What is the most appropriate next step in managing a 9-year-old girl with allergic rhinitis symptoms and eosinophilia in nasal secretions?

From the Guidelines

The most appropriate next step in management for this 9-year-old girl is the use of a corticosteroid nasal spray (option A). This patient presents with classic symptoms of allergic rhinitis, including chronic nasal itching, sneezing, clear rhinorrhea, nasal congestion, and allergic shiners (dark circles under the eyes). The presence of numerous eosinophils in her nasal secretions further supports this diagnosis. Intranasal corticosteroids are the first-line therapy for persistent allergic rhinitis as they effectively reduce inflammation, decrease nasal congestion, and improve other symptoms by suppressing the allergic inflammatory response. These medications work by reducing the infiltration of inflammatory cells and inhibiting the release of chemical mediators involved in the allergic cascade. Corticosteroid nasal sprays have a favorable safety profile when used appropriately, with minimal systemic absorption.

Key Points

• The patient's symptoms are consistent with allergic rhinitis, which is best managed with intranasal corticosteroids as the first line of treatment 1.
• Intranasal corticosteroids are effective in reducing inflammation, nasal congestion, and other symptoms associated with allergic rhinitis.
• The presence of eosinophils in the nasal secretions supports the diagnosis of allergic rhinitis.
• Oral antihistamines (H1-receptor blockers) can be helpful for symptoms like itching and sneezing but are generally less effective than intranasal corticosteroids for nasal congestion.
• There is no evidence of bacterial infection, indication for theophylline therapy, or structural abnormalities requiring surgical intervention.

Management

• Intranasal corticosteroid therapy is the most appropriate next step in management for this patient, given its effectiveness in treating allergic rhinitis and its favorable safety profile.
• The use of oral antihistamines or other medications may be considered as adjunctive therapy if necessary, but intranasal corticosteroids should be the primary treatment.
• Regular follow-up with a healthcare provider is essential to monitor the patient's response to treatment and adjust the management plan as needed.

From the FDA Drug Label

In 4 randomized, doubleblind, vehicle placebo-controlled, parallel- group allergic rhinitis studies and 2 studies of patients in an outdoor “park” setting (park studies), a decrease in nasal symptoms in treated subjects compared to placebo was shown to occur as soon as 12 hours after treatment with a 200-mcg dose of Fluticasone Propionate Nasal Spray, USP. Pediatric patients (4 years of age and older) should be started with 100 mcg (1 spray in each nostril once daily). Treatment with 200 mcg (2 sprays in each nostril once daily or 1 spray in each nostril twice daily) should be reserved for pediatric patients not adequately responding to 100 mcg daily

The most appropriate next step in management for the 9-year-old girl is to use a corticosteroid nasal spray, such as fluticasone, at a dose of 100 mcg (1 spray in each nostril once daily), as this is the recommended starting dose for pediatric patients 4 years of age and older 2.

From the Research

Diagnosis and Symptoms

• The patient is a 9-year-old girl presenting with constant itching of her nose and throat for 3 weeks, along with episodes of sneezing, profuse clear rhinorrhea, and difficulty breathing through her nose.
• Examination shows dark circles under the eyes, boggy nasal membranes, and clear lungs.
• A smear of nasal secretions reveals numerous eosinophils, indicating an allergic reaction.

Appropriate Management

• According to the studies 3, 4, 5, the most appropriate next step in management for this patient would be the use of a corticosteroid nasal spray, as it is a first-line treatment for allergic rhinitis, especially for moderate to severe cases.
• The use of corticosteroid nasal sprays has been shown to be effective in reducing nasal congestion, itching, rhinorrhea, and sneezing 4, 6.
• Combination therapy with an antihistamine (oral or intranasal) may also be considered, as it has been shown to be superior to solo intranasal corticosteroid or antihistamine in improving total nasal symptom scores 7.

Treatment Options

• Corticosteroid nasal sprays, such as fluticasone, triamcinolone, or budesonide, are available and have been shown to be effective in treating allergic rhinitis 3, 4, 5.
• Antihistamines, such as cetirizine, fexofenadine, or desloratadine, may also be used, either alone or in combination with a corticosteroid nasal spray 3, 5, 7.
• It is essential to educate the patient on the proper use of the corticosteroid nasal spray, including the need for daily use and potential side effects 6.