Treating allergic rhinitis in pregnancy - Safety considerations

Allergic rhinitis affects approximately one-third of women of childbearing age. As a result, symptoms ranging from sneezing and itching to severe nasa l obstruction may require pharmacotherapy. However, product labels state th at medications for allergic rhinitis should be avoided during pregnancy due to lack of fetal safety data, even though the majority of the agents have human data which refute these notions. We present a systematic and critical review of the medical literature on the use of pharmacotherapy for the man agement of allergic rhinitis during pregnancy. Electronic databases and oth er literature sources were searched to identify observational controled stu dies focusing on the rate of fetal malformations in pregnant women exposed to agents used to treat allergic rhinitis and related diseases compared wit h controls. Immunotherapy and intranasal sodium cromoglycate (cromolyn) and beclomethas one would be considered as first-line therapy, both because of their lack o f association with congenital abnormalities and their superior efficacy to other agents. First-generation (e.g. chlorpheniramine) and second-generatio n (e.g. cetirizine) antihistamines have not been incriminated as human tera togens. However, first-generation antihistamines are favoured over their se cond generation counterparts based on their longevity, leading to more conc lusive evidence of safety. There are no controlled trials with loratadine a nd fexofenadine in human pregnancy. Oral, intranasal and ophthalmic decongestants (e.g. pseudoephedrine, phenyl ephrine and oxymetazoline, respectively) should be considered as second-lin e therapy, although further studies are needed to clarify their fetal safet y. No human reproductive studies have been reported with the ophthalmic ant ihistamines ketorolac and levocabastine, although preliminary data reported suggest no association between pheniramine and congenital malformations. T here are no documented epidemiological studies with intranasal corticostero ids (e.g. budesonide, fluticasone propionate, mometasone) during pregnancy; however, inhaled corticosteroids (e.g. beclomethasone) have not been incri minated as teratogens and are commonly used by pregnant women who have asth ma. In summary, women with allergic rhinitis during pregnancy can be treated wi th a number of pharmacological agents without concern of untoward effects o n their unborn child. Although the choice of agents in part should be based on evidence of fetal safety, issue of efficacy needs to be addressed in or der to optimally manage this condition.