Bagaimana Tatalaksana dan Pencegahan Rhinitis Alergi Pencegahan yang aman dan efektif atau menghilangkan gejala adalah tujuan pengobatan. Antihistamin oral (Tabel 142-2) diberikan sesuai kebutuhan merupakan farmakoterapi yang dapat sedikit diterima, gejala intermiten bersin dan pilek. Antihistamin generasi pertama dan loratadin, semua tersedia tanpa resep, dikaitkan dengan efek samping pada fungsi kognitif dan pembelajaran sebagai akibat dari sifat sedatifnya. Generasi kedua antihistamin lebih disukai karena efek sedasinya lebih sedikit. Empat sediaan generasi kedua oral antihistamin disetujui untuk anak-anak: cetirizine dan desloratadine untuk usia lebih dari 6 bulan , loratadin untuk usia lebih 2 tahun, dan fexofenadine untuk usia lebih dari 6 tahun. Azelastine adalah antihistamin topikal aktif yang tersedia sebagai obat semprot hidung untuk anak-anak lebih dari 5 tahun. Pseudoefedrin, tersedia tanpa resep, umumnya dalam kombinasi dengan antihistamin, merupakan vasokonstriktor oral yang dapat digunakan untuk hidung tersumbat. Hal ini terkait dengan iritabilitas dan insomnia. Antikolinergik semprot nasal ipratropium bromide dapat digunakan untuk rhinorrhea serius. Dekongestan intranasal harus digunakan untuk 3 sampai 5 hari, jangan diulang lebih dari 1 siklus bulan. Sodium cromoglycate, yang tersedia tanpa resep, efektif tetapi membutuhkan administrasi sering. Agen memodifikasi leukotrien memiliki efek sederhana pada rhinorrhea dan hidung tersumbat.Pasien persisten, gejala berat memerlukan kortikosteroid intranasal, merupakan terapi yang paling efektif untuk AR (Tabel 142-3). Agen ini mengurangi semua gejala AR disebabkan oleh peradangan eosinofilik, tapi bukan dari rhinitis terkait dengan neutrofil atau bebas dari peradangan. Obat lama beclomethasone, triamsinolon, dan flunisolide diserap dari saluran pencernaan serta saluran pernapasan. Mometason, fluticasone, budesonide dan memberikan aktivitas topikal lebih besar dengan paparan sistemik rendah dan profil keamanan yang lebih baik. Mometason disetujui untuk anak-anak lebih 2 tahun, flutikason anak lebih dari 4 tahun, dan budesonide untuk anak lebih dari 6 tahun. Pasien yang lebih parah dapat mengambil manfaat dari pengobatan kombinasi dengan antihistamin, kortikosteroid intranasal, dan obat lain (Tabel 142-4).Imunoterapi alergen spesifik harus dipertimbangkan untuk anak-anak di antaranya manifestasi alergi yang dimediasi IgE tidak dapat dikontrol secara memadai oleh pengobatan simtomatik, terutama terdapatnya kondisi co-morbid. Imunoterapi alergen yang menghambat produksi IgE dan gejala yang diinduksi allergen efektif dalam pengobatan AR.Monoklonal rekombinan manusiawi anti-IgE mengurangi respon alergi pada hidung. Strategi pengobatan yang menggabungkan anti-IgE dan berjanji terus imunoterapi alergen untuk masa depan. Imunoterapi local yang diterapkan ialah imunoterapi oral, sublingual, atau nasal telah digunakan dengan sukses di Eropa dan Amerika Selatan.TABLE 142-2 --Antihistamines and Decongestants for Allergic Rhinitis and Related ConditionsDRUG AND TRADE NAMESINDICATIONS (MECHANISM OF ACTION) AND ORAL DOSINGCAUTIONS AND ADVERSE EVENTS

Brompheniramine (without prescription) DimetappAllergic rhinitis (H1 receptor antagonist) 12 yr: 48 mg/dose every 46 hr; maximum 24 mg/day. Sustained release: 10 mg/dose every 12 hr; maximum 40 mg/dayUsed primarily in combination preparations, most commonly with pseudoephedrine, recommended for cough and colds. For combination preparations with pseudoephedrine, base the dose on pseudoephedrine. Use for treatment of upper respiratory tract infections is unfounded. Has anticholinergic and sedating properties and may cause slight to moderate drowsiness, headache, excitability, fatigue, nervousness, dizziness.

Cetirizine (prescription) ZyrtecAllergic rhinitis, urticaria (H1-receptor antagonist) 0.52 yr: 2.5 mg once daily 25 yr: 2.55 mg once daily 10 mg/day may cause significant drowsiness.

Chlorpheniramine (without prescription) Chlor-TrimetonAllergic rhinitis, atopic dermatitis, urticaria, nighttime sedation (H1 receptor antagonist) 26 yr: 1 mg every 46 hr; maximum 6 mg/day 612 yr: 2 mg every 46 hr; maximum 12 mg/day. Sustained release: 8 mg at bedtime >12 yr: 4 mg every 46 hr; maximum 24 mg/day. Sustained release: 812 mg every 812 hrAvailable in many preparations recommended for cough and colds. Use for treatment of upper respiratory tract infections is unfounded. Has anticholinergic and sedating properties and may cause slight to moderate drowsiness, headache, excitability, fatigue, nervousness, dizziness.

Desloratadine (prescription) ClarinexAllergic rhinitis, urticaria (a major metabolite of loratadine, a long-acting tricyclic antihistamine with selective H1-receptor antagonist properties) 612 mo: 1 mg once daily 15 yr: 1.25 mg once daily 612 yr: 2.5 mg once daily >12 yr: 5 mg once daily Allergic rhintis, atopic dermatitis, urticaria, nighttime sedationMay cause headache, fatigue, somnolence, dizziness. Oral disintegrating tablets contain phenylalanine.

Diphenhydramine (without prescription) Benadryl(H1-receptor antagonist) 26 yr: 6.25 mg every 46 hr; maximum 37.5 mg/day 612 yr: 12.525 mg every 46 hr; maximum 150 mg/day >12 yr: 2550 mg every 46 hr; maximum 300 mg/dayMarked anticholinergic and sedating properties and may cause hypotension, tachycardia, drowsiness paradoxical excitement, dry mouth. Chewable tables contain phenylalanine.

Fexofenadine (prescription) AllegraAllergic rhinitis, urticaria (H1-receptor antagonist; an active metabolite of terfenadine) 612 yr: 30 mg twice daily >12 yr: 60 mg twice daily, or 180 mg once dailyGood safety profile. May cause headache, fever, drowsiness, fatigue, dizziness.

Loratadine (without prescription) Claritin, Alavert, Dimetapp Children's NDAllergic rhinitis, urticaria (long-acting tricyclic antihistamine with selective H1-receptor antagonist properties) 25 yr: 5 mg once daily >6 yr: 10 mg once dailyDo not exceed recommended dosage. May cause nervousness, fatigue, malaise, excessive dreaming, hyperkinesia, rash, abdominal pain.

Pseudoephedrine (without prescription) SudafedTemporary symptomatic relief of nasal congestion due to common cold, allergic rhintis, and sinusitis (-agonist, used as a decongestant) = 12 years: 10 to 20 mg orally every 4 hours as needed oral liquid: >= 2 years to < 6 years: 3.75 mg orally every 6 hours not to exceed 15 mg dailyOrally dissolving table contains phenylalanine drug interactions: sympathomimetics, -receptor antagonists, monoamine oxidase inhibitors

Sudafed PE>= 6 years to < 12 years: 7.5 mg orally every 6 hours not to exceed 30 mg daily >= 12 years: 15 mg orally every 6 hours not to exceed 60 mg daily oral disintegratng strip: >= 12 years: 10 mg orally every 4 hours not to exceed 6 doses daily

TABLE 142-3 --Intranasal Inhaled Corticosteroids for Allergic Rhinitis[*]DRUG AND TRADE NAME (DOSE/SPRAY)INTRANASAL DOSING (SPRAYS PER NOSTRIL)

Beclomethasone

Beconase AQ (42 g/spray)6 yr: 12 sprays twice daily

Budesonide

Rhinocort AQ (32 g/spray)>6 yr: 1 spray once daily; maximum 2 sprays/day

>2 yr: 1 spray once daily; maximum: 4 sprays/day

Flunisolide

Nasarel (25 g/spray)6 yr: intial dose 1 spray 3 times a day or 2 sprays twice daily.

Reduce to lowest effective dose.

Fluticasone

Flonase (50 g/spray)4 yr: 12 sprays once daily; maximum: 4 sprays/day.

Mometasone

Nasonex (50 g/spray)212 yr: 1 spray once daily 2 yr: 2 sprays once daily

Triamcinolone

Nasacort HFA (55 g/spray)

Nasacort AQ (55 g/spray)

612 yr: 2 sprays once daily

12 yr: 4 sprays once daily

*The mechanism of action of intranasal corticosteroids is as an anti-inflammatory immune modulator. Doses given as sprays per nostril. For administration, shake the container before use; blow the nose; occlude one nostril and administer the dose to the other nostril. Repeat for the other nostril. May cause burning and irritation of the nasal mucosa, and epistaxis. Monitor the patient for adverse effects on growth, which are rare.

TABLE 142-4 --Miscellaneous Intranasal Sprays for Allergic Rhinitis and Related ConditionsDRUG AND TRADE NAMEINDICATIONS (MECHANISM OF ACTION) AND DOSING (SPRAYS PER NOSTRIL)COMMENTS (CAUTIONS, ADVERSE EVENTS, MONITORING)

Ipratropium bromideSymptomatic relief of rhinorrhea (anticholinergic)Contraindicated in patients with hypersensitivity to soy lecithin.

Atrovent nasal spray>6 yr: 0.03% solution 2 sprays 23 times a dayMay cause epistaxis, nasal dryness, nausea.

AzelastineRhinorrhea, sneezing, and nasal pruritus. (H1-receptor antagonist)May cause drowsiness, headache, somnolence, bitter taste.

Astelin612 yr: 1 spray twice daily >12 yr: 2 sprays twice daily

NasalcromAllergic rhinitis (inhibition of mast cell degranulation)Not effective immediately.

Cromolyn sodium>2 yr: 1 spray 34 times a day; maximum: 6 sprays/dayRequires frequent administration.

OxymetazolineSymptomatic relief of nasal mucosal congestion (adrenergic agonist, vasoconstricting agent)Excessive dosage may cause profound neurological depression.

Use for >3 days may result in severe rebound nasal congestion.

Afrin Nostrilla6 yr: 0.05% 23 drops, or 12 metered sprays twice dailyDo not repeat sequence >1 per month. Use with caution in patients with hyperthyroidism, heart disease, hypertension, and diabetes. May cause hypertension, palpitations, reflex bradycardia, nervousness, dizziness, insomnia, headache, neurological depression, convulsions, hallucinations, nausea, vomiting, mydriasis, elevated intraocular pressure, blurred vision.

Neo-SynephrineSymptomatic relief of nasal mucosal congestion (adrenergic agonist, vasoconstricting agent)Use for >3 days may result in severe rebound nasal congestion.

Phenylephrine>6 mo: 12 drops 0.16% solution every 4 hrDo not repeat sequence >1 per month. The 0.125% solution is available as Little Noses.

16 yr: 23 drops 0.125% solution every 4 hrMay cause reflex bradycardia, excitability, headache, anxiety, and dizziness.

612 yr: 23 drops 0.25% solution every 4 hr

>12 yr: 23 drops or 12 sprays 0.25% or 0.5% solution every 4 hr

Sumber:Kliegman Robert M. et all., 2011. Allergic Rhinitis in Nelson Textbook of Pediatrics, 19th ed. Philadelphia: Saunders