AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 9

LTRAs can be effective in controlling allergy symptoms, but they are not recommended for primary therapy of allergic rhinitis. LTRAs can be effec- tive as a combination therapy and in patients with reactive airway disease. Mast cell stabilizers, like cromolyn, inhibit mast cell degranula- tion, but often require frequent dosing and are ineffective after exposure. Routine use of oral steroids is not recommended for managing chronic symptoms of allergy. Steroids are most effective for controlling late-phase responses and can be used to control acute exacerbations significantly affecting quality of life that are unresponsive to standard therapy or exac- erbate asthma. Side effects of oral steroids include bone loss, hypergly- cemia, cataracts, mental status change, increased appetite, insomnia, and avascular necrosis. Other adjunctive therapies that can be used to control allergy symp- toms include antihistamine eye drops for chronic allergic eye symp- toms, ipratropium bromide for chronic rhinorrhea, topical/oral decongestants to improve nasal congestion, mucolytics to help thin mucus, and nasal saline irrigations to improve nasal mucociliary clear- ance and hygiene. Immunotherapy Immunotherapy candidates must have an IgE-mediated allergic response with allergy symptoms that reasonably correlate with allergy testing results. This form of therapy is indicated in patients who are unre- sponsive to medical therapy or averse to or intolerant of medications. Immunotherapy has been shown to reduce symptoms and medication use, prevent the development of additional allergen sensitivities and asthma in children, and reduce asthma exacerbations. This is the only treatment option capable of altering the immune system’s response to allergens. After testing has identified the offending allergen(s) triggering the IgE-mediated response, very small doses of the allergen are adminis- tered to the patient and titrated up to a known-to-be-effective target dose. Immunotherapy decreases antigen-specific IgE, increases antigen-specific immunoglobulin G (IgG4), induces antigen-specific T-cell “tolerance” to the antigen, and tilts the immune system toward the Th1 response. Immunotherapy has traditionally been administered via subcutaneous injection (SCIT).

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Primary Care Otolaryngology