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At the start of the ragweed pollen season, 61 adults with ragweed hay fever were randomized to begin treatment with either a nasal steroid backed up by a non-sedating antihistamine or alteratively the non-sedating antihistamine followed when necessary with the nasal steroid. Clinical responses were assessed by the patient responses to a standardized rhinoconjunctivitis questionnaire to determine the Health Related Quality of Life (HRQL).
There was little difference in the two approaches for ragweed pollen hay fever, although fewer patients receiving nasal steroids as the first medication required the additional help of the antihistamine.
Juniper and colleagues believe the approach to treatment should be based upon patient preference and cost. Regardless of the initial treatment, many patients require both types of medication to control symptoms adequately.
This study is of major interest to pediatricians and primary care providers who treat patients with allergic rhinitis. Allergic rhinitis, both seasonal and perennial, is extremely common, with an estimated 30 million Americans suffering from the ailment. In the pediatric population, studies have shown that up to 10% of children and 25% of adolescents have the disease, and it is a significant cause of school absenteeism.1
Juniper et al point out that it is better to start medication a week or two before the pollen season starts and to continue daily medication throughout the season than to use as-needed treatment. Combination of nasal steroid and antihistamine may be required in about one-half of all patients for adequate relief of symptoms.
Many children and adolescents dislike using nasal sprays and prefer oral medication. Inexpensive chlorpheniramine may frequently be used with minimal or no drowsiness and has been shown to be as effective as the more expensive non-sedating antihistamines. Patients with allergic conjunctivitis as a major symptom frequently are not helped with nasal steroid. The newly released antihistamine nasal spray (Astelyn) looks promising but needs to be compared with oral antihistamines and/or nasal steroid sprays. When all is said and done, the treatment for each patient must be individualized. Immunotherapy (allergy shots), which has been shown to be effective in up to 90% of patients with seasonal allergic rhinitis, is reserved for those who do not respond to or who cannot tolerate the medications discussed and whose symptoms alter the patient’s quality of life. (Dr. Gruskay is Associate Clinical Professor of Pediatrics and Director of the Pediatric Allergy Clinic, Yale University School of Medicine.)
1. Broder J, et al. Epidemiology of asthma and allergic rhinitis in a total community, Tecumseh, Michigan, IV Natural History. J Allergy Clin Immunol 1974; 540:100-110.