Cost Effective Topical Therapy for Allergic Rhinitis (AR) and Chronic Rhinosinusitis (CRS)
|Raghuvir B. Gelot M.D. F.A.C.S.
Vidant Roanoke Chowan Hospital
202 NC Hwy 42 West
Ahoskie, N.C. 27910
AR and CRS are common medical conditions. AR affects 10-30% children and adults in the U.S. It accounts for 3.4 billion dollars in direct cost for prescription and over the counter medicines and clinicians’ billing cost annually. In addition there are indirect costs such as missing school, work, restricted activities and loss of productivity. There are hidden direct costs associated with comorbidities such as otitis media, sinusitis and asthma. Economic burden of AR is increasing. The number of prescriptions written for AR patients are twice the number written for those without AR. CRS approximately affects 16% adult population. It accounts for 20 million doctor visits per year and nearly 20% antibiotics prescribed. Total annual expenditure for CRS is estimated at 8.6 billion dollars in direct cost in 2007.
In the past decade, topical therapies have emerged as important component of management of AR and CRS. These therapies target therapeutic agents directly to diseased sinonasal mucosa with minimal systemic absorption and minimal systemic adverse effects. These include Saline irrigation, Topical steroids, Topical antibiotics and antifungal agents and Additives such as surfactants.
Of these, use of saline irrigations have the strongest evidence of efficacy and benefits. In a Cochrane review of 8 randomized control trials, saline irrigation improved both CRS symptoms and quality of life when used as the sole treatment and as adjunctive therapy.
Saline solution can be isotonic (0.9%) or hypertonic (2.7%). Hypertonic saline seems to be more effective in relieving nasal congestion but it can have local adverse effect such as irritation and burning.
Saline irrigation is performed once or twice a day. A cordless pulsatile device such as Sinugator which delivers the solution with positive pulsatile pressure is a preferred method. Alternatively, a large volume low pressure squeeze bottle or Neti pot as gravitational effect can be used.
When using nasal steroid inhalers or other topical agents, saline irrigation should be used first. Doing so enhances the efficacy of agent used on sinonasal mucosa as saline removes the particulate matter (pollen and irritants) and mucus allowing the medication to reach deeper into the nose.