MANAGEMENT OF ALLERGIC RHINITIS REVIEWED

โรคจมกูอกัเสบจากภูมแิพ ้(allergic rhinitis:AR) เป็นความผดิปกตขิองระบบหายใจส่วนบนทีพ่บไดบ้่อยซึง่

แมจ้ะมอีนัตรายตํา่เมือ่เทยีบกบัโรคเรื้อรงัชนิดอื่นๆ แต่ก็มผีลอย่างมากต่อคุณภาพชีวติ ประสทิธิภาพการทาํงาน การ

เรยีน และเป็นปจัจยัเสีย่งต่อการเกดิโรครา้ยแรงอืน่ๆ เช่นหอบหดื

ภาวะจมกูอกัเสบจากภูมแิพ ้เกี่ยวเนื่องกบัการทาํงานของ immunoglobulin E ซึ่งถูกกระตุน้ดว้ยสารก่อ

ภูมแิพห้ลากหลายชนิดเช่น ไรฝุ่ น แมลง รงัแคของสตัว ์ละอองรา รวมถงึละอองเกษร อาการที่พบไดบ้่อยของผูป่้วย

AR คือมนีํา้มกู คดัแน่นในโพรงจมูก และผื่น-คนั แนวทางการรกัษาที่มใีนปจัจุบนัไดแ้ก่การหลกีเลีย่งสารก่อภูมแิพ ้

การรกัษา/ควบคุมอาการดว้ยยาชนิดต่างๆ immunotherapy รวมไปถงึการรกัษาหอบหดืหากพบร่วมดว้ย บทความซึง่

ตพีมิพใ์นวารสาร American Family Physician เดอืนมถินุายนทีผ่่านมาไดม้กีารทบทวนและสรุปเป็นแนวทางการ

รกัษาไว ้มรีายละเอยีดดงัน้ี

Treatment Strategies: Key Recommendations

• Patient age and symptom severity should guide treatment of allergic rhinitis. Clinicians

should educate patients about the condition and counsel them to avoid known allergens.

• The symptoms of allergic rhinitis may be classified as mild to moderate and moderate to

severe.

• Pharmacologic options include intranasal corticosteroids, topical antihistamines,

decongestants, intranasal cromolyn, intranasal anticholinergics, and leukotriene receptor

antagonists.

• An intranasal corticosteroid alone is recommended first-line therapy for mild to moderate

disease.

• Second-line treatment is recommended for moderate to severe disease.

• Those not responding to second-line treatment should be considered for immunotherapy.

• Intranasal corticosteroids have an onset of 30 minutes and peak at several hours, with

maximal effectiveness noted after 2 to 4 weeks of use.

• According to several studies, nasal corticosteroids are more effective than oral and

intranasal antihistamines for allergic rhinitis.

• Symptom scores for the 2 treatments are comparable, but quality of life is superior for the

intranasal corticosteroid treatment.

• There is no evidence that one corticosteroid is superior to another.

• Only budesonide is FDA approved for use in pregnancy with a category B safety rating.

• Mometasone is the only corticosteroid that has a delivery device, with recognition from the

National Arthritis Foundation for ease of use.

• Adverse effects of intranasal corticosteroids include headache, throat irritation, epistaxis,

stinging, burning, and dryness.

• Data on effect of intranasal corticosteroids on skeletal growth in children are conflicting,

and this class of medications carries an FDA warning that long-term use may restrict

growth in children.

• Oral antihistamines are second-line treatment of allergic rhinitis. Second-generation vs first-

generation antihistamines (except for cetirizine) have a better adverse effect profile for

sedation.

• The second-generation antihistamines stabilize and control some of the nasal and ocular

symptoms but have little effect on nasal congestion.

• Azelastine and olopatadine are FDA-approved intranasal antihistamines for allergic rhinitis.

Onset is 15 minutes with effects up to 4 hours, but their use is limited by adverse effects.

• These adverse effects include bitter aftertaste, headache, nasal irritation, epistaxis, and

sedation.

• Intranasal cromolyn is available over the counter but has an inconvenient dosing schedule

of 3 to 4 times daily.

• Intranasal anticholinergics such as ipratropium are useful for excessive rhinorrhea but have

to be administered 2 to 3 times daily.

• Oral montelukast is FDA approved for allergic rhinitis but has been found to be less

effective than intranasal corticosteroids and antihistamines and should be used as third-line

therapy.

• Combination therapy has not been found to be superior to monotherapy with intranasal

corticosteroids.

• There is insufficient evidence for the efficacy of nonpharmacologic therapies such as

acupuncture, probiotics, and herbals; therefore, such alternative treatments cannot be

recommended at this time.

• Initial treatment of allergic rhinitis should be an intranasal corticosteroid alone, followed by

second-line therapies such as oral or intranasal antihistamines.

• Nasal saline irrigation is beneficial for chronic rhinorrhea and may be used alone or as

adjuvant therapy.

• Immunotherapy is reserved for moderate or severe persistent allergic rhinitis not responsive

to usual treatment; the greatest risk is anaphylaxis.

• Recombinant DNA technology allows for allergen-specific vaccines, which can significantly

reduce rhinosinusitis symptoms, medication use, and skin sensitivity.

• Studies have not found benefit from using mite-proof impermeable mattress and pillow

covers.

• Interventions without documented evidence include breast-feeding, delayed exposure to

solid foods in infancy, and the use of air filtration systems.

Clinical Implications

• First-line pharmacotherapy for allergic rhinitis consists of intranasal corticosteroids, which

are superior to oral or intranasal antihistamines.

• Immunotherapy is reserved for moderate to severe allergic rhinitis nonresponsive to

pharmacotherapy, and the evidence does not currently support use of alternative therapies

for allergic rhinitis.

แปลและเรยีบเรยีง เภสชักรกติยิศ ยศสมบตั ิ

21 สงิหาคม 2553 สถานปฏบิตักิารเภสชักรรมชมุชน

คณะเภสชัศาสตร ์จฬุาลงกรณม์หาวทิยาลยั

www.osotsala-chula.com

ที่มา Am Fam Physician 2010; 81: 1440-1446.