Treatment of Allergic Rhinitis in Pregnancy and Breastfeeding

- May 30, 2019

Allergic rhinitis is characterised by symptoms such as sneezing, a runny, itchy or blocked nose and itchy, watery eyes. It is very common, affecting up to 30% of the adult population. People with seasonal rhinitis (“hay fever”) exhibit symptoms at specific times of the year (usually spring and summer), while those with perennial rhinitis can have symptoms all year. Wind-borne pollen from trees, grass and weeds are the usual seasonal allergens, while perennial allergens include house dust mites, indoor mould and pets. In reality many people are allergic to both indoor and outdoor allergens, and their symptoms are perennial, with seasonal exacerbations. Rhinitis during pregnancy is not necessarily caused by allergens. Pregnancy-induced vascular changes, especially in the third trimester, can result in increased nasal congestion or secretions. Pregnancy-induced rhinitis does not usually respond well to treatment. Ideally all drug therapy should be avoided during pregnancy, especially in the first trimester. If treatment is necessary in a pregnant or breastfeeding woman, then choice should be based on symptom type and severity, foetal or infant safety, product efficacy, and patient preference.

 

First line Corticosteroid nasal sprays e.g. budesonide, fluticasone, beclometasone

  • Highly effective, especially for nasal congestion
  • Minimal absorption
  • Good safety data in  pregnancy and breastfeeding
Second line Non-sedating antihistamines e.g. cetirizine, loratadine

  • Less effective than corticosteroid nasal sprays, especially for nasal congestion
  • Good safety data in pregnancy
  • Less safety data in breastfeeding but reasonable to use

Cromoglicate nasal spray and eye drops

  • Minimal absorption and good safety data in pregnancy
  • No safety data in breastfeeding but reasonable to use
  • Less effective than corticosteroid nasal sprays and need frequent dosing
Third line Sedating antihistamines e.g. chlorphenamine, promethazine

  • More sedative and anticholinergic adverse effects than non-sedating options
  • Good safety data in pregnancy but avoid high doses near term (may increase risk of neonatal respiratory depression)
  • No safety data in breastfeeding

Olopatadine eye drops, azelastine nasal spray and ipratropium nasal spray

  • Need frequent dosing
  • No safety data in pregnancy or breastfeeding, but likely minimal absorption
Avoid Oral or nasal decongestants e.g. phenylephrine, oxymetazoline, xylometazoline

  • Dubious efficacy for allergy
  • Uncertain risk of birth defects with phenylephrine
  • No safety data in breastfeeding
  • Rebound congestion tends to occur with nasal sprays (use for up to 3 days only)

As with all medicines during pregnancy and breastfeeding, use the lowest effective dose for the shortest duration possible.
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