Allergic conjunctivitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
To suppress the inflammation that underlies AC signs and symptoms, interventions that target one or more points in the inflammatory response cascade are necessary (Table 1). The most common treatment approach for management of extant AC is use of a topical pharmacologic medication (e.g., a dual-acting antihistamine–mast cell stabilizer agent) to reduce inflammation combined with nonpharmacologic remedies (e.g., cold compresses or artificial tears) to provide temporary symptomatic relief.23,32 Although this approach is effective for most patients with mild symptoms of SAC or PAC, none of these medications last a full 24 hours. In addition, patients who experience moderate to severe symptoms that significantly interfere with daily activities and quality of life may require more effective and longer-lasting treatment. There have been few recent developments in strategies for treatment of AC. Existing drug classes and immunotherapies have been modified to improve safety and efficacy profiles, but AC remains inconvenient and costly to manage. A key limitation of many topical AC treatments is the need for multiple daily instillations to maintain symptomatic relief.2,16,33
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 require twice-daily dosing[2]. Olopatadine 0.2%[3] and alcaftadine[4] 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[5].
- Most mast cell stabilizers need to be given four to six times daily; nedocromil sodium can be given twice daily[6].
- The required loading time for maximal efficacy of mast cell stabilizers, necessitates their initiation before symptoms appear[5].
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[7].
- 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[8].
- They require four times daily dosing.
- A systematic review revealed that topical NSAIDs were ineffective on other symptoms, such as chemosis or swelling[9].
- 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.
Leukotriene receptor antagonists[10]
- 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[5].
- Like topical antihistamines, combination antihistamine-vasoconstrictor formulations have a relatively short duration of action and are administered four times daily[2].
Topical antihistamines
References
- ↑ 1.0 1.1 1.2 1.3 1.4 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.
- ↑ 2.0 2.1 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.
- ↑ 5.0 5.1 5.2 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.
- ↑ 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.
- ↑ 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.