Current therapeutical strategies for allergic rhinitis

ABSTRACT

Introduction: Allergic rhinitis is a common condition with increasing prevalence and is associated with several comorbid disorders such as bronchial asthma and atopic dermatitis. If allergen avoidance is not possible, allergen-specific immunotherapy is the only causal treatment option.

Areas covered: This review focuses on current treatments and the future outlook for allergic rhinitis. Pharmacotherapy includes mast cell stabilizers, antihistamines, glucocorticosteroids (GCSs), leukotriene receptor antagonists, and nasal decongestants. Nasal GCSs are currently regarded as the most effective treatment and are considered first-line therapy together with non-sedating antihistamines. The new formulation MP29-02 combines the nasal GCS fluticasone propionate with azelastine in one single spray and has achieved greater improvements than those under monotherapy with modern GCSs or antihistamines. Furthermore, this review discusses allergen immunotherapy alone and in combination with modern monoclonal antibodies.

Expert opinion: Despite the variety of medications for allergic rhinitis, ranging from general symptomatic agents like GCSs or decongestants, to more specific ones like histamine receptor or leukotriene blockers, to causal therapy like immunotherapy, many patients still experience treatment failures or unsatisfactory results. The ultimate goal may be to endotype every downstream pathway separately in order to offer patients individualized, targeted therapy with specific antibodies against the respective pathway.

KEYWORDS:

• Allergic rhinitis
• nasal glucocorticosteroids
• antihistamines
• allergen immunotherapy

Article highlights

• Allergic rhinitis is a prevalent disorder for which numerous symptomatic and systemic medications are available, but allergen-specific immunotherapy remains the only causal therapeutic approach.

• Pharmacotherapy presently targets mast cells and various receptors, such as histamine, glucocorticoid and leukotriene receptors, with various degrees of effectiveness.

• Comorbidities and patients’ preferences must be considered when choosing a therapy strategy to optimize patient compliance and treatment efficacy.

• Some combinations of treatment approaches are more effective than others and a fixcombination of azelastine and fluticasone has the highest evidence of combination therapies.

• Research on anti-IgE antibodies combined with allergen-specific immunotherapy showed interesting results.

• Future research needs to explore the possibility of identifying and endotyping the downstream pathways involved in individual patients’ allergic reactions in order to determine their unique cytokine profile and consequently tailor their individual therapy with specific antibodies against those pathways (biologicals)

This box summarizes key points contained in the article.

Acknowledgments

The authors are deeply grateful to Gena Kittel of CRI – Clinical Research International Ltd., Cologne, Germany, for editing the manuscript.

Declaration of interest

Over the past 5 years, L Klimek has received grants and personal fees from ALK Abello, Novartis, Allergopharma, Bionorica, GlaxoSmithKline, and Lofarma. He has also received grants from Biomay, HAL, LETI, Roxall, and Bencard as well as personal fees from MEDA and Boehringer Ingelheim. S Becker has received fees for presentations and consultancy from ALK, Bencard Allergy, Alleropharma, HAL Allergy, Thermo Fisher Scientific, Stor GmbH, Ambu, Pari GmbH, Sanofi-Genzyme, and Bristol-Myers Squibb. R Mosges is an employee of Clinical Research International Ltd and reports personal fees from ALK Abello and grants from ASIT Biotech. R Mosges also reports personal fees from Nuvo, STADA, UCB Pharma, Bayer Healthcare, FAES, GlaxoSmithKline, Merck Sharp and Dohme, Johnson & Johnson, MEDA, Allergopharma, Allergy Therapeutics, Friulchem, Hexal, Servier, and Klosterfrau. He also reports grants and personal fees from Bencard and Stallergenes as well as grants from LETI, Optima, Bitop AG, Hulka and Ursapharm. Finally, R Mosges reports receiving grants, personal fees and non-financial support from Lofarma, personal fees and non-financial support from Novartis and non-financial support from Roxall, Atmos, Bionorica, Otonomy, and Ferrero. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript has not been funded.