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Three classes of pharmacotherapy are useful for IgE-mediated diseases, based on (1) inhibition of release of mediators from mast cells, (2) inhibition of the action of mediators on their target cells, and (3) reversal of the vascular and inflammatory responses in the target tissues (Table 19 1) 1 Antihistamines Antihistamine drugs competitively inhibit the binding of histamine to H1 receptors and are useful for the treatment of IgE-mediated allergy There are a number of such drugs, but the use of first-generation antihistamines (chlorpheniramine, brompheniramine, diphenhydramine, clemastine, hydroxyzine) are limited by sedation, neurocognitive impairment, and dry mucous membranes Rare complications include seizures and tachyarrhythmias Second-generation nonsedating histamine H1-receptorblocking drugs, loratadine, fexofenadine, and desloratadine appear not to be associated with arrhythmias and, along with cetirizine, are the systemic drugs of choice Cetirizine is mildly sedating, but the incidence of side effects is markedly lower than that of its parent compound, hydroxyzine Azelastine is a topical antihistamine preparation that is applied intranasally to decrease its systemic side effects Because of methodologic issues, publication bias, and inability to generalize findings, providing a rank order of potency and clinical efficacy for the available antihistamines is difficult Clinical tolerance or tachyphylaxis does not occur at prescribed dosages but an incomplete response to antihistamine therapy often indicates the need for combined treatment with a corticosteroid nasal spray This highlights the necessity to control both the early phase and late phase of the allergic response for optimal symptom control
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from concomitant eye pruritus and have shown positive effects on sleep, which can be adversely affected in patients with allergic rhinitis Topical corticosteroids may also be effective for treatment of vasomotor rhinitis and may be used as adjunctive treatment for sinusitis in combination with antibiotic therapy 4 Cromolyn sodium and sodium nedocromil Pretreatment with these drugs prevents the response to allergen by stabilizing the mast cell, although the specific molecular mechanisms of action are unknown Although unrelated, they have similar effects and, because of poor bioavailability, are effective only when applied directly to the involved organ Their action is short-lived, so that they must be given three or four times a day Cromolyn is available as a bronchial inhaler, nasal spray, and ophthalmologic preparation; nedocromil is available in metered-dose inhalers In comparison with topical corticosteroids they appear to be much less potent, but the drugs have very few side effects and wide margins of safety 5 Anticholinergic agents Ipratropium bromide is effective as a nasal topical agent for use in rhinitis Mucous membrane glandular secretion is under cholinergic control and can be inhibited by anticholinergic agents First-generation antihistamines have systemic anticholinergic activity, but ipratropium is preferred as adjunctive treatment of allergic rhinitis or as primary treatment for many types of nonallergic rhinitis Ipratropium does not alleviate sneezing, pruritus, or nasal congestion but can be useful for treatment of postnasal drip and rhinorrhea 6 Leukotriene antagonists Montelukast is an effective drug for the treatment of asthma To a much more limited degree, leukotriene antagonists can be efficacious for the treatment of allergic rhinitis, either as monotherapy or combined with an antihistamine By inhibiting leukotriene-mediated vasodilation vascular permeability and by potentially reducing eosinophilic inflammation, orally administered montelukast can provide symptomatic relief, especially for nasal congestion It is less effective than intranasal corticosteroids, however 7 Nasal saline irrigation A variety of methods can be used to lavage the nasal cavity Nasal saline irrigation can improve mucociliary clearance, as well as remove crusts, inspissated mucus, and accumulated secretions Some studies have shown improvement in chronic rhinosinusitis with hyperosmolar lavage but isotonic normal saline (8 ounces lukewarm tap water mixed with salt (one-quarter to one-half teaspoon), and a pinch of baking soda) seems preferred by many patients In cases where patients suffer from thick, tenacious nasal discharge, saline irrigation prior to administration of topical agents may improve drug delivery and efficacy
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