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 alergic 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 AntihistamineMast 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 0.25%[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].

Common drug regimens: 2%Cromolyn sodium[7], 2% nedocromil sodium[8]

Corticosteroids

Nonsteroidal Anti-inflammatory Drugs[1]

Leukotriene receptor antagonists[12]

AntihistamineVasoconstrictor Combinations[1]

Topical antihistamines[1]

Allergen specific immunotherapy

References

  1. 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.
  2. 2.0 2.1 2.2 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.
  3. 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.
  4. 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. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 12.0 12.1 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.
  13. 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.
  14. 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.
  15. 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.

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