알레르기비 염의 치료흐름도
국내 가이드라인
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알레르기비염 약물요법의 원칙
2008 ARIA guideline에서 중요 치료지침
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알레르기 비염의 치료약물
| 작용기전 | 부작용 | 비고 |
경구 H1 antihistamine | |||
2nd generation 1st generation | Blockage of H1 receptor Some antiallergic activity New generation drugs can be used once daily No development of tachyphylaxis | New generation No sedation for most drugs No anticholinergic effect No cardiotoxicity for products still available Acrivastine has sedative effects Mequitazine has an anticholinergic effect Oral azelastine may induce sedation and a bitter taste Old generation Sedation is common And/or anticholinergic effect | New generation oral H1-antihistamines should be preferred for their favorable efficacy/safety ratio and pharmacokinetics Rapidly effective (<1 h) on nasal and ocular symptoms Moderately effective on nasal congestion Cardiotoxic drugs are no longer marketed in most countries |
국소 H1-antihistamines(intranasal, intraocular) | |||
Azelastine Levocabastine Olopatadine | Blockage of H1 receptor Some antiallergic activity for azelastine | Minor local side effects Azelastine: bitter taste
| Rapidly effective (<30 min) on nasal or ocular symptoms |
비강 내 glucocorticosteroids |
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Beclomethasone dipropionate Budesonide Ciclesonide Flunisolide Fluticasone propionate Fluticasone furoate Mometasone furoate Triamcinolone acetonide | Potently reduce nasal inflammation Reduce nasal hyperreactivity
| Minor local side effects Wide margin for systemic side effects Growth concerns with BDP only In young children consider the combination of intranasal and inhaled drugs | The most effective pharmacologic treatment of allergic rhinitis Effective on nasal congestion Effective on smell Effect observed after 12 h but maximaleffect after a few days |
전신 glucocorticosteroids(경구/근육 내) | |||
Dexamethasone Hydrocortisone Methylpredisolone Prednisolone Prednisone Triamcinolone | Potently reduce nasal inflammation Reduce nasal hyperreactivity
| Systemic side effects common in particular for IM drugs Depot injections may cause local tissue atrophy | When possible, intranasal glucocorticosteroids should replace oral or IM drugs However, a short course of oral glucocorticosteroids may be needed if moderate/severe symptoms |
국소 cromones (intranasal, intraocular) | |||
Cromoglycate Nedocromil
| Mechanism of action poorly known | Minor local side effects | Intraocular cromones are very effective Intranasal cromones are less effective and their effect is short lasting Overall excellent safety |
경구 비충혈제거제 | |||
Ephedrine Phenylephrine Phenyl propanolamine Pseudoephedrine Oral H1-antihistamine– decongestant combinations | Sympathomimetic drugs Relieve symptoms of nasal congestion | Hypertension. Palpitations Restlessness, Agitation Tremor, Insomnia Headache Dry mucous membranes Urinary retention Exacerbation of glaucoma or thyrotoxicosis | Use oral decongestants with caution in patients with heart disease Oral H1-antihistamine–decongestant combination products may be more effective than either product alone but side effects are combined |
비강 내 비충혈제거제 | |||
Oxymethazoline Xylomethazoline Others | Sympathomimetic drugs Relieve symptoms of nasal congestion | Same side effects as oral decongestants but less intense Rhinitis medicamentosa is a rebound phenomenon occurring with prolonged use (over 10 days) | Act more rapidly and more effectively than oral decongestants Limit duration of treatment to <10 days to avoid rhinitis medicamentosa |
비강 내 항콜린제 | |||
Ipratropium | Anticholinergics block almost exclusively rhinorrhoea | Minor local side effects Almost no systemic anticholinergic activity | Effective on allergic and nonallergic patients with rhinorrhoea |
Leukotriene antagonists | |||
Montelukast Pranlukast Zafirlukast | Block CystLT receptor | Excellent tolerance | Effective on rhinitis and asthma Effective on all symptoms of rhinitis and on ocular symptoms |
알레르기 비염의 치료제의 효능에 대한 근거(ARIA 가이드라인)
Intervention | SAR | PAR | PER | ||
adult | children | adult | children | ||
oral H1 Antihistamine | A | A | A | A | A |
Intranasal H1 Antihistamine | A | A | A | A | A |
Intranasal CS | A | A | A | A | A |
Intranasal cromone | A | A | A | A |
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LTRAs | A | A(>6세) | A |
| A |
Subcutaneous SIT | A | A | A | A | A |
Sublingual / nasal SIT | A | A | A | B | A |
Allergen avoidance | D | D | A | B |
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알레르기 비염에 사용되는 주요 약물
종류 | 증상별 추천 | 알레르겐 노출 상황별 추천 | 증상빈도별 추천 | 중증도별 추천 | |||||||
비충혈 | 콧물 | 재채기 | 코 가려움증 | 계절성 | 통년성 | Episodic | 간헐적 | 지속적 | 경증 | 중증 | |
비강 내 스테로이드 | +++ | +++ | +++ | +++ | ++ | ++ | + | ++ | ++ | ++ | ++ |
경구 항히스타민 | + | ++ | ++ | ++ | + | + | + | ++ | + | + | 비추천 |
비강 내 항히스타민 | ++ | ++ | ++ | ++ | ++ | + | ++ | ++ | + | ++ | + |
류코트리엔억제제 | + | + | + | + | + | + | 비추천 | 비추천 | 추천함 | 추천함 | 단독요법으로는 추천 안함 |
| 국외 | 국내 |
항히스타민제 | 2010 ARIA 가이드라인 지침
미국 이비인후과학회(2015년)
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류코트리엔 수용체 길항제(LTRA) | 2010 ARIA 가이드라인 지침
미국 이비인후과학회(2015년)
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비강 내 스테로이드제 | 2010 ARIA 가이드라인 지침
미국 이비인후과학회(2015년)
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스테로이드 점안액 | 국내 가이드라인
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전신스테로이드(경구, 주사) | 2010 ARIA 가이드라인 지침 전신적 스테로이드제는 국소 스테로이드제나 항히스타민제에 반응하지 않는 심한 코막힘이 있는 환자에서 단기간에만 사용한다.
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혈관수축제 | 2010 ARIA 가이드라인 지침
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기타 약물 | chromones(intranasal, intraocular) - 2010 ARIA 가이드라인 지침
intranasal ipratropium Bromide - 2010 ARIA 가이드라인 지침
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알레르기 비염 단계별 약물치료
단계 | 추천되는 치료 |
Mild IAR |
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Moderate/severe IAR |
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Mild PER |
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Moderate/severe PER |
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알레르기 비염 약물 치료 흐름도(미국이비인후과학회, 2015)
2010 ARIA 가이드라인 지침 | 국내 가이드라인 |
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참고자료