-down treatment. Not recommended for use in the primary-care setting.

Abbreviation: INCS, intranasal corticosteroids.

Box 9 Practical Considerations for the Use of Intranasal Anticholinergics

The only available intranasal anticholinergic is ipratropium bromide. Rapid onset of action but requires frequent administration due to short half-life. Though effective to reduce rhinorrhea or watery nose, there is no effect on other nasal symptoms. Special precaution for use in patients with prostate hypertrophy or narrow-angle glaucoma. Response should be reassessed at 2 weeks to decide whether to maintain, step-up or step-down treatment. Not recommended for use in the primary-care setting.

Bilastine. Full prescribing information. A. Menarini; 2021.

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Cetirizine. Full prescribing information. GlaxoSmithKline. Available from: https://www.mims.com/malaysia/drug/info/zyrtec?type=full. Accessed April 14, 2022.

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Desloratidine. Full prescribing information. Organon. Available from: https://www.mims.com/malaysia/drug/info/aerius?type=full. Accessed April 14, 2022.

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Fexofenadine. Full prescribing information. Available from: https://www.mims.com/malaysia/drug/info/fexofenadine?mtype=generic. Accessed April 14, 2022.

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Levocetirizine. Full prescribing information. Organon. Available from: https://www.mims.com/malaysia/drug/info/levocetirizine?mtype=generic. Accessed April 14, 2022.

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Loratadine. Full prescribing information. Organon. Available from: https://www.mims.com/malaysia/drug/info/loratadine?mtype=generic. Accessed April14, 2022.

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