What are the Philippines guidelines for the treatment of allergic rhinitis?

Philippines Guidelines for Allergic Rhinitis Treatment

First-Line Pharmacologic Therapy

Intranasal corticosteroids (INCS) should be the first-line treatment for Filipino patients with allergic rhinitis whose symptoms affect quality of life. 1 This strong recommendation is based on high-quality evidence showing INCS are the most effective single medication class for controlling all four cardinal symptoms: nasal congestion, rhinorrhea, sneezing, and nasal itching. 1, 2

Evidence from Philippine Practice Patterns

Filipino physicians demonstrate good awareness of international guidelines, with 77% using ARIA guidelines for diagnosis and management. 3 However, there is a notable gap between guideline recommendations and actual prescribing patterns:

• For intermittent AR: Filipino specialists and generalists prefer oral second-generation antihistamines as first-line therapy 3, 4, despite guidelines recommending INCS for patients with quality-of-life impairment 1
• For persistent AR: INCS are appropriately preferred by Filipino physicians 3, 4, aligning with guideline recommendations 1

Diagnostic Approach

Clinical history and physical examination should establish the diagnosis when patients present with nasal congestion, runny nose, itchy nose, or sneezing, along with findings consistent with an allergic cause. 1 Specific findings to document include:

• Clear rhinorrhea 1
• Nasal congestion 1
• Pale discoloration of nasal mucosa 1
• Red and watery eyes 1

Allergy testing (skin or blood IgE) should be performed or referred when patients fail empiric treatment, when diagnosis is uncertain, or when specific allergen identification is needed to target therapy. 1 However, Philippine data shows only 62.2% of physicians "sometimes" recommend allergy testing, and diagnostic tests are not routinely used by 81% of specialists and 92% of generalists. 3, 4

Treatment Algorithm by Severity

Mild Intermittent or Mild Persistent Disease

Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine) or intranasal antihistamines (azelastine, olopatadine) effectively reduce rhinorrhea, sneezing, and itching. 2 Among Filipino physicians, loratadine is the most preferred second-generation antihistamine (55.3% of GPs, 58.9% of pharmacists). 5

First-generation antihistamines must be avoided due to significant sedation and anticholinergic effects including dry mouth and urinary retention. 2

Moderate-to-Severe or Persistent Disease

INCS (fluticasone, budesonide, mometasone) are the most effective monotherapy for all symptoms including nasal congestion. 1, 2 This represents the primary gap in Philippine practice, where monotherapy preferences are split between INCS and other agents despite clear guideline recommendations. 4

What NOT to Do

Do not routinely add oral antihistamines to INCS monotherapy—this combination provides no additional benefit. 1, 2 The largest trials show no benefit of INCS plus oral antihistamine compared with INCS plus placebo in adults. 1

Do not offer oral leukotriene receptor antagonists (montelukast) as primary therapy for allergic rhinitis. 1, 2 INCS are significantly more effective than montelukast, with clinically meaningful reductions in nasal symptoms. 1 LTRAs may only be considered for patients who refuse intranasal therapy or have concurrent mild persistent asthma. 1, 2

Combination Therapy for Inadequate Response

When INCS monotherapy fails to adequately control symptoms, add intranasal antihistamine to INCS rather than oral antihistamine. 1, 2 This is the most effective additive therapy to INCS. 1

For moderate-to-severe seasonal allergic rhinitis, fixed-dose combination products (azelastine + fluticasone) achieve superior symptom reduction compared with either component alone. 1, 2 Studies show:

• Total nasal symptom scores improved from baseline 18.1-19.0 out of 24 to reductions of -5.31 to -5.7 for combination therapy versus -3.84 to -5.1 for fluticasone alone 1
• Combination therapy represents approximately 40% greater relative improvement than monotherapy 1, 2
• Dysgeusia occurs in 2-13% of users 1, 2
• Somnolence occurs in 0.4-1.1% of users 1, 2

This recommendation is weak due to increased cost and potential adverse effects. 1, 2

Alternative Combination for Patients Who Refuse Intranasal Therapy

If nasal sprays are not tolerated, oral antihistamine plus oral decongestant is the next most effective combination. 1 This combination controls symptoms better than either agent alone. 1

Adjunctive Therapies

Topical Decongestants (Oxymetazoline)

Limit intranasal oxymetazoline use to ≤3 days to avoid rhinitis medicamentosa (rebound congestion). 1, 2 Short-term addition of oxymetazoline to INCS for severe nasal obstruction has proven benefit. 1

Oral Decongestants

Pseudoephedrine or phenylephrine reduce nasal congestion and enhance antihistamine effects. 2 Monitor blood pressure in hypertensive patients due to variable hemodynamic responses. 2

Nasal Irrigation

Nasal irrigation/douche is preferred by 82% of Filipino specialists as adjuvant therapy. 4 This is safe, inexpensive, and removes secretions, allergens, and mediators; hypertonic solutions provide decongestant activity. 6

Immunotherapy

Offer or refer for allergen-specific immunotherapy (subcutaneous or sublingual) for patients with inadequate response to pharmacotherapy with or without environmental controls. 1, 2 This is the only disease-modifying treatment that alters natural history, improves long-term symptom control, decreases medication needs, and may prevent new sensitizations. 1

However, familiarity with immunotherapy remains a gap among Filipino physicians. 3

Comorbidity Assessment

Assess and document associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. 1 Three-fifths of Filipino physicians "always" routinely evaluate AR patients for asthma, and 57% "always" evaluate asthma patients for AR. 3

In patients with concurrent asthma, inhaled corticosteroids are strongly recommended over oral leukotriene receptor antagonists as single controlling medication for asthma. 1

Key Factors Influencing Treatment Choice in Philippine Setting

Filipino physicians prioritize the following when selecting therapy 3, 4:

1. Guideline recommendations 3
2. Efficacy 3, 4
3. Onset of action 3
4. Cost and availability 3, 4

Cost is perceived as the primary reason for patient noncompliance with treatment. 4 This economic consideration may explain why oral antihistamines are preferred over INCS for mild disease despite guideline recommendations, as antihistamines are more widely available (94.8% in GP clinics, 97.2% in pharmacies). 5

Practical Administration Tips

Instruct patients to aim intranasal sprays away from the nasal septum to reduce local irritation and epistaxis. 2

Continuous daily use of intranasal therapy is more effective than intermittent use for seasonal or perennial disease. 2

Common Pitfalls to Avoid

• Do not rely on pale nasal turbinates alone to confirm allergic rhinitis—non-allergic rhinitis can present with similar mucosal appearance 2
• Do not use imaging routinely—sinonasal imaging should not be performed in patients presenting with symptoms consistent with allergic rhinitis 1
• Do not combine INCS with oral antihistamines as first-line therapy—this is a common practice pattern but lacks evidence of benefit 1