Nasal sprays for allergies

Like a lot of folks, I suffer from seasonal allergies. While the red, watery eyes do spring up (no pun intended), this time of year I am much more bothered by the constant, unrelenting runny nose accompanying my seasonal allergy attacks. Which shouldn’t be surprising. -42% of patients suffering from allergic conjunctivitis also experience symptoms of allergic rhinitis (AR).¹

As an eye doctor, I’m aware of the connection between allergic conjunctivitis (AC) and AR, yet this point was really driven home in a paper by my good friend and mentor Milton Hom, OD. Dr. Hom has been collaborating with the world-renown expert on allergy Leonard Bielory, MD, and their most recent work was published in the journal Allergy and Rhinology in the fall of 2013.²  

Making the connection

The presence of AR and AC has been reported to be as high as 70%.³ The authors make the argument that AC should be included in the “one airway, one disease” concept, in which asthma and AR are a inflammation continuum in the airway. One way to look at this is the ocular conjunctiva is the upper limit of the airway mucosa; the two share a continuous mucosal surface and are connected by the nasolacrimal sac.

So, it is little wonder that in studies of either ocular allergy or AR, the correlation between the two conditions is high. In a survey of 20,010 people, 29.7% reported both ocular and nasal symptoms.³ Finally, greater than 50% of patients with nasal allergy stated that watering and red/itching eyes were “moderately bothersome” to “extremely bothersome” in the recent Allergies in America survey.⁴         

The authors coin the term the “naso-ocular relationship” to describe this relationship between the nasal mucosa and the ocular conjunctiva. Two double-masked crossover clinical trials investigated the nasal ocular reflex with a nasal allergen challenge and AC.^5,6 Supporters of this concept propose there may be another form of AC, a secondary AC related to the stimulus of the nasal mucosa, while primary AC is caused by direct stimulation of the ocular surface.

Treatment considerations

The first therapeutic approach to controlling allergy symptoms is prevention, by identifying and avoiding the causative allergen if possible. Complete allergen avoidance may not be realistic, but a reduction in the amount of environmental allergens can lessen the severity of the presentation and also reduce the amount of pharmacologic therapy needed.⁷

Topical decongestants are often the initial intranasal therapy for allergic rhinitis.¹ Symptom improvement usually occurs within 5 to 10 minutes of administration. However, prolonged therapy or excessive application of topical decongestants can results in edema and rebound congestion of the nasal mucosa, known as rhinitis medicamentosa.⁷

Topical decongestants are useful for short-term, symptomatic relief and control of nasal secretions, but they do nothing to inhibit the nasal response to allergens. Patients should be cautioned not to use nasal decongestants for more than 5 consecutive days and not to exceed the recommended dosage. ⁷

Cromolyn sodium is a mast cell stabilizer which can be effective in reducing sneezing, nasal mucous secretions, and nasal itching and often prevents the symptoms of both seasonal and perennial AR. Its diligent use can significantly reduce both immediate and late symptoms after allergen exposure.⁷

Cromolyn is available OTC as a 4% nasal solution (Nasalcrom, Prestige) in a pump spray delivery system. The recommended initial dosage for adults and children 6 years of age and older is 1 spray in each nostril 3 to 4 times daily, increasing as needed up to 6 times a day. For management of seasonal AR, treatment should begin 2 to 4 weeks prior to contact with offending allergens and continue throughout the allergy season.⁷

Corticosteroid nasal sprays comprise a large portion of rhinitis treatment and are the gold standard in therapy of allergic rhinoconjunctivitis.⁸ Intranasal corticosteroids are the most effective treatment for the nasal symptoms of seasonal AR and are considered first-line therapy when nasal congestion forms a substantial component of the patient's rhinitis symptoms.⁹ Intranasal steroids have a strong anti-inflammatory action and are superior to antihistamines for all nasal symptoms.

Nasal sprays have shown an added advantage on ocular allergy by reduction of symptoms.¹⁰ Intranasal corticosteroids had a positive impact on the eye symptoms of AR,¹¹ and they probably alleviate eye watering by relieving nasal congestion. Intranasal steroids started before the onset of symptoms can be particularly effective at preventing nasal symptoms, and their long-term use does not produce atrophy of the nasal mucosa.¹

The nasolacrimal anatomy is a conduit for many pharmaceutical treatments to potentially reach either the nose or the eye. Nasal sprays have been reported to have a positive impact on ocular symptoms, but does the effect happen in reverse? The topical application of antihistamine reduces rhinitis symptoms. In one study, the topical medication reduced rhinorrhea by 77% 8 hours after dosing.¹²

Olopatadine hydrochloride is an antihistamine and mast cell stabilizer available as a nasal spray (Patanase, Alcon) and has been shown to be significantly more effective than placebos in alleviating the symptoms of allergic rhinitis and conjunctivitis.¹³ Yet do corticosteroid intranasal sprays cause IOP spikes?

The studies are mixed on the subject, Drs. Hom and Bielory say. Some studies show no real effects on IOP, ¹⁴ while other studies show significant effects, especially in glaucoma patients.¹⁵ The literature supports the use of intranasal steroids over several months as there appears to be no considerable increase in the risk of ocular hypertension or glaucoma.¹⁶

Likewise, there were no ophthalmic-related adverse events of cataract formation nor IOP elevation in a 2-year study of fluticasone furoate nasal spray.¹⁷

Future treatments for AR will involve a combination of intranasal antihistamine and steroid because clinical trials have demonstrated an improved efficacy without a significant increase in adverse effects.¹³

AC substantially contributes to symptoms and complaints of AR, especially in patients suffering from seasonal allergies. The connection between the nasal mucosa and ocular surface offers potential advantages in treating AC. When treating your patients presenting with ocular allergies, consider adding a nasal treatment to their therapeutic regimen.ODT

References

1. Van Cauwenberge P, De Belder T, Vermeiren J, et al. Global resources in allergy (GLORIA): allergic rhinitis and allergic conjunctivitis. Clin Exp All Rev. 2003 Feb;3(1):46-50.

2. Hom MM, Bielory L. The anatomical and functional relationship between allergic conjunctivitis and allergic rhinitis. Allergy Rhinol (Providence). 2013 Fall;4(3): e110-9.

3. Singh K, Axelrod S, Bielory L. The epidemiology of ocular and nasal allergy in the United States, 1988–1994. J Allergy Clin Immunol. 2010 Oct;126(4):778–83.

4. Bielory L, Katelaris CH, Lightman S, et al. Treating the ocular component of allergic rhinoconjunctivitis and related eye disorders. Med Gen Med. 2007Aug 15;9(3):35.

5. Baroody FM, Foster KA, Markaryan A, et al. Nasal ocular reflexes and eye symptoms in patients with allergic rhinitis. Ann Allergy Asthma Immunol. 2008:100; 194 –199.

6. Baroody FM, Naclerio RM. Nasal-ocular reflexes and their role in the management of allergic rhinoconjunctivitis with intranasal steroids. World Allergy OrganJ. 2011 Jan:4(1 Suppl);S1–5.

7. Dushay ME, Johnson CE. Management of allergic rhinitis: Focus on intranasal agents. Pharmacotherapy. 1989;9(6):338-50.

8. Bergmann J, Witmer MT, Slonim CB. The relationship of intranasal steroids to intraocular pressure. Curr Allergy Asthma Rep. 2009 Jul;9(4):311-5.

9. Lightman S, Scadding GK . Should intranasal corticosteroids be used for the treatment of ocular symptoms of allergic rhinoconjunctivitis? A review of their efficacy and safety profile. Int Arch Allergy Immunol. 2012;158(4):317-25.

10. Baroody FM, Shenaq D, DeTineo M, et al. Fluticasone furoate nasal spray reduces the nasal-ocular reflex: A mechanism for the efficacy of topical steroids in controlling allergic eye symptoms. J Allergy Clin Immunol. 2009 Jun;123(6):1342–8.

11. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews.  2011. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: a systematic review.

12. Torkildsen GL, Williams JI, Gow JA, et al. Bepotastine besilate ophthalmic solution for the relief of nonocular symptoms provoked by conjunctival allergen challenge. Ann Allergy Asthma Immunol. 2010 Jul;105(1):57–64.

13. Nickels AS, Dimov V, Wolf R. Pharmacokinetic evaluation of olopatadine for the treatment of allergic rhinitis and conjunctivitis. Expert Opin Drug Metab Toxicol. 2011 Dec;7(12):1593-9.

14. Ozkaya E, Ozsutcu M, Mete F. Lack of ocular side effects after 2 years of topical steroids for allergic rhinitis. J Pediatr Ophthalmol Strabismus. 2011 Sep-Oct;48(5): 311–7.

15. Bui CM, Chen H, Shyr Y, et al. Discontinuing nasal steroids might lower intraocular pressure in glaucoma. J Allergy Clin Immunol. 2005 Nov;116(5):1042–7.

16. Lightman S, Scadding GK. Should intranasal corticosteroids be used for the treatment of ocular symptoms of allergic rhinoconjunctivitis? A review of their efficacy and safety profile. Int Arch Allergy Immunol. 2012;158(4):317-25.

17. LaForce C, Journeay GE, Miller SD, et al. Ocular safety of fluticasone furoate nasal spray in patients with perennial allergic rhinitis: a 2-year study. Ann Allergy Asthma Immunol. 2013 Jul;111(1):45-50.