Pregnant Women144

Women who have AR may suffer an exacerbation of symptoms during pregnancy. However, only minor changes in the routine approach to therapy are necessary as a result of the pregnancy. Second-generation antihistamines are generally considered safe, based on an increasing number of studies and experience.1 The same generalization applies to intranasal corticosteroids. However, the products with the best documented safety record are beclomethasone, budesonide, and fluticasone propionate.1 If an intranasal product is started during pregnancy, the wisest choice might be to use budesonide, based on the fact that it is FDA Pregnancy category of B. Cromolyn is also FDA Pregnancy category B, and is considered safe. The disadvantages, however, are frequent administration and lesser efficacy than antihistamines and intranasal corticosteroids. Montelukast is also FDA Pregnancy category B, but some recommend it be used primarily in those with concurrent asthma or in those who have demonstrated a good response prior to pregnancy.1 Ipratropium is FDA Pregnancy category B, despite limited data.44 The decongestants are not considered safe, especially in the first trimester. If nasal congestion is severe enough to warrant consideration for a decon-gestant, the intranasal route of administration is preferable, due to decreased systemic exposure and the short-term duration of therapy.

Elderly1'8

Elderly patients can be treated for AR according to the approach for (younger) adults.1, However, the elderly may be more sensitive to the sedative and antimus-carinic effects of antihistamines and to the cardiovascular and CNS stimulant effects of decongestants. Also, the aging process can affect the manifestations of AR. Generalized atrophy of nasal tissues can result in more nasal congestion. An increase in cholinergic activity may result in more rhinorrhea.

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