NUTRACEUTICAL MANAGEMENT OF ALLERGIC RHINITIS

Tejashree V, Saniya Mehvish S, Sharika Samrin T, Aiswarya V

ABSTRACT:

Worldwide, the number of people with allergic rhinitis (AR) exceeds 500 million. Oral antihistamines
and intranasal corticosteroids are two common treatments now in use, but they frequently have negative
effects and are not recommended for long-term use. This study aims to analyse the efficacies and
mechanisms of natural compounds in AR therapies by evaluating prior literature. Natural goods could
be a viable option. A total of fifty-seven investigations were gathered and categorized into decoctions of
plants, fungus, and minerals; clinical trials were arranged independently. Most natural products
demonstrated their effectiveness through two mechanisms: The first approach targeted antioxidation,
which controlled the activity of the nuclear factor kappa-light-chain-
enhancer of activated B cells (NFκB) pathway activated by reactive
oxygen species (ROS). The second approach focused on anti-
inflammation, regulating various mediators. Interleukin (IL)-
4, IL-5, IL-13, interferon-gamma (IFN-γ), tumor necrosis factor-
alpha (TNF-α), cyclooxygenase 2 (COX-2), and phospho-ERK1/2
(p-ERK1/2) were among the key factors associated with allergic
rhinitis that were modulated by natural [Link] products
have a big impact on treating AR, even if further research is needed
to confirm their safety and efficacy.

(Figure 1.1)

INTRODUCTION:
Allergic rhinitis, also referred to as hay fever, is the nasal irritation that arises as a result of exposure to
particular allergens, such as dust or pollen [1].
AR, due to its widespread occurence and significant adverse consequences on life quality of patients, is
categorized as a severe and enduring chronic ailment. More than 500 million individuals suffering from AR
possess the capacity to influence approximately 40% of the global population.. Rhinitis is a nasal ailment that is
caused by the interaction between an allergen in the air and specific IgE antibodies on mast cells. This interaction
is mediated by IgE. Mast cells release inflammatory mediators upon
contact, leading to further inflammation in the adjacent tissues. [2]
Therefore, it is regarded as a component of the broader inflammatory
process within the body.

The symptoms are connected to respiratory membrane ailments affecting

both the upper and lower airways, including conditions like rhinosinusitis,
asthma, conjunctivitis, polyposis rhinorrhea, nasal pruritus, sternutation,
and nasal obstruction. Mast cells are the primary source of histamine,
which is the principal catalyst for allergic reactions. Consequently, the
release of T helper cell – 2 (Th2) cytokines, namely interleukin (IL) - 4
and IL - 5, occurs. Therefore, it is essential to regulate histamine pathways
when treating AR. The prevailing treatment methods commonly employed
includes oral antihistamine and intranasal corticosteroid drugs.[3] (Figure 1.2)

Antihistamines stop histamine from attaching to the H1 receptor, which stops histamine from being released.
Second-generation antihistamines are nonetheless sedative and may cause psychomotor
slowness and decreased academic performance although having fewer adverse effects. [4,5] By controlling the
release of mediators, intranasal corticosteroids manage inflammation.

On the other hand, prolonged exposure may raise the risk of headache, hyperglycaemia, fractures, cataracts,
infections, and sluggish wound healing. Natural goods may be a good option for treating AR since there is a need
for medications that neutralize these enemies and preserve therapeutic efficacy.
For thousands of years, plant extracts have been utilized as traditional medicine in various nations, such as China,
Japan, Korea, and others.[6] They reduce the negative effects of different therapies, such radiation or onco-
chemotherapy, and down-regulate their detrimental side effects, in contrast to manufactured medications.
Additionally, because they are made up of various compounds in nature, they have the ability to target the immune
system multiple times.

Despite the existence of earlier research demonstrating the effectiveness of individual plant extracts in reducing
allergy symptoms, a comprehensive analysis of various plant extracts has not yet been conducted. [7] This study
examines the various plant extracts that can be assessed as treatment for allergic rhinitis.

CAUSES AND RISK FACTORS:

CAUSES:

Your body's immune system reacts to an irritant in the air, causing allergic rhinitis. Due to their small size,
the allergens and irritants are easily inhaled through the mouth or nose. Most people are not harmed by allergens.
However, your immune system perceives an allergen as an intruder if you have hay fever. [8] Your immune
system releases organic compounds into your bloodstream in an attempt to defend your body. The primary
constituent is known as histamine. As your body tries to expel the allergen, it makes the mucous membranes of
your nose, eyes, and throat irritated and irritating. [9,10] Numerous allergens can cause allergic rhinitis, including:

• Dust mites that live in carpets, drapes, bedding and furniture.

• Pollen from trees, grass and weeds.
• Pet dander (tiny flakes of dead skin cells).
• Mold spores.
• Cockroaches (their saliva and waste).

(Figure 1.3)

Allergies to certain foods can also irritate your throat and nose. item allergies can be fatal, so if you think that a
certain item is frequently triggering your allergy symptoms, seek medical attention straight away.

RISK FACTORS:
Since allergies are hereditary, having a parent or close relative with an allergy increases your chance of
developing hay fever. [11] Hay fever is also more common in people with eczema or asthma.
 (Figure 1.4)

COMPLICATIONS:
1. Asthma, sinusitis, and otitis media with effusion are among the upper and lower respiratory conditions that
commonly exacerbate allergic rhinitis. [12]
2. Allergic rhinitis can cause serious medical problems in the short- and long-term, which can impair quality of
life and be a contributing factor to other health problems. [13]

3. Allergy-related rhinitis problems, including eosinophilic esophagitis, otitis media, concomitant asthma, and
chronic cough. [14]

4. Acute or chronic sinusitis, otitis media, sleep disorders, dental problems, and other related issues are some of
the side effects of allergic rhinitis. [15]

5. The effects of allergic rhinitis on healthcare expenses, missed workdays, quality of life, and the development
of asthma. [16]
 OTITIS MEDIA

UPPER
RESPIRATORY HEARING SPEECH
INFECTION DEVELOPMENT
IMPAIRMENT
ALLERGY
RHINITIS
SLEEP
APNEA
SYNDROME NASAL
POLPS
RHINO-
SINUSITIS

(Figure 1.5)

Unfortunately, AR is often treated more as a bothersome ailment than a medical one by doctors. When in fact,
allergic rhinitis is a pretty general illness condition which affects up to 42% of the US population cumulatively
by the age of 40, and it can have major short- and long-term medical effects. Unmanaged symptoms of allergic
rhinitis can cause sleep disorders, secondary fatigue throughout the day, cognitive impairment, a decrease in
general learning and cognitive functioning, and a lower quality of life. In addition, poorly treated allergic rhinitis
may also be linked to the development of other related disease processes, including hearing loss, abnormal
craniofacial development, recurrent nasal polyps, chronic and acute sinusitis, otitis media along with effusion,
apnea in sleep and its complications, and exacerbation of asthma. Some of these issues may be related to the
negative neuropsychiatric effects of sedating antihistamine medications used to treat allergic rhinitis. [17] It may
also be dangerous to use sedating antihistamines in a number of other scenarios, such as while operating machinery
that could be dangerous or while driving. Conversely, studies have demonstrated that nonsedating antihistamines
alleviate the symptoms of allergic rhinitis.

PATHOPHYSIOLOGY OF THE ALLERGY RHINITIS:

Airborne allergens triggers allergic rhinitis by prompting the release of histamine in the body. [18] This
condition involves two distinct phases: an early phase and a late phase. In individuals who are already sensitive
to allergens, the process begins when substances like pollen, mites, or animal dander are identified by
immunoglobulin E (IgE) receptors on mast cells and basophils. While most people aren't affected by these
allergens, individuals with hay fever perceive them as threats to the immune system. Type I hypersensitivity, an
allergic reaction to these allergens, is facilitated by IgE antibodies. It involves the activation of mast and
inflammatory cells, typically within 20 minutes of exposure [19].

The early phase starts within 20 minutes of exposure to harmful allergens. Allergenic peptides are broken down
and presented on the mucosal surface by antigen-presenting cells like dendritic cells, incorporating them into
Major Histocompatibility Complex (MHC) class II molecules [20,21]. Immature CD4+ T cells mature into Th2
cells, specific to allergens, through the activation of Th cell receptors. B cells and activated Th2 cells produce
cytokines like IL-4 and IL-13, crucial for the production of allergen-specific IgE. When allergen-specific IgE
binds to high-affinity Fc receptors for IgE (The Fc region of immunoglobulin E (IgE), an antibody isotype
implicated in allergic disorders and parasite immunity, has a high-affinity receptor called FcεRI.), mast cells are
activated, releasing allergic mediators upon cross-linking of FcεR. This leads to intestinal hypermotility,
inflammation, and vascular leakage. Histamine, a key mediator, triggers reflex responses like sneezing. The late
phase occurs approximately four to six hours after allergen exposure, characterized by inflammation of the nasal
mucosa due to the influx and activation of various inflammatory cells. Cytokines such as IL-4 and IL-5 attract
these cells, leading to the production of chemokines like eotaxin, RANTES, and TARC from structural cells [22].
This enhances adhesion molecules on endothelial cells, facilitating the entry of inflammatory cells.

(Figure 1.6) Diagrammatic depiction of the pathogenesis of AR [23]

 ALLOPATHIC REMEDY:

Allergy Rhinitis

Symptoms of Intermittent Symptoms of Persistent

rhinitis rhinitis

Mild Moderate Mild Severe/

Moderate

• Leukotriene modifiers;
• Intranasal corticosteroids • Intranasal steroid
• Oral H1-blockers
• Intranasal H1 receptor antagonists - and/or
• Intranasal H1-
decongestant
blockers; and/or • Oral H1 receptor antagonists - and/or Patient follow-up after
decongestants decongestant
• Nasal cromones 2-4 weeks
• Leukotriene modifiers

If improved: step-down and

• Follow up with the patient in two to
continue *1 month
four weeks
If Failed: add intranasal H1-
blockers

Step up if failure happens Failure

Continue *one month if it gets better

Review dx
Review compliance

(Figure 1.7). • Algorithms for treating allergic rhinitis using medications. [24,25,26]
DRUGS USED:
DECONGESTANTS:
(Table 1.1) Drugs used as Decongestant

Dosage form Drugs Brand Names of the drugs

Cetirizine and pseudoephedrine Zyrtec-D 12 Hour
Desloratadine and pseudoephedrine Clarinex-D
Pills and Liquids
Fexofenadine and pseudoephedrine Allegra-D
Loratadine and pseudoephedrine Claritin-D
Oxymetazoline Afrin
Nasal spray and drops Tetrahydrozoline Tyzine

ANTIHISTAMINE:
(Table 1.2) Drugs used as Antihistamine

Dosage form Drugs Brand Names of the drugs

Cetirizine Zyrtec, Zyrtec Allergy
Desloratadine Clarinex
Pills and Liquids Fexofenadine Allegra, Allegra Allergy
Levocetirizine Xyzal, Xyzal Allergy
Loratadine Alavert, Claritin
Azelastine Astelin, Astepro
Nasal spray and drops
Olopatadine Patanase
Ketotifen Alaway, Zaditor
Eye drods Olopatadine Pataday, Patanol, Pazeo
Pheniramine and naphazoline Visine, Opcon-A, others

CORTICOSTEROIDS:
(Table 1.3) Drugs used as Corticosteroids
Dosage form Drugs Brand Names of the drugs
Prednisone Prednisone Intensol, Rayos
Pills and Liquids Methylprednisolone Medrol
Prednisolone Prelone
Fluticasone furoate Flonase , Sensimist
Budesonide Rhinocort
Nasal spray Fluticasone propionate Flonase Allergy Relief
Triamcinolone Nasacort Allergy 24 Hour
Metrometasone Nasonex
Fluorometholone FML, Flarex
Eye drops Prednisolone Omnipred, Pred Forte, others
Loteprednol Alrex, Lotemax
NEUTRACEUTICAL MANAGEMENT:
A frequent childhood illness, allergic rhinitis affects as much as 40% of the general population. It is
brought on by type 2 immunity and manifests as inflammation, sneezing, and congestion of the nasal passages. It
is frequently connected to other allergic disorders such as asthma and allergic conjunctivitis. Keeping away from
triggers for allergic rhinitis and using pharmacological therapies in accordance with ARIA guidelines are key
components of good management. Nasal corticosteroids or intranasal/oral antihistamines may be used in these
treatments. For histamine-dependent symptoms such as rhinorrhea, sneezing, and itching, antihistamines are
prescribed. Corticosteroids are used to treat nasal obstructions. To get rid of mediators and allergens, employ nasal
lavage [27,28]. Decongesting qualities can be seen in hypertonic solutions. Immunotherapy targeted to allergens
is the sole treatment for causality. Moreover, nutraceuticals reduce symptoms. This evaluation contrasts novel and
conventional treatment modalities for pediatric allergic rhinitis caused by pollen.
Nutraceuticals and non-pharmacological treatments are commonly used in complementary medicine to treat
patients with allergic rhinitis (AR). These include hyaluronic acid, probiotics, vitamins, minerals, saline solutions,
and safe herbal therapies for children with AR. Studies have shown that the multicomponent nutraceutical Lertal
can reduce the requirement for antihistamines, therefore relieving symptoms of allergic rhinitis in children.
Furthermore, there is positive evidence to support the use of some dietary supplements, including as tomato
extract, spirulina, conjugated linoleic acid, apple polyphenols, and chlorophyll C2. Nutraceuticals, including
spirulina, have been found to alleviate the symptoms of allergic rhinitis by reducing mast cell degranulation
[29,30].

(Figure 1.8) [31]

Allergic rhinitis caused by pollen ( PIAR ) is a prevalent disorder in children, and its incidence is rapidly rising.
Moreover, it could be associated with other atopic disorders , including asthma. To effectively manage PIAR, it
is advisable to minimize contact with the allergens that trigger it and follow the ARIA guidelines (Allergic Rhinitis
and its Impact on Asthma is a non-governmental organisation that collaborates with the World Health
Organisation (WHO) through the Global Alliance Against Chronic Respiratory Diseases (GARD). It is an
integrated part of EUFOREA that facilitates pocket guides and treatment algorithms for physicians.) by using
symptomatic medications like intranasal/oral antihistamines or nasal corticosteroids. In recent decades, significant
research and progress have been made in medicine, resulting in the development of novel drugs like allergen-
specific immunotherapy (AIT), anti-IgE antibodies, and probiotics. Additionally, nutraceuticals have been
employed as supplementary treatments. This review seeks to investigate and contrast historical and contemporary
therapeutic approaches for pediatric idiopathic acute renal injury. (PIAR). Potential novel treatments may
comprise the application of integrated therapies, specifically emphasizing the utilization of predetermined
mixtures of antihistamines and corticosteroids, nutraceutical products, and innovative formulations of allergen
immunotherapy (AIT).
(Table 1.4) Synthetic list of the most common food supplements used in clinical practice.
[32]
Polyphenols Resveratrol, Rosmarinic acid, Gingerol, Catechins (green tea),
Curcumin

ω−3 fatty acids flaxseed oil and Fish oil

Flavonoids Quercitin, rutin, spirein

Oligo-elements Short chain fatty acids

Immuno-modulants Glucans, Lactoferrin, Melatonin,

Probiotics Bifidobacteria strains, Lactobacilli

Vitamins Vitamin D, Vitamin C, Vitamin E, β-carotene

Prebiotics FOS (fructo-olygo saccharides), Inulin

CONCLUSION:
Allergy Rhinitis (AR) can be efficiently treated using natural remedies. The majority of the assessed trials
had favourable outcomes in lowering sneezing and nose-rubbing associated with allergic rhinitis (AR), as well as
preventing inflammation in both living organisms and laboratory settings. The clinical study results confirmed the
safety and effectiveness of the medications. Hence, natural substances can serve as promising targets for drugs
designed to address AR.

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