Allergic rhinitis and oral corticosteroid therapy

The anti-inflammatory effect of oral corticosteroids in allergic rhinitis (AR)/hay fever is well known and has been demonstrated experimentally using the nasal challenge model and clinically in the context of seasonal disease (1):

• in the late phase of the allergic reaction process in AR, the influx of inflammatory cells is facilitated by chemoattractants and upregulation of adhesion molecules
  • leads to further infiltration of the tissue by eosinophils, basophils, and T-cells
    
    
• compared to placebo, premedication with oral prednisone for 2 days prior to an allergen challenge showed a reduction in sneezes, and levels of histamine and mediators of vascular permeability in nasal lavages during the late phase response
  
  
• prednisone has also been shown to reduce the influx of eosinophils and levels of the eosinophil mediators (major basic protein and eosinophil derived neurotoxin) into nasal secretions during the late-phase response compared to placebo
  
  
• with respect to use of oral steroids in AR
  • .."Although not recommended for routine use in AR, certain clinical scenarios warrant the use of short courses of systemic corticosteroids after a discussion of the risks and benefits with the patient. This may include patients with significant nasal obstruction that would preclude penetration of intranasal agents (INCS or antihistamines). In these cases, a short course of systemic oral corticosteroids could improve congestion and facilitate access and efficacy of the topical agents..."

Dose and duration of steroid therapy in AR/hay fever:

• has been suggested (2)
  • brief course of prednisolone (for example, 0.5mg per kg orally in the morning for five days) (2,3) can be used as rescue to reduce severe symptoms, but this should be accompanied by continued local nasal therapy
  • depot injection corticosteroid preparations have an adverse risk/benefit profile and are not recommended, especially not as early season preventative treatment because the timing of release is inappropriate
• other guidance suggests (4):
  • oral corticosteroids may be considered for very severe or intractable nasal symptoms or nasal polyps
  • use a short course of five to seven days only, 20-40 mg per day in adults and 10 mg per day in children. Continue intranasal corticosteroid during treatment

Reference:

• International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.
• Scadding G (GP online, May 11th 2017). Hayfever: clinical review
• Scadding, G.K., Kariyawasam, H.H. and Scadding, G. et al (2017) BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised edition 2017; first edition 2007). Clin Exp Allergy 47(7), 856-889.
• Best Practice Advocacy Centre (www.bpac.org.nz). Seasonal Allergic Rhinitis (Accessed 2/10/19)