Allergic conjunctivitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sujaya Chattopadhyay, M.D.[2]
Overview
Therapeutic interventions for allergic conjunctivitis target one or more points in the inflammatory response cascade. The most common treatment approach is use of a topical pharmacologic medication combined with cold compresses or artificial tears.Moderate to severe symptoms affecting quality of life may warrant more effective and longer-lasting treatment.A key limitation of many topical treatments is the need for multiple daily dosing for maintenance.
Medical Therapy
Dual-Acting Antihistamine–Mast Cell Stabilizing Agents[1]
- Inhibits binding of free histamine to its receptors, thus preventing further release of inflammatory mediators from mast cells.
- Olopatadine, alcaftadine, epinastine, bepotastine besilate are the current first-line agents for acute symptomatic relief and control of inflammation and suitable for long-term use.
- Most dual-acting agents, like ketotifen 0.025% ophthalmic solution[2], require twice-daily dosing[3]. Olopatadine 0.2%[4] and alcaftadine 0.25%[5] are administered once-daily and maintain effectiveness through 16 hours after administration, as demonstrated in conjunctival allergen challenge studies.
Mast Cell Stablizers
- Topical mast cell stabilizers (e.g., cromolyn sodium, lodoxamide tromethamine, nedocromil sodium, pemirolast potassium) inhibit the early phase response by preventing release of histamine, cytokines, and other inflammatory and chemotactic mediators[6].
- Most mast cell stabilizers need to be given four to six times daily; nedocromil sodium can be given twice daily[7].
- The required loading time for maximal efficacy of mast cell stabilizers, necessitates their initiation before symptoms appear[6].
Common drug regimens: 2% Cromolyn sodium[8], 2% nedocromil sodium[9]
Corticosteroids
- They inhibit formation of multiple classes of late-phase response mediators, including prostaglandins, leukotrienes, histamine, and some cytokines[1].
- Corticosteroids are not the first choice for AC except for moderate-to-severe inflammation unlikely to respond adequately to antihistamine–mast cell stabilizer medications.
- Due to the potential for side effects, they are administered for short durations in the early stages or during flare-ups until controlled with safer medications such as antihistamines, mast cell stabilizers, or dual-acting, single-molecule antihistamine–mast cell stabilizer agents[10].
- Most cases of SAC or PAC do not often require corticosteroids. For patients who require long-term use of corticosteroids, close observation by an ophthalmologist is recommended[1].
Nonsteroidal Anti-inflammatory Drugs[1]
- All topical NSAIDs (e.g., ketorolac, nepafenac, bromfenac) can be used chronically to relieve itching[11].
- They require four times daily dosing.
- A systematic review revealed that topical NSAIDs were ineffective on other symptoms, such as chemosis or swelling[12].
- They are rarely used today because of their lack of efficacy as a result of inhibition of release of only one type of inflammatory mediator (i.e., prostaglandins.
Common drug regimens: Ketorolac 0.4%-0.5% ophthalmic solution[13]
Leukotriene receptor antagonists[14]
- Montelukast, available for oral dosing, prevent binding of leukotrienes to their conjunctival receptors to decrease inflammation and relieve multiple ocular allergic symptoms.
- Leukotriene receptor antagonists have a slower onset of action and are less effective than topical [[antihistamines]. Therefore, they are not the first-line therapy or monotherapy for allergic conjunctivitis.
Antihistamine–Vasoconstrictor Combinations[1]
- Topical vasoconstrictors effectively reduces ocular hyperemia by stimulating vascular α-adrenergic receptors.
- Vasoconstrictors come in common, nonprescription combination formulations consisting of an antihistamine (e.g., naphazoline-antazoline, naphazoline-pheniramine). They start acting rapidly,and improve redness and itchiness.
- Long-term use reduces effectiveness over time and gives rise to a potential rebound effect characterized by persistent red eye on discontinuation[6].
- Like topical antihistamines, combination antihistamine-vasoconstrictor formulations have a relatively short duration of action and are administered four times daily[3].
Topical antihistamines[1]
- Topical antihistamines are widely available over the counter medications.
- They competitively block histamine receptors on nerve endings and blood vessels of the mucosal surface, thereby reducing itching and conjunctival hyperemia[14].
- First-generation antihistamines gave rise to various systemic adverse effects (e.g., sedation, dizziness, cognitive impairment, blurred vision) due to the anticholinergic actions and nonspecific binding to the H2 receptors. Newer oral, intranasal, and topical ocular antihistamines demonstrate improved H1 receptor selectivity, however burning and dryness of the eyes remain a concern.
- Topical antihistamines (e.g., levocabastine, emedastine difumarate) provide rapid, symptomatic relief, but require dosing four times daily due to shorter duration of action[3].
Allergen specific immunotherapy
- Allergen immunotherapy is indicated for patients with inadequate response to or unacceptable adverse effects from pharmacologic agents[15].
- Immunotherapy improves symptoms of itchiness, watery eyes, and red eyes by desensitizing individuals to the triggers and preventing the activation of inflammatory signaling pathways[16].
- Despite its effectiveness, this treatment approach,a majority of patients do not pursue desensitizing immunotherapy options recommended by their health care providers.Rather, they use prescription or nonprescription medications to manage their symptoms[17].
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Carr W, Schaeffer J, Donnenfeld E (2016). "Treating allergic conjunctivitis: A once-daily medication that provides 24-hour symptom relief". Allergy Rhinol (Providence). 7 (2): 107–14. doi:10.2500/ar.2016.7.0158. PMC 5010431. PMID 27466061.
- ↑ Abelson MB, Chapin MJ, Kapik BM, Shams NB (2003). "Efficacy of ketotifen fumarate 0.025% ophthalmic solution compared with placebo in the conjunctival allergen challenge model". Arch Ophthalmol. 121 (5): 626–30. doi:10.1001/archopht.121.5.626. PMID 12742839.
- ↑ 3.0 3.1 3.2 Bielory L, Meltzer EO, Nichols KK, Melton R, Thomas RK, Bartlett JD (2013). "An algorithm for the management of allergic conjunctivitis". Allergy Asthma Proc. 34 (5): 408–20. doi:10.2500/aap.2013.34.3695. PMID 23998237.
- ↑ Abelson MB, Gomes PJ (2008). "Olopatadine 0.2% ophthalmic solution: the first ophthalmic antiallergy agent with once-daily dosing". Expert Opin Drug Metab Toxicol. 4 (4): 453–61. doi:10.1517/17425255.4.4.453. PMID 18433347.
- ↑ Greiner JV, Edwards-Swanson K, Ingerman A (2011). "Evaluation of alcaftadine 0.25% ophthalmic solution in acute allergic conjunctivitis at 15 minutes and 16 hours after instillation versus placebo and olopatadine 0.1%". Clin Ophthalmol. 5: 87–93. doi:10.2147/OPTH.S15379. PMC 3037035. PMID 21339800.
- ↑ 6.0 6.1 6.2 Bielory BP, O'Brien TP, Bielory L (2012). "Management of seasonal allergic conjunctivitis: guide to therapy". Acta Ophthalmol. 90 (5): 399–407. doi:10.1111/j.1755-3768.2011.02272.x. PMID 22067457.
- ↑ Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
- ↑ Kray KT, Squire EN, Tipton WR, Selner JC, O'Dea J, Nelson HS (1985). "Cromolyn sodium in seasonal allergic conjunctivitis". J Allergy Clin Immunol. 76 (4): 623–7. doi:10.1016/0091-6749(85)90785-7. PMID 3932499.
- ↑ Melamed J, Schwartz RH, Hirsch SR, Cohen SH (1994). "Evaluation of nedocromil sodium 2% ophthalmic solution for the treatment of seasonal allergic conjunctivitis". Ann Allergy. 73 (1): 57–66. PMID 8030804.
- ↑ O'Brien TP (2013). "Allergic conjunctivitis: an update on diagnosis and management". Curr Opin Allergy Clin Immunol. 13 (5): 543–9. doi:10.1097/ACI.0b013e328364ec3a. PMID 23974684.
- ↑ Kim SJ, Flach AJ, Jampol LM (2010). "Nonsteroidal anti-inflammatory drugs in ophthalmology". Surv Ophthalmol. 55 (2): 108–33. doi:10.1016/j.survophthal.2009.07.005. PMID 20159228.
- ↑ Swamy BN, Chilov M, McClellan K, Petsoglou C (2007). "Topical non-steroidal anti-inflammatory drugs in allergic conjunctivitis: meta-analysis of randomized trial data". Ophthalmic Epidemiol. 14 (5): 311–9. doi:10.1080/09286580701299411. PMID 17994441.
- ↑ Schechter BA (2008). "Ketorolac tromethamine 0.4% as a treatment for allergic conjuctivitis". Expert Opin Drug Metab Toxicol. 4 (4): 507–11. doi:10.1517/17425255.4.4.507. PMID 18433352.
- ↑ 14.0 14.1 Gane J, Buckley R (2013). "Leukotriene receptor antagonists in allergic eye disease: a systematic review and meta-analysis". J Allergy Clin Immunol Pract. 1 (1): 65–74. doi:10.1016/j.jaip.2012.07.001. PMID 24229824.
- ↑ Joint Task Force on Practice Parameters. American Academy of Allergy, Asthma and Immunology. American College of Allergy, Asthma and Immunology. Joint Council of Allergy, Asthma and Immunology (2007). "Allergen immunotherapy: a practice parameter second update". J Allergy Clin Immunol. 120 (3 Suppl): S25–85. doi:10.1016/j.jaci.2007.06.019. PMID 17765078.
- ↑ Calderon MA, Penagos M, Sheikh A, Canonica GW, Durham SR (2011). "Sublingual immunotherapy for allergic conjunctivitis: Cochrane systematic review and meta-analysis". Clin Exp Allergy. 41 (9): 1263–72. doi:10.1111/j.1365-2222.2011.03835.x. PMID 21848759.
- ↑ Blaiss MS, Dykewicz MS, Skoner DP, Smith N, Leatherman B, Craig TJ; et al. (2014). "Diagnosis and treatment of nasal and ocular allergies: the Allergies, Immunotherapy, and RhinoconjunctivitiS (AIRS) surveys". Ann Allergy Asthma Immunol. 112 (4): 322–8.e1. doi:10.1016/j.anai.2014.02.006. PMID 24679733.