Philippine Society of Allergology & Immunology, Inc.

Children's Medical Center & General Hospital, 11 Banawe St., Quezon City
Tel. No.: 712-0845 loc 158 & 197; Telefax No.: 743-1818

Officers and Board Members 1996-1998

President
President Elect
Secretary
Treasurer
P.R.O.

Alendry P. Caviles, Jr., M.D.

Remedios C. Ong, M.D.
Manuel M. Po, M.D.
Madeleine W. Sumpaico, M.D.
Hiyasmin W. Lim, M.D.

Board of Directors

Benigno F. Agbayani,M.D.
Nenita L. Alberto, M.D.
Nanneth T. Tiu, M.D.
Ruby Nagtalon-Foronda, M.D.
Felicidad G. Cua-Lim, M.D.
Manuel F. Ferreria, M.D.
Miguel L. Noche, Jr., M.D.

CPM 2ND EDITION

ALLERGIC RHINITIS

Algorithm for the Treatment of Allergic Rhinitis

1

Rhinitis*

2
History,
Physical
Examination
3

4
Is an
allergy
present?

ALLERGY
(Seasonal,
Perennial or
Occupational)

Refer to
ALLERGY
SPECIALIST
6

Skin test,
RAST*
IgE, Eosinophil
count
9

10
Is an
infection
present?

12

N
Are there
structural
defects?

15

OTHERS
(eg Idiopathic,
NARES**,
Vasomotor,
Hormonal, etc)
Rhinitis

11
Acute or
chronic
infection

Appropriate
antibiotics
14

13
Polyps
Septum,
Turbinates

Positive
laboratory
results?

8
Allergen
avoidance
Antihistamine
Y (topical, oral)
Topical/nasal
steroids
Allergen
immunotherapy

Topical
nasal steroids
17

16
Acute or
chronic
infection

18
Appropriate
antibiotics

REFER to
ENT specialist
if no response

* RAST - radioallergosorbent test
** NARES - non-allergic rhinitis with eosinophile syndrome
+ Rhinitis defined as 2 or more of the following symptoms for
>1 hour on most days; nasal discharge, blockage, sneezing/itch.

267

ALLERGIC RHINITIS

CPM 2ND EDITION

Guidelines for the

Treatment of Allergic Rhinitis
Definition
Rhinitis is defined as inflammation of the lining of the
nose, characterized by the following symptoms: nasal
congestion, rhinorrhea, sneezing and itching: occurring
for more than one (1) hour on most days.
Confirmed as allergic rhinitis by skin testing with potent
allergen extracts.
Epidemiology
A. Incidence
In a series of studies, from different countries,
considerable variations occur in the estimate of
prevalence of allergic rhinitis, ranging from 0.5%
(Switzerland) to 28% (Finland).
Allergic rhinitis usually develops in school age or
adolescence.
Incidence (new onset) peaks between ages 10 and
15; declines after age 35.
More frequent in boys than in girls (childhood);
same frequency from adolescence.
B. Risk Factors
1. early allergic rhinitis in persons with a family
history of atopy
2. more common in non-whites than whites, upper
than lower classes (SIBBALD, 1993)
3. birth 1-3 months before the pollen seasons increases risk of allergic rhinitis
4. allergic rhinitis more common in urban than rural
areas.
Diagnosis
Detailed history will usually give the diagnosis of rhinitis.
Important to note: Onset of symptoms, frequency of
symptoms, whether symptoms are daily, episodic, seasonal or perennial; severity and duration of symptoms,
environmental/occupational factors, family history.
A. Signs and symptoms:
Sneezers and runners
sneezing, especially paroxysmal
watery rhinorrhea
itching nose, nasal blockage (variable)
diurnal rhythm (worse during day and improving
during night)
often associated with conjunctivitis
Blockers
little or no sneezing
268

thick nasal mucus (catarrh) more often, posterior

(postnasal drip)
no itch
nasal blockage often severe
constant day and night but may be worse at
night
B. Classification of Rhinitis:
1. Allergic - main symptoms are itching and
irritation in the nose, sneezing and watery, often
associated with nasal congestion.
a. seasonal
b. perennial
2. Infectious rhinitis
a. acute-usually viral, but may have secondary
bacterial infection with sinus involvement
(Strep pneumonia, H. influenza)
b. chronic maybe caused by specific organisms
e.g. M. tuberculosis, K. rhinoscleromatis
3. Others
a. Idiopathic
b. NARES (non-allergic rhinitis with eosinophile syndrome)
c. Hormonal
d. Occupational
e. Rhinitis medicamentosa
C. Diagnostic Tests:
The tests and procedures listed represent a spectrum of
investigations, only a small number are applicable to
each individual patient.
1. General ENT examination
2. Allergy tests - skin tests (prick, intradermal), total
serum IgE, specific serum IgE
3. Endoscopy rigid, flexible
4. Nasal smear/cytology
5. Nasal swab - bacteriology
6. Radiology - plain sinus radiograph (Water's view),
CT scan, MRI, CXR
7. Mucociliary - nasal mucociliary clearance
(NMCC)
8. Nasal airway assessment
NIPF - nasal inspiratory peak flow
Rhinomanometry (anterior and posterior)
Acoustic rhinometry
9. Olfaction - threshold testing
Scratch and Sniff tests
10. Blood- CBC with differential count
ESR
Thyroid Function tests
(ANCA) - and neutrophil cytoplasmic antibody
Immunoglobulins and IgG subclasses

CPM 2ND EDITION

Treatment & Prevention

A. Environmental Control and Avoidance
In most cases, allergen or irritant avoidance
measures should be advised
When possible, environmental control measures
for indoor allergens should be applied, as they
may generally be inspired by the patient. This may
reduce the need for pharmacologic treatment.
Preventive Measures
1. First remove all rugs, curtains and draperies from
the room except the clothes for daily use. Always
keep closet doors closed.
2. Then clean the woodwork, window sills, screens,
closets and floor of the room. Wax the floor.
3. Change all mattresses and pillows in the bedroom
to solid rubber foam. No cotton, kapok, coconut
coif and feather (down) pillows are allowed.
Remember that spring beds may have kapok
or coconut coir stuffings at the bottom. Change
these beds to plain wooden ones with solid rubber
foam mattresses. Encase pillows and mattresses in
zippered air-tight covers.
4. Prepare the bed using washable sheets and
bedspreads (plain cotton). Do not use fuzzy
bedding such as wool, chenilles, etc. Wash
blankets, bedding and covers in hot water at least
every two weeks
5. Every month, remove all solid rubber foam pillows
and mattresses from their covers and expose both
sides to sunlight for several hours. Change covers
before reusing.
6. Clean wooden and metal chairs may be used. Plain
light curtains may be used only if they are washed
weekly.
7. Books, leather products, stuffed toys, wood
paneling and wall papers should be avoided. Wipe
walls with a mold killing solution.
8. The bedroom may be aired daily (windows open
but doors closed). To avoid dust from adjoining
rooms, the door must be opened only to allow
entrance and exit.
9. The room must be cleaned daily and given a
complete cleaning weekly. The allergic patient
should avoid the room during and up to 3-4
hours after cleaning. If the patient has to do the
housecleaning and making the beds, he should
always wear a face mask.
10. Cleaning should include the use of a damp doth,
mop or oil mop. Brooms and dusters should never
used. Vacuum cleaning is strongly advised.
Environmental Control in Other Parts of the House
1. No smoking rule should be strongly enforced.
2. Do not allow the patient to use a bed other than
his own unless it has been properly prepared.

ALLERGIC RHINITIS

3. Use only washable toys. Avoid wall pennants,

macrame hangings and other dust collectors.
4. No animal (dog, cat, bird) should be in contact
with the patient either in or out of the house unless
your doctor derides otherwise.
5. If possible, upholstered furniture should be covered with airtight plastic or vacuumed daily.
6. Dust and molds often contaminate air conditioners.
It is essential that the filter and fan can be cleaned
once a week. An electric fan may be used but must
be cleaned weekly.
7. Limit the numbers of house plants. Pollens and
mold spores become airborne when plants are
watered or disturbed.
8. Do not use insect sprays or powders. Children
should not play with cosmetics. Avoid substances
with strong odors, such as paint, moth balls and
air fresheners.
9. Blankets and clothings that have been stored
should be thoroughly cleaned and ironed before
use.
10. Bathroom and kitchen walls, floors and sinks
should be cleaned frequently with a mold killing
solution of equal parts of water and household
bleach.
11. Plumbing leaks and roof leaks indicated by water
stains or peeling paint should be repaired as soon
as possible.
12. Correct drainage problems near the house. Prune
trees shading the house, compost collection of
leaves are potential mold sources.
Other instructions:
1. Reasonable exercise and outdoor exposure are
encouraged for allergic people. Unless a definite
pollen allergy is known, the person with allergic
symptoms should not limit his outdoor activities
during any season.
2. Although the patient should not help with the
house cleaning, he should be expected to help with
the other work in the house which do not involve
dust exposure.
B. Phannacologic Treatment
1. Antihistamines - bind to histamine receptor
a. sedating - e.g. (Diphenhydramine,
Clemastine, Tydroxyzine)
b. non-sedating - e.g. (Cetirizine, Loratadine,
Acrivastine, Terfenadine, Astemizole)
- Oral
- Topical antihistamines Azelastine
2. Corticosteroids (topical nasal)
reduces inflammatory cell infiltration; decreases
the number of mast cells, eosinophils in the superficial layers of the nasal mucosa, diminishes
hypersensitivity and vascular permeability
3. Sodium cromoglycate
269

ALLERGIC RHINITIS

4. Decongestants
5. Anticholinergics
C. Immunotherapy
Is a method employing subcutaneous injections of
gradually increasing doses of antigenic (allergenic
materials) for the purpose of altering the immunologic response of atopic agents. Many studies show
that immunotherapy, especially benefits patients
with allergic rhinitis and bronchial asthma.
It should be considered if: pharmacotherapy
insufficiently controls symptoms or produces
undesirable side effects.
Appropriate avoidance measures of indoor
allergens fail to control symptoms.
There are positive skin tests or serum specific IgE
which correlates with rhinitis symptoms.

270

CPM 2ND EDITION

CPM 2ND EDITION

ALLERGIC RHINITIS

Drugs Mentioned in the Treatment Guideline

The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class.
Antihistamines
Hydroxyzine
Cibacen
Captopril
Capoten
Primace
Vasogard
Captopril/Hydrochlorothiazide
Capozide
Cetirizine
Virlix.................................... 31
Zyrtec................................... 31
Chlorpheniramine
Chlor-Trimeton..................... 31
Clormetamine....................... 31
Cohistan .............................. 31
Pharex-Chlorpheniramine.. . 31
UL-Chlorphenamine ........... 31
USA-Chlorphenamine.......... 32
Clemastine
Tavegyl................................. 32
Dimenthindene
Fenistil.................................. 32
Diphenhydramine
Alertuss................................ 32
Benadryl............................... 32
Diphenhydarmine Hizon................................. 32
Nebrecon.............................. 33
USALab
Diphenhydramine.............. 33
Loratadine
Claritin ..................................33
Mebhydrolin
Fabahistin............................. 33
Terfenadine
Terfar.....................................33
Bethamethasone/
Chlorphenamine
Betneton ...............................34
Bethamethasone/
Dexchlorphenamine
Celestamine ..........................34
Chlorphenamine/Prednisolone
Clormetalone........................ 34
Dexamethasone/
Chlorphenamine
Decilamine........................... 34
Disodium cromoglycate
benzalkonium
Vividrin Nasal Spray............ 33

Nasal Steroids
Beclomethasone
Bedomethasone Pharbita............................ 356
Beconase............................ 240
Becotide/Becloforte............ 356
Respocort ............................356
Budesonide
Budecort Nasal............ 240,356
Fluticasone
Flixotide Aqueous
Nasal Spray .................240,356
Fusafungine
Locabiotal ...........................240

Pheniramine/Mepyramine
Triaminic ............................344
Sodium cromoglycate
Intal.................................... 357

Others (Decongestants)
Phenylpropanolamme
Disudrin
Reformulated................... 342
Phamaco Phenylpropanolamine...... 342
Brompheniramine/
Phenylephrine/
Phenylpropanolamme
Dimetapp ............................342
Carbinoxime/Phenylephrine
Rhinopront......................... 343
Carbinoxime/Pseudoephedrine
Rondec-D/
Rondec-S......................... 343
Clemastine/
Phenylpropanolamine
Tavegyl-D........................... 343
Loratadine/Pseudoephedrine
Clarinase .............................342
Phenylpropanolamine/
Chlorphenamine
Nafarin ................................343
Phenylpropanolamine/
Paracetamol
Coldenal Pediatric
Suspension .......................342
Nasathera . ..........................343
Omex.................................. 343
Phenylpropanolamine/
Chlorphenamine/Paracetamol
Alledec .............................. 342
Coldrex............................... 342
Nafarin-A........................... 343
Phenylpropanolaminel
271