Recommendation: Pharmacological and non pharmacological therapy

Non pharmacological

Allergic rhinitis cannot be cured. The goal of the treatment are to reduce symptoms and improve the patient’s functional status and sense of well-being

• Allergen Avoidance:
  • This is the cornerstone of non-pharmacological management. Strategies include:
    • Pollen:
      • Monitoring pollen counts and limiting outdoor activities on high pollen days.
      • Keeping windows closed, especially during peak pollen times.
      • Using air conditioning with HEPA filters.
      • Showering and changing clothes after outdoor exposure.
    • Dust Mites:
      • Using dust mite-proof covers for mattresses and pillows.
      • Washing bedding frequently in hot water.
      • Reducing clutter and keeping the home clean.
      • Using HEPA filters in vacuum cleaners.
    • Pet Dander:
      • Keeping pets out of bedrooms.
      • Regularly bathing pets.
      • Using HEPA filters.
    • Mold:
      • Controlling indoor humidity levels.
      • Repairing leaks and preventing moisture buildup.
      • Cleaning moldy surfaces.
• Nasal Saline Irrigation:
  • This involves rinsing the nasal passages with a saline solution to remove allergens and mucus.
  • It can help relieve nasal congestion, runny nose, and postnasal drip.
  • Various devices are available, including neti pots and squeeze bottles.
• Environmental Control:
  • Creating a clean and allergen-free environment is crucial
  • Air Purifiers: Using air purifiers with HEPA filters can remove airborne allergens.
  • Humidifiers: Maintaining optimal humidity levels can help prevent nasal dryness.
• Lifestyle Adjustments:
  • Hydration: Drinking plenty of fluids can help thin mucus.
  • Healthy Diet: A balanced diet can support overall immune function.
  • Stress Management: Stress can exacerbate allergy symptoms, so practicing relaxation techniques is beneficial.

• Antihistamines
  • Dose
    • Cetirizine: 10 mg once daily
    • Loratadine: 10 mg once daily
    • Fexofenadine: 180 mg once daily or 60 mg twice daily
    • Levocetirizine: 5 mg once daily in the evening
    • Diphenhydramine: 25-50 mg every 4-6 hours as needed
    • Chlorpheniramine: 4 mg every 4-6 hours as needed or 8-12 mg every 12 hours (sustained-release)
  • Adverse effect/caution
    • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
    • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
    • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
    • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
    • 1st gen avoid in children (paradoxical excitation as well as safety issues)
  • Remarks
    • May not be effective for nasal congestion but useful for postnasal drip in pharyngitis
    • Second generation antihistamines preferred over first generation to treat allergic rhinitis
    • Pregnancy: Diphenhydramine and chlorpheniramine is compatible; levocetrazine, loratidine, cetrizine carry low adverse fetal risk; fexofenadine is associated with moderate risk and should not be used
    • Sedation: Of 2nd gen. antihistamines- fexofenadine and loratidine are non-sedating; Cetrizine more potent than fexofenadine or loratadine but it causes sedation in approx 10% of patients
    • Children choice of drug: loratadine>fexofenadine>levocetrazine>cetrizine
    • Elderly: Loratadine is first line; fexofenadine and levocetrizine adjusted in renal impairment; loratadine and cetrizine dosage adjusted in hepatic impairment.
• Nasal decongestants
  • Dose
    • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
    • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
    • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
    • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
  • Adverse effect/caution
    • Use cautiously in patients with hypertension
  • Remarks
    • low systemic absorption makes it ideal for special populations and patients with comorbidities
    • therapy should be limited to 3-5 days to avoid rebound congestion
    • may be used during pregnancy owing to low systemic absorption
• Oral decongestant
  • Dose
    • • Phenylephrine:
        • Adults/Children ≥12 years: 10 mg every 4 hours (maximum daily dosage: 60 mg)
        • Children 6-12 years: 5 mg every 4 hours (maximum daily dosage: 30 mg)
        • Children 2-6 years: 2.5 mg every 4 hours (maximum daily dosage: 15 mg)
      • Pseudoephedrine:
        • Adults/Children ≥12 years: 60 mg every 4-6 hours (maximum daily dosage: 240 mg)
        • Children 6-12 years: 30 mg every 4-6 hours (maximum daily dosage: 120 mg)
        • Children 2-6 years: 15 mg every 4-6 hours (maximum daily dosage: 60 mg)
  • Adverse effect/caution
    • cardiovascular stimulation (e.g., elevated BP, tachycardia, palpitation, or arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, or hallucinations)
    • Refer to physicians if patient has diabetes, hypertensives, BPH, hyperthyroidism, ischemic heart disease, increased intraocular pressure
    • Avoid in pregnancy
    • Decongestants should not be given to children under six years and treatment for children aged six to 12 years should be restricted to five days or less.
  • Remarks
    • Pseudoephedrine compatible with breast feeding
    • Avoid taking at bedtime, because of potential to cause insomnia and restlessness
    • pseudoephedrine max dose: 240 mg/day

Referral:

Id symptoms worsens during therapy or do not decrease after 2-4 weeks of treatment

Recommendation: Pharmacological and non pharmacological therapy

Non pharmacological

Allergic rhinitis cannot be cured. The goal of the treatment are to reduce symptoms and improve the patient’s functional status and sense of well-being

• Allergen Avoidance:
  • This is the cornerstone of non-pharmacological management. Strategies include:
    • Pollen:
      • Monitoring pollen counts and limiting outdoor activities on high pollen days.
      • Keeping windows closed, especially during peak pollen times.
      • Using air conditioning with HEPA filters.
      • Showering and changing clothes after outdoor exposure.
    • Dust Mites:
      • Using dust mite-proof covers for mattresses and pillows.
      • Washing bedding frequently in hot water.
      • Reducing clutter and keeping the home clean.
      • Using HEPA filters in vacuum cleaners.
    • Pet Dander:
      • Keeping pets out of bedrooms.
      • Regularly bathing pets.
      • Using HEPA filters.
    • Mold:
      • Controlling indoor humidity levels.
      • Repairing leaks and preventing moisture buildup.
      • Cleaning moldy surfaces.
• Nasal Saline Irrigation:
  • This involves rinsing the nasal passages with a saline solution to remove allergens and mucus.
  • It can help relieve nasal congestion, runny nose, and postnasal drip.
  • Various devices are available, including neti pots and squeeze bottles.
• Environmental Control:
  • Creating a clean and allergen-free environment is crucial
  • Air Purifiers: Using air purifiers with HEPA filters can remove airborne allergens.
  • Humidifiers: Maintaining optimal humidity levels can help prevent nasal dryness.
• Lifestyle Adjustments:
  • Hydration: Drinking plenty of fluids can help thin mucus.
  • Healthy Diet: A balanced diet can support overall immune function.
  • Stress Management: Stress can exacerbate allergy symptoms, so practicing relaxation techniques is beneficial.

• Antihistamines
  • Dose
    • Beclomethasone dipropionate : 1-2 sprays in each nostril twice daily or 2 sprays in each nostril once daily
    • Budesonide: 1-2 sprays in each nostril once daily or 1 spray in each nostril twice daily (may start with 2 sprays twice daily for initial control)
    • Ciclesonide: 2 sprays in each nostril once daily
    • Flunisolide: 2 sprays in each nostril twice daily (may start with 2 sprays three times daily for initial control)
    • Fluticasone furoate: 2 sprays in each nostril once daily
    • Fluticasone propionate (Flonase)Nasal spray1-2 sprays in each nostril once daily or 2 sprays in each nostril twice daily
    • Mometasone furoate: 2 sprays in each nostril once daily
    • Triamcinolone acetonide: 2 sprays in each nostril once daily
  • Adverse effect/caution
    • minor and include nasal discomfort or bleeding, sneezing, cough, pharyngitis.
    • Patient who are sensitive to INCS or use higher than recommended doses may experience systematic effects such as headache, dizziness, nausea, and vomiting.
    • Long-term use has been linked to changes in vision, glaucoma, cataracts and increased risk of infection (e.g., Candida) and growth inhibition in children)
    • For lactating mothers, reports of harm are lacking and hence considered “probably compatible”
  • Remarks
    • Use them consistently for best results, even if you feel some relief initially.
    • Generally, they are safe for long-term use.
    • It starts working right away but full effect may not be visible at least 1 week
    • have variable systemic absorption (e.g., fluticasone <2%, budenoside 34%)
    • Inappropriate nasal spray technique can injure the nose
    • INCS (fluticasone furoate and proprionate) have additional approval for ophthalmic symptoms (itching, redness, watery discharge)
    • INCS are compatible with pregnancy however systemic use should be avoided for the risk of cleft lip and palate
    • Intranasal fluticasone furoate, triamcinolone acetonide can be used >2 years
    • Intranasal fluticasone proprionate safe >4 years
    • Intranasal budenoside safe > 6 years
    • Speak with parents if plan to use > 2 months (may cause grownth inhibition)
    • Prime the spray before use or when has not been used for one week or more
    • shake the bottle gently before use to ensure suspension is mixed and uniform
    • INCS may irritate the nose of the bottle tip can injure the nose if used forcefully
    • more effective if used regularly rather than episodically
• Antihistamines
  • Dose
    • Cetirizine: 10 mg once daily
    • Loratadine: 10 mg once daily
    • Fexofenadine: 180 mg once daily or 60 mg twice daily
    • Levocetirizine: 5 mg once daily in the evening
    • Diphenhydramine: 25-50 mg every 4-6 hours as needed
    • Chlorpheniramine: 4 mg every 4-6 hours as needed or 8-12 mg every 12 hours (sustained-release)
  • Adverse effect/caution
    • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
    • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
    • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
    • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
    • 1st gen avoid in children (paradoxical excitation as well as safety issues)
  • Remarks
    • May not be effective for nasal congestion but useful for postnasal drip in pharyngitis
    • Second generation antihistamines preferred over first generation to treat allergic rhinitis
    • Pregnancy: Diphenhydramine and chlorpheniramine is compatible; levocetrazine, loratidine, cetrizine carry low adverse fetal risk; fexofenadine is associated with moderate risk and should not be used
    • Sedation: Of 2nd gen. antihistamines- fexofenadine and loratidine are non-sedating; Cetrizine more potent than fexofenadine or loratadine but it causes sedation in approx 10% of patients
    • Children choice of drug: loratadine>fexofenadine>levocetrazine>cetrizine
    • Elderly: Loratadine is first line; fexofenadine and levocetrizine adjusted in renal impairment; loratadine and cetrizine dosage adjusted in hepatic impairment.
• Nasal decongestants
  • Dose
    • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
    • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
    • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
    • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
  • Adverse effect/caution
    • Use cautiously in patients with hypertension
  • Remarks
    • low systemic absorption makes it ideal for special populations and patients with comorbidities
    • therapy should be limited to 3-5 days to avoid rebound congestion
    • may be used during pregnancy owing to low systemic absorption
• Oral decongestant
  • Dose
    • • Phenylephrine:
        • Adults/Children ≥12 years: 10 mg every 4 hours (maximum daily dosage: 60 mg)
        • Children 6-12 years: 5 mg every 4 hours (maximum daily dosage: 30 mg)
        • Children 2-6 years: 2.5 mg every 4 hours (maximum daily dosage: 15 mg)
      • Pseudoephedrine:
        • Adults/Children ≥12 years: 60 mg every 4-6 hours (maximum daily dosage: 240 mg)
        • Children 6-12 years: 30 mg every 4-6 hours (maximum daily dosage: 120 mg)
        • Children 2-6 years: 15 mg every 4-6 hours (maximum daily dosage: 60 mg)
  • Adverse effect/caution
    • cardiovascular stimulation (e.g., elevated BP, tachycardia, palpitation, or arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, or hallucinations)
    • Refer to physicians if patient has diabetes, hypertensives, BPH, hyperthyroidism, ischemic heart disease, increased intraocular pressure
    • Avoid in pregnancy
    • Decongestants should not be given to children under six years and treatment for children aged six to 12 years should be restricted to five days or less.
  • Remarks
    • Pseudoephedrine compatible with breast feeding
    • Avoid taking at bedtime, because of potential to cause insomnia and restlessness
    • pseudoephedrine max dose: 240 mg/day

Referral:

Id symptoms worsens during therapy or do not decrease after 2-4 weeks of treatment

Recommendation: Pharmacological and non pharmacological therapy

For conjunctivitis

Avoidance of Allergens:

• This is fundamental. Reducing exposure to the specific allergens that trigger your allergic rhinitis can also lessen eye symptoms.
  • Stay indoors on high pollen days.
  • Keep windows closed.
  • Use air purifiers.

Non-Pharmacological Measures:

• • Cold Compresses: Applying cool compresses to your eyes can provide soothing relief from itching and swelling.
  • Artificial Tears: Over-the-counter artificial tears help to:
    • Wash away allergens
    • Lubricate the eyes
    • Reduce dryness and irritation
  • Use preservative-free artificial tears if you need to use them frequently.
  • Avoid Irritants: Avoid rubbing your eyes, as this can worsen irritation.
  • Avoid contact lenses if your eyes are very irritated.

 Pharmacological Treatments:

• • Topical Antihistamine/Mast Cell Stabilizer Eye Drops: These are often the first-line treatment for allergic conjunctivitis.
  • Antihistamines block the action of histamine, while mast cell stabilizers prevent the release of histamine and other inflammatory mediators.
  • Examples:
    • Olopatadine: (0.2%): 1 drop in each eye once daily; (0.1%): 1 drop in each eye twice daily.
    • Ketotifen/ Bepotastine/ Azelastine: 1 drop in each eye every 12 hours.
  • Topical Decongestant Eye Drops: These can reduce redness by constricting blood vessels in the eye.
    • However, they should be used sparingly and for short periods (no more than 3 days), as prolonged use can lead to rebound redness.
    • Naphazoline/Pheniramine: 1-2 drops in each eye up to 4 times daily
      • Contraindicated in people with narrow-angle glaucoma.
    • Tetrahydrozoline: 1-2 drops in each eye up to 4 times daily.
  • Topical NSAID Eye Drops: Nonsteroidal anti-inflammatory drugs can help reduce inflammation, swelling, and itching.
    • Ketorolac: 1 drop in each eye four times daily.
  • Oral Antihistamines: Oral antihistamines, used for nasal symptoms, can also provide some relief from eye symptoms. Second-generation antihistamines (cetirizine, loratadine, fexofenadine) are preferred because they cause less drowsiness than first-generation antihistamines (like diphenhydramine).
    • Cetirizine (Zyrtec): 10 mg once daily.
    • Loratadine (Claritin): 10 mg once daily.
    • Fexofenadine (Allegra): 180 mg once daily.
  • Topical Corticosteroid Eye Drops: These are potent anti-inflammatory agents but should only be used under the supervision of an eye care professional due to the risk of side effects (e.g., increased intraocular pressure, cataracts). Examples: Prednisolone, loteprednol, fluorometholone.

Important Considerations:

• • Hygiene: Practice good hygiene to prevent secondary eye infections. Wash your hands frequently.
  • Avoid sharing towels.
• Contact Lenses: If you wear contact lenses:
  • Clean them thoroughly.
  • Consider switching to daily disposable lenses during allergy season.
  • In severe cases, avoid wearing them altogether until your symptoms improve.
• When to See a Doctor:
  • If your symptoms are severe or don't improve with over-the-counter treatments.
  • If you experience eye pain, vision changes, or sensitivity to light.
  • If you suspect an eye infection (e.g., thick discharge).

For rhinitis

Non pharmacological

Allergic rhinitis cannot be cured. The goal of the treatment are to reduce symptoms and improve the patient’s functional status and sense of well-being

• Allergen Avoidance:
  • This is the cornerstone of non-pharmacological management. Strategies include:
    • Pollen:
      • Monitoring pollen counts and limiting outdoor activities on high pollen days.
      • Keeping windows closed, especially during peak pollen times.
      • Using air conditioning with HEPA filters.
      • Showering and changing clothes after outdoor exposure.
    • Dust Mites:
      • Using dust mite-proof covers for mattresses and pillows.
      • Washing bedding frequently in hot water.
      • Reducing clutter and keeping the home clean.
      • Using HEPA filters in vacuum cleaners.
    • Pet Dander:
      • Keeping pets out of bedrooms.
      • Regularly bathing pets.
      • Using HEPA filters.
    • Mold:
      • Controlling indoor humidity levels.
      • Repairing leaks and preventing moisture buildup.
      • Cleaning moldy surfaces.
• Nasal Saline Irrigation:
  • This involves rinsing the nasal passages with a saline solution to remove allergens and mucus.
  • It can help relieve nasal congestion, runny nose, and postnasal drip.
  • Various devices are available, including neti pots and squeeze bottles.
• Environmental Control:
  • Creating a clean and allergen-free environment is crucial
  • Air Purifiers: Using air purifiers with HEPA filters can remove airborne allergens.
  • Humidifiers: Maintaining optimal humidity levels can help prevent nasal dryness.
• Lifestyle Adjustments:
  • Hydration: Drinking plenty of fluids can help thin mucus.
  • Healthy Diet: A balanced diet can support overall immune function.
  • Stress Management: Stress can exacerbate allergy symptoms, so practicing relaxation techniques is beneficial.

• Antihistamines
  • Dose
    • Cetirizine: 10 mg once daily
    • Loratadine: 10 mg once daily
    • Fexofenadine: 180 mg once daily or 60 mg twice daily
    • Levocetirizine: 5 mg once daily in the evening
    • Diphenhydramine: 25-50 mg every 4-6 hours as needed
    • Chlorpheniramine: 4 mg every 4-6 hours as needed or 8-12 mg every 12 hours (sustained-release)
  • Adverse effect/caution
    • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
    • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
    • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
    • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
    • 1st gen avoid in children (paradoxical excitation as well as safety issues)
  • Remarks
    • May not be effective for nasal congestion but useful for postnasal drip in pharyngitis
    • Second generation antihistamines preferred over first generation to treat allergic rhinitis
    • Pregnancy: Diphenhydramine and chlorpheniramine is compatible; levocetrazine, loratidine, cetrizine carry low adverse fetal risk; fexofenadine is associated with moderate risk and should not be used
    • Sedation: Of 2nd gen. antihistamines- fexofenadine and loratidine are non-sedating; Cetrizine more potent than fexofenadine or loratadine but it causes sedation in approx 10% of patients
    • Children choice of drug: loratadine>fexofenadine>levocetrazine>cetrizine
    • Elderly: Loratadine is first line; fexofenadine and levocetrizine adjusted in renal impairment; loratadine and cetrizine dosage adjusted in hepatic impairment.
• Nasal decongestants
  • Dose
    • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
    • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
    • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
    • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
  • Adverse effect/caution
    • Use cautiously in patients with hypertension
  • Remarks
    • low systemic absorption makes it ideal for special populations and patients with comorbidities
    • therapy should be limited to 3-5 days to avoid rebound congestion
    • may be used during pregnancy owing to low systemic absorption
• Oral decongestant
  • Dose
    • • Phenylephrine:
        • Adults/Children ≥12 years: 10 mg every 4 hours (maximum daily dosage: 60 mg)
        • Children 6-12 years: 5 mg every 4 hours (maximum daily dosage: 30 mg)
        • Children 2-6 years: 2.5 mg every 4 hours (maximum daily dosage: 15 mg)
      • Pseudoephedrine:
        • Adults/Children ≥12 years: 60 mg every 4-6 hours (maximum daily dosage: 240 mg)
        • Children 6-12 years: 30 mg every 4-6 hours (maximum daily dosage: 120 mg)
        • Children 2-6 years: 15 mg every 4-6 hours (maximum daily dosage: 60 mg)
  • Adverse effect/caution
    • cardiovascular stimulation (e.g., elevated BP, tachycardia, palpitation, or arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, or hallucinations)
    • Refer to physicians if patient has diabetes, hypertensives, BPH, hyperthyroidism, ischemic heart disease, increased intraocular pressure
    • Avoid in pregnancy
    • Decongestants should not be given to children under six years and treatment for children aged six to 12 years should be restricted to five days or less.
  • Remarks
    • Pseudoephedrine compatible with breast feeding
    • Avoid taking at bedtime, because of potential to cause insomnia and restlessness
    • pseudoephedrine max dose: 240 mg/day

Referral:

Id symptoms worsens during therapy or do not decrease after 2-4 weeks of treatment

Recommendation: Pharmacological and non pharmacological therapy

For conjunctivitis

Avoidance of Allergens:

• This is fundamental. Reducing exposure to the specific allergens that trigger your allergic rhinitis can also lessen eye symptoms.
  • Stay indoors on high pollen days.
  • Keep windows closed.
  • Use air purifiers.

Non-Pharmacological Measures:

• • Cold Compresses: Applying cool compresses to your eyes can provide soothing relief from itching and swelling.
  • Artificial Tears: Over-the-counter artificial tears help to:
    • Wash away allergens
    • Lubricate the eyes
    • Reduce dryness and irritation
  • Use preservative-free artificial tears if you need to use them frequently.
  • Avoid Irritants: Avoid rubbing your eyes, as this can worsen irritation.
  • Avoid contact lenses if your eyes are very irritated.

 Pharmacological Treatments:

• • Topical Antihistamine/Mast Cell Stabilizer Eye Drops: These are often the first-line treatment for allergic conjunctivitis.
  • Antihistamines block the action of histamine, while mast cell stabilizers prevent the release of histamine and other inflammatory mediators.
  • Examples:
    • Olopatadine: (0.2%): 1 drop in each eye once daily; (0.1%): 1 drop in each eye twice daily.
    • Ketotifen/ Bepotastine/ Azelastine: 1 drop in each eye every 12 hours.
  • Topical Decongestant Eye Drops: These can reduce redness by constricting blood vessels in the eye.
    • However, they should be used sparingly and for short periods (no more than 3 days), as prolonged use can lead to rebound redness.
    • Naphazoline/Pheniramine: 1-2 drops in each eye up to 4 times daily
      • Contraindicated in people with narrow-angle glaucoma.
    • Tetrahydrozoline: 1-2 drops in each eye up to 4 times daily.
  • Topical NSAID Eye Drops: Nonsteroidal anti-inflammatory drugs can help reduce inflammation, swelling, and itching.
    • Ketorolac: 1 drop in each eye four times daily.
  • Oral Antihistamines: Oral antihistamines, used for nasal symptoms, can also provide some relief from eye symptoms. Second-generation antihistamines (cetirizine, loratadine, fexofenadine) are preferred because they cause less drowsiness than first-generation antihistamines (like diphenhydramine).
    • Cetirizine (Zyrtec): 10 mg once daily.
    • Loratadine (Claritin): 10 mg once daily.
    • Fexofenadine (Allegra): 180 mg once daily.
  • Topical Corticosteroid Eye Drops: These are potent anti-inflammatory agents but should only be used under the supervision of an eye care professional due to the risk of side effects (e.g., increased intraocular pressure, cataracts). Examples: Prednisolone, loteprednol, fluorometholone.

Important Considerations:

• • Hygiene: Practice good hygiene to prevent secondary eye infections. Wash your hands frequently.
  • Avoid sharing towels.
• Contact Lenses: If you wear contact lenses:
  • Clean them thoroughly.
  • Consider switching to daily disposable lenses during allergy season.
  • In severe cases, avoid wearing them altogether until your symptoms improve.
• When to See a Doctor:
  • If your symptoms are severe or don't improve with over-the-counter treatments.
  • If you experience eye pain, vision changes, or sensitivity to light.
  • If you suspect an eye infection (e.g., thick discharge).

For rhinitis

Non pharmacological

Allergic rhinitis cannot be cured. The goal of the treatment are to reduce symptoms and improve the patient’s functional status and sense of well-being

• Allergen Avoidance:
  • This is the cornerstone of non-pharmacological management. Strategies include:
    • Pollen:
      • Monitoring pollen counts and limiting outdoor activities on high pollen days.
      • Keeping windows closed, especially during peak pollen times.
      • Using air conditioning with HEPA filters.
      • Showering and changing clothes after outdoor exposure.
    • Dust Mites:
      • Using dust mite-proof covers for mattresses and pillows.
      • Washing bedding frequently in hot water.
      • Reducing clutter and keeping the home clean.
      • Using HEPA filters in vacuum cleaners.
    • Pet Dander:
      • Keeping pets out of bedrooms.
      • Regularly bathing pets.
      • Using HEPA filters.
    • Mold:
      • Controlling indoor humidity levels.
      • Repairing leaks and preventing moisture buildup.
      • Cleaning moldy surfaces.
• Nasal Saline Irrigation:
  • This involves rinsing the nasal passages with a saline solution to remove allergens and mucus.
  • It can help relieve nasal congestion, runny nose, and postnasal drip.
  • Various devices are available, including neti pots and squeeze bottles.
• Environmental Control:
  • Creating a clean and allergen-free environment is crucial
  • Air Purifiers: Using air purifiers with HEPA filters can remove airborne allergens.
  • Humidifiers: Maintaining optimal humidity levels can help prevent nasal dryness.
• Lifestyle Adjustments:
  • Hydration: Drinking plenty of fluids can help thin mucus.
  • Healthy Diet: A balanced diet can support overall immune function.
  • Stress Management: Stress can exacerbate allergy symptoms, so practicing relaxation techniques is beneficial.

• Antihistamines
  • Dose
    • Beclomethasone dipropionate : 1-2 sprays in each nostril twice daily or 2 sprays in each nostril once daily
    • Budesonide: 1-2 sprays in each nostril once daily or 1 spray in each nostril twice daily (may start with 2 sprays twice daily for initial control)
    • Ciclesonide: 2 sprays in each nostril once daily
    • Flunisolide: 2 sprays in each nostril twice daily (may start with 2 sprays three times daily for initial control)
    • Fluticasone furoate: 2 sprays in each nostril once daily
    • Fluticasone propionate (Flonase)Nasal spray1-2 sprays in each nostril once daily or 2 sprays in each nostril twice daily
    • Mometasone furoate: 2 sprays in each nostril once daily
    • Triamcinolone acetonide: 2 sprays in each nostril once daily
  • Adverse effect/caution
    • minor and include nasal discomfort or bleeding, sneezing, cough, pharyngitis.
    • Patient who are sensitive to INCS or use higher than recommended doses may experience systematic effects such as headache, dizziness, nausea, and vomiting.
    • Long-term use has been linked to changes in vision, glaucoma, cataracts and increased risk of infection (e.g., Candida) and growth inhibition in children)
    • For lactating mothers, reports of harm are lacking and hence considered “probably compatible”
  • Remarks
    • Use them consistently for best results, even if you feel some relief initially.
    • Generally, they are safe for long-term use.
    • It starts working right away but full effect may not be visible at least 1 week
    • have variable systemic absorption (e.g., fluticasone <2%, budenoside 34%)
    • Inappropriate nasal spray technique can injure the nose
    • INCS (fluticasone furoate and proprionate) have additional approval for ophthalmic symptoms (itching, redness, watery discharge)
    • INCS are compatible with pregnancy however systemic use should be avoided for the risk of cleft lip and palate
    • Intranasal fluticasone furoate, triamcinolone acetonide can be used >2 years
    • Intranasal fluticasone proprionate safe >4 years
    • Intranasal budenoside safe > 6 years
    • Speak with parents if plan to use > 2 months (may cause grownth inhibition)
    • Prime the spray before use or when has not been used for one week or more
    • shake the bottle gently before use to ensure suspension is mixed and uniform
    • INCS may irritate the nose of the bottle tip can injure the nose if used forcefully
    • more effective if used regularly rather than episodically
• Antihistamines
  • Dose
    • Cetirizine: 10 mg once daily
    • Loratadine: 10 mg once daily
    • Fexofenadine: 180 mg once daily or 60 mg twice daily
    • Levocetirizine: 5 mg once daily in the evening
    • Diphenhydramine: 25-50 mg every 4-6 hours as needed
    • Chlorpheniramine: 4 mg every 4-6 hours as needed or 8-12 mg every 12 hours (sustained-release)
  • Adverse effect/caution
    • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
    • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
    • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
    • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
    • 1st gen avoid in children (paradoxical excitation as well as safety issues)
  • Remarks
    • May not be effective for nasal congestion but useful for postnasal drip in pharyngitis
    • Second generation antihistamines preferred over first generation to treat allergic rhinitis
    • Pregnancy: Diphenhydramine and chlorpheniramine is compatible; levocetrazine, loratidine, cetrizine carry low adverse fetal risk; fexofenadine is associated with moderate risk and should not be used
    • Sedation: Of 2nd gen. antihistamines- fexofenadine and loratidine are non-sedating; Cetrizine more potent than fexofenadine or loratadine but it causes sedation in approx 10% of patients
    • Children choice of drug: loratadine>fexofenadine>levocetrazine>cetrizine
    • Elderly: Loratadine is first line; fexofenadine and levocetrizine adjusted in renal impairment; loratadine and cetrizine dosage adjusted in hepatic impairment.
• Nasal decongestants
  • Dose
    • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
    • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
    • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
    • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
  • Adverse effect/caution
    • Use cautiously in patients with hypertension
  • Remarks
    • low systemic absorption makes it ideal for special populations and patients with comorbidities
    • therapy should be limited to 3-5 days to avoid rebound congestion
    • may be used during pregnancy owing to low systemic absorption
• Oral decongestant
  • Dose
    • • Phenylephrine:
        • Adults/Children ≥12 years: 10 mg every 4 hours (maximum daily dosage: 60 mg)
        • Children 6-12 years: 5 mg every 4 hours (maximum daily dosage: 30 mg)
        • Children 2-6 years: 2.5 mg every 4 hours (maximum daily dosage: 15 mg)
      • Pseudoephedrine:
        • Adults/Children ≥12 years: 60 mg every 4-6 hours (maximum daily dosage: 240 mg)
        • Children 6-12 years: 30 mg every 4-6 hours (maximum daily dosage: 120 mg)
        • Children 2-6 years: 15 mg every 4-6 hours (maximum daily dosage: 60 mg)
  • Adverse effect/caution
    • cardiovascular stimulation (e.g., elevated BP, tachycardia, palpitation, or arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, or hallucinations)
    • Refer to physicians if patient has diabetes, hypertensives, BPH, hyperthyroidism, ischemic heart disease, increased intraocular pressure
    • Avoid in pregnancy
    • Decongestants should not be given to children under six years and treatment for children aged six to 12 years should be restricted to five days or less.
  • Remarks
    • Pseudoephedrine compatible with breast feeding
    • Avoid taking at bedtime, because of potential to cause insomnia and restlessness
    • pseudoephedrine max dose: 240 mg/day

Referral:

Id symptoms worsens during therapy or do not decrease after 2-4 weeks of treatment