PRACTICE GUIDELINE J Korean Med Assoc 2017 February; 60(2):183-193 pissn 1975-8456 / eissn 2093-5951 https://doi.org/10.5124/jkma.2017.60.2.183 임상의를위한알레르기비염진료지침 : 내과적치료 김영효 1 * 김미애 2 * 양현종 3,4 최정희 5 김동규 6 유영 7,8 이보라 9 김봉성 10 김원영 11 김정희 12 박소연 13 배우용 14 송기재 15 양민석 16 이상민 17 이영목 18 이현종 19 조재홍 20 지혜미 21 박양 22 고영일 23 대한천식알레르기학회비염연구팀 1 인하대학교의과대학이비인후과, 2 차의과학대학교분당차병원호흡기알레르기내과, 3 순천향대학교의과대학소아청소년과, 4 SCH Biomedical Informatics Research Unit, 한림대학교의과대학 5 호흡기알레르기내과, 6 이비인후과, 고려대학교 7 의과대학소아청소년과, 8 알레르기면역연구소, 9 순천향대학교부천병원의학통계상담실, 10 울산대학교의과대학강릉아산병원소아청소년과, 11 우리들내과의원, 12 인하대학교의과대학소아청소년과, 13 분당에이엔에이내과, 14 동아대학교의과대학이비인후과, 15 가톨릭관동대학교의과대학이비인후과, 16 서울특별시보라매병원알레르기내과, 17 가천대학교의과대학호흡기알레르기내과, 18 GF 내과, 19 리앤홍이비인후과, 20 조앤박이비인후과, 21 차의과학대학교소아청소년과, 22 원광대학교의과대학산본병원소아청소년과, 23 전남대학교의과대학알레르기내과 Crinical diagnostic guidelines for allergic rhinitis: medical treatment Young Hyo Kim, MD 1* Mi-Ae Kim, MD 2* Hyeon-Jong Yang, MD 3,4 Jeong-Hee Choi, MD 5 Dong-Kyu Kim, MD 6 Young Yoo, MD 7,8 Bora Lee, MD 9 Bong-Seong Kim, MD 10 Won-Young Kim, MD 11 Jeong Hee Kim, MD 12 So Yeon Park, MD 13 Woo Yong Bae, MD 14 Keejae Song, MD 15 Min-Suk Yang, MD 16 Sang Min Lee, MD 17 Young-Mok Lee, MD 18 Hyun Jong Lee, MD 19 Jae-Hong Cho, MD 20 Hye Mi Jee, MD 21 Yang Park, MD 22 Young-Il Koh, MD 23 Work Group for Rhinitis, the Korean Academy of Asthma, Allergy and Clinical Immunology 1 Department of Otorhinolaryngology, Inha University College of Medicine, Incheon; 2 Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam; 3 Department of Pediatrics, Soonchunhyang University College of Medicine, Seoul; 4 SCH Biomedical Informatics Research Unit, Seoul; Departments of 5 Pulmonology and Allergy, 6 Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon; 7 Department of Pediatrics, Korea University College of Medicine, Seoul; 8 Allergy Immunology Center, Korea University, Seoul; 9 Department of Biostatistics, Soonchunhyang University Bucheon Hospital, Bucheon; 10 Department of Pediatrics, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung; 11 Wooridul Private Internal Clinic, Gwangju; 12 Department of Pediatrics, Inha University College of Medicine, Incheon; 13 A & A Clinic, Seongnam; 14 Department of Otorhinolaryngology, Head and Neck Surgery, Dong-A University College of Medicine, Busan; 15 Department of Otorhinolaryngology-Head and Neck Surgery, Catholic Kwandong Universtiy College of Medicine, Incheon; 16 Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul; 17 Division of Pulmonology and Allergy, Department of Internal Medicine, Gachon University College of Medicine, Incheon; 18 GF Allergy Clinic, Seoul; 19 Lee & Hong ENT, Seongnam; 20 Cho&Park ENT Clinics, Suwon; 21 Department of Pediatrics, CHA University School of Medicine, Seongnam; 22 Department of Pediatrics, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo; 23 Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea The social and economic burden of allergic rhinitis (AR) is increasing, with significant effects on the quality of life of patients suffering from AR. Therefore, physicians require evidence-based guidelines regarding the diagnosis, differential diagnosis and proper management management of patients with AR. The Korean Academy of Asthma, Allergy and Clinical Immunology developed new clinical guidelines for the appropriate management of AR, especially in Korean patients. For the core questions (i.e. questions that most practitioners were curious about), several experts in the field of allergology, pediatrics, and otorhinolaryngology developed a set of practical guidelines based on a systematic review of the literature. Furthermore, we determined the level of evidence associated with the recommendations for each answer. In this article, we suggest 15 answers for core questions about the medical treatment of AR. Key Words: Rhinitis, allergic; Guideline; Medicine; Therapeutics 알레르기비염내과적치료지침 183
J Korean Med Assoc 2017 February; 60(2):183-193 Received: November 27, 2016 Accepted: January 10, 2017 *These two authors contributed equally to this work. Corresponding author: Young-Il Koh, E-mail: yikoh@chonnam.ac.kr Yang Park, E-mail: pyallergy@gmail.com Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 알레르기비염은한국인에서가장흔한만성질환중의하 나로, 환자들은심각한사회경제적부담및삶의질저하를 호소한다. 따라서알레르기비염에대한정확한진단및치료 가필수적임에도불구하고, 그간임상의의주관적인판단에 의해경험적인치료를수행하는경우가많았다. 이는부정확 한진단및이로인한치료효과감소를가져올수있다. 따라 서최근국내환경과의료여건을잘반영하는새로운알레 르기비염가이드라인개발의필요성이강조되어왔다. 이에 따라대한천식알레르기학회를중심으로가이드라인개발작 업을수행하였다. 본가이드라인에서는실질적으로진료를수행하는임상의 사들이필요로하는임상적요구를파악하여이를핵심질문 으로만들고, 이에대해내과, 소아청소년과, 이비인후과전 문가들이광범위한문헌고찰을통해권고안을정리하였다. 가이드라인을보다간단명료하게기술함으로써, 일차진료를 수행하는개원의가쉽게활용할수있도록하였다. 본논문 에서는전체핵심질문중, 알레르기비염의내과적치료에관 한 15 개의핵심질문에대한답을주로다루고자하였다. 가이드라인개발과정 대한천식알레르기학회산하알레르기비염연구팀 ( 알레르 기내과전문의 12 인, 소아청소년과전문의 11 인, 이비인후 과전문의 18 인 ) 이주축이되어본가이드라인을개발하였다. 집필및감수를위해운영위원회, 집필위원회, 자문위원회 ( 개 원의 ), 감수위원회를조직하였다. 핵심질문선정을위해운영위원회및감수위원회에서일차적으로 117개의질문을개발하였다. 이후 이질문에대하여기존의가이드라인으로는설명이불충분하며, 새로운임상가이드라인에서이에대한지침을개발하여야하는지 에대하여설문을시행하였다. 이설문에대하여 99명의개원의및전공의 ( 내과, 소아청소년과및이비인후과각 33명 ) 가응답하였고, 5-point Likert scale (1=strongly disagree, 2=disagree, 3=not sure, 4=agree, 5=strongly agree) 을사용하여응답하였다. 이설문을통해현장에서필요한 40개의핵심질문을선정하였다 ( 이중본고에서는내과적치료관련 15개의문항을다루고자한다 ). 이에대하여집필위원회에서 Pubmed, Embase, Cochrane Library, KoreaMed 등의데이터베이스내문헌고찰을통해일차적인권고안을작성한후, 수차례운영위원회및감수위원들의감수과정을거쳤고, 공청회개최후토의된사항들을수용하여, 최종적인수정보완작업을하였다. 문헌근거수준과권고안등급 권고안도출의근거자료로사용된문헌의근거수준은연구의설계방법, 연구의질, 일관성등을포함한전반적인근거수준을평가하여 A, B, C, D 네가지로구분하였다, 근거수준 A는 1개이상의무작위임상연구, 메타분석, 또는체계적문헌고찰에의해근거가입증되어권고도출의근거가명백한경우, 근거수준 B는 1개이상의잘수행된환자-대조군연구또는코호트연구와같은비무작위임상연구를통해권고도출의근거가신뢰할만한경우, 근거수준 C는관찰연구, 증례보고와같은권고도출의근거는있으나신뢰할수없는경우, 근거수준 D는권고도출의근거가임상경험과전문성을기반으로한전문가의견인경우로정의하였다. 권고등급은 modified GRADE (grading of recommendations assessments, development and evaluation) 방법을사용하여근거수준, 편익과위해, 국내의료환경에서의활용도와같은요소들을반영하였다. 근거수준은낮지만편익이명백하거나국내의료환경에서의활용도가높은것 184 대한의사협회지
Kim YH et al. Treatment guideline for allergic rhinitis Table 1. Levels of recommendations Level of recommendation Definite Probable Possible Not recommended Definition Evidence level A. Clear benefits Highly available for practitioners Evidence level B. Reliable benefits Moderately to highly available for practitioners Evidence level C or D. No reliable benefits Moderately to highly available for practitioners Evidence level C or D. No reliable benefits May cause harmful effect for patients Unavailable for practitioners 2개는 high efficiency particulate air 필터, 1개는집먼지진드기비투과성커버와살충제를함께이용하는방법의효과를비교한연구이다. 7개의연구에서집먼지진드기농도를줄이는조치를통해실제로공기중의집먼지진드기알레르겐농도가줄어든것을보여주었으나증상의호전을보인연구는 4개였고, 나머지연구에서는대조군에비해증상이호전되지않았다. 그러나각각의연구에서집먼지진드기알레르겐을줄이기위해사용한방법이나그효과를평가하는방법등이달라결과를함께비교하기에는 무리가있다. 여러가지방법중집먼지진드기비투과성커 으로평가된권고에대해서는운영, 집필, 감수위원회의합의하에권고등급을일부상향조정하였고, 근거수준은높지만국내의료환경에서활용도가낮거나위해결과를초래할수있는권고에대해서는권고등급을일부하향조정하였다 (Table 1). 버를이용한연구가현재까지보고된연구중가장많은수의환자를가장객관적인방법으로평가하였는데이연구에서임상적효과를보이지못하였기때문에집먼지진드기비투과성커버를단독으로사용하는방법은추천하지않는다 [2]. 집먼지진드기살충제의효과를평가한연구에서는 임상적으로유의한효과를보였으나아직까지추천할정도 핵심질문 1. 알레르기비염에서실내알레르겐회피요법이증상개선에도움이되는가? 집먼지진드기알레르기비염환자에서회피요법을고려할수있다. ( 근거수준 C, 권고를고려할수있음 ) 반려동물알레르겐을회피하는가장효과적인방법은반려동물을키우지않는것이다. ( 근거수준 D, 강하게권고함 ) 반려동물을키우면서시행하는회피요법, 곰팡이, 바퀴에대한회피요법은현재까지임상적으로추천할근거는부족하나, 실내알레르겐의농도를줄일수있고, 그방법이인체에유해하지않으므로추천한다. ( 근거수준 C, 권고를고려함 ) 의근거는부족하다. 그러나집먼지진드기회피요법이특별히유해한방법은아니기때문에치료의한방법으로고려할수있다. 반려동물알레르겐을효과적으로회피할수있는가장좋은방법은반려동물을키우지않는것이다 [3]. 공기필터사용은반려동물알레르겐의농도를낮추지못하였고비염증상이호전되지않았다 [4]. 고양이털알레르기비염환자를대상으로시행한무작위대조군연구에서벽과바닥청소, 카펫제거, 매주빨래, 집먼지진드기비투과성커버사용등과함께고양이를 2주에한번씩씻기고침실에들어오지못하게하는방법을이용하여환경관리를하였을때고양이알레르 겐농도가감소되고비염증상이호전되었다는보고가있다 집먼지진드기알레르겐은통년성알레르기비염의가장흔한원인이다. 실내의집먼지진드기알레르겐농도를낮추기위한조치로온습도조절, 잦은청소와빨래, 집먼지진드기비투과성커버, 살충제, high efficiency particulate air 필터등의방법이시도되고있으나실효성은뚜렷하지않다. 집먼지진드기회피요법의임상적효과를평가한체계적문헌고찰에의하면 [1], 9개의연구중 4개는집먼지진드기비투과성커버, 2개는집먼지진드기살충제, [5]. 현재까지는반려동물을키우지않는것이외에다른환경관리방법을추천할만한근거는부족하다. 곰팡이는중요한실내알레르겐의하나인데곰팡이에대한회피요법으로는실내습기를제거하거나눈에보이는곰팡이를제거하는등주거환경개선의효과를평가한연구가많았다. 3개의무작위대조군연구에서천식증상의호전을보여주었으나비염증상에대해서는결과가일정하지않았는데역시연구간에방법론적차이가있어직접비교가 알레르기비염내과적치료지침 185
J Korean Med Assoc 2017 February; 60(2):183-193 힘들다 [6-8]. 현재까지는곰팡이알레르기비염환자의치료에서회피요법을추천할만한근거는부족하다. 바퀴알레르겐은도시에사는알레르기비염환자의주된원인중하나이다. 바퀴를퇴치함으로써알레르겐의농도는줄일수있으나 [9], 현재까지바퀴회피요법의임상적효과에대한근거는없다. 핵심질문 2. 알레르기비염치료에 2세대항히스타민제가 1세대항히스타민제보다좋은가? 알레르기비염치료에 2세대항히스타민제를권고한다. ( 근거수준 A, 강하게권고함 ) 2세대항히스타민제는 H1 수용체에더선택적이며, 혈뇌장벽통과가상대적으로적다. 성인에서 1세대와 2세대항히스타민제간의뇌혈관투과성을비교한연구결과, 1세대 50-90%, 2세대는 0-30% 의투과성을보였다 [10,11]. 약제의효과도 1세대보다 2세대항히스타민제가더빨리나타나서장시간지속되며 [12], 1세대항히스타민제와달리 loratadine, desloratadine, cetirizine, levocetirizine, fexofenadine과같은 2세대항히스타민제는다른약제와의병용치료에더안전하다 [13]. 특히 1세대항히스타민제를과량복용했을때드물지만부정맥과같은중증부작용이있을수있어 2세대항히스타민제의사용을권고하고있다 [14]. 결론적으로 1세대와 2세대항히스타민제는약제효과에있어서는큰차이가나타나지않으나, 보다안전한 2세대항히스타민제사용을권고한다. 핵심질문 3. 감기또는비알레르기비염치료에 2세대항히스타민제가도움이되는가? 감기치료에 2세대경구항히스타민제의효과는약하다. 그러나직업상의이유나기타집중을요하는경우는진정작용이적은 2세대경구항히스타민제를처방할수있다. ( 근거수준 C, 권고를고려할수있음 ) 비알레르기비염치료에 2세대경구항히스타민제의효과는약하나, 비강내항히스타민제는도움이된다. ( 근거수준 A, 강하게권고함 ) 감기치료에 2세대경구항히스타민제의효과는약하다. 그러나직업상의이유나기타집중을요하는경우는진정작용이적은 2세대경구항히스타민제를처방할수있다. 비알레르기비염치료에서항콜린작용을가진 1세대경구항히스타민제는도움이될수있으나 2세대경구항히스타민제는효과적이지않다 [15]. 2세대경구항히스타민제를비알레르기비염환자에게경험적으로처방하지만, 환자들의증상호전에도움이되지않는다 [16]. 반면비강내항히스타민제는효과적인것으로알려져있다 [15,17,18]. 최근의다기관무작위임상연구에따르면비알레르기비염환자들에서비강내 azelastine을투여한그룹이위약그룹에비해비염증상이유의하게개선되었다 [18]. 핵심질문 4. 항히스타민제치료에도호전되지않는알레르기비염환자에서용량을증량하거나, 두가지이상다른종류를병용하는것이효과적인가? 용량의증량이나서로다른종류의항히스타민제를두가지이상사용하는것보다는비강내스테로이드제등다른치료약제의병용을권장한다. ( 근거수준 C, 권고를고려함 ) 경구항히스타민제는표적세포의 H1 수용체길항작용을통해콧물, 재채기, 코가려움증, 눈증상에효과적이나코막힘증상은잘조절되지않는다. 비강내항히스타민제는경구항히스타민제보다코막힘증상에효과적인것으로알려져있지만 [19,20], 비강내스테로이드제보다는효과가떨어진다. 항히스타민제로충분한효과를얻지못한환자에서는비강내스테로이드제, 경구혈관수축제, 류코트리엔수용체길항제를추가하는것으로조절한다 [21-23]. 적절한치료에도호전되지않는알레르기비염환자에서항히스타민제를 2배까지증량하거나서로다른종류의항히스타민제를병용할수는있으나근거수준은높지않다 [24-26]. 코막힘등의증상에는두가지혹은그이상의항히스타민제를병용투여해도단독투여에비해효과가우수하다는근거가없으며오히려과량사용시중추신경계억제및녹내장, 전립선비대등부작용이증가할수있다. 186 대한의사협회지
Kim YH et al. Treatment guideline for allergic rhinitis 핵심질문 5. 알레르기비염치료에서류코트리엔수용체길항제의효능은무엇인가? 류코트리엔수용체길항제는알레르기비염의염증매개체인류코트리엔을차단하여항염증효과를나타낸다. ( 근거수준 A) 류코트리엔수용체길항제는알레르기비염치료에좋은효과를보이나항히스타민제와병용투여시상승효과는확실하지않다. ( 근거수준 A, 권고를고려함 ) 류코트리엔수용체길항제는알레르기비염의중요한염증매개체인류코트리엔이수용체에작용하는것을차단하는약제로서, 알레르기비염환자에서코증상과눈증상개선에도움이된다 [27,28]. 류코트리엔수용체길항제단독치료에비해항히스타민제와병용투여의상승효과에대해서는아직이견이있는상태이며 [29,30], 비강내스테로이드제와병용투여는증상개선에더욱효과적이다 [31,32]. 류코트리엔수용체길항제는계절성, 통년성알레르기비염에모두사용할수있으며 [33], 효과는항히스타민제와비슷하나비강내스테로이드제에비해서는효과가낮다 [34,35]. 천식의치료에도류코트리엔수용체길항제가사용되므로천식이동반된알레르기비염환자에서특히유용하다 [35,36]. Montelukast는우수한안전성으로 6개월이상의나이에서사용할수있고, pranlukast는 2세이상, zafirlukast 는 12세이상에서사용할수있다 [35,36]. 핵심질문 6. 비강내스테로이드제는비알레르기비염치료에효과가있나? 비알레르기비염치료에비강내스테로이드제는효과적이다. ( 근거수준 A, 강하게권고함 ) 비알레르기비염은여러질환으로분류할수있어비강내스테로이드제의유용성에대해일관되게기술할수는없다 [37]. 혈관운동성비염과호산구성비알레르기비염증후군에서는비강내스테로이드제사용이증상조절에도움이될수있다 [38-40]. 핵심질문 7. 비강내스테로이드제는얼마나오랫동안안전하게사용할수있나? 비강내스테로이드제를 1년정도지속적으로사용하여도안전하다. ( 근거수준 A, 강하게권고함 ) 1년이상사용시부작용에대한연구는부족하다. ( 근거수준 D, 권고하지않음 ) 4-8주정도비강내스테로이드제사용시코막힘을포함한증상까지완화되는것이일반적이며, 이후분무하는빈도를반으로줄여유지한다. 그러나환자마다원인알레르겐의종류가다르고증상의중증도와지속기간이다르므로치료종료시점을일괄적으로정하기는어렵다 [41]. 사춘기이전소아통년성알레르기비염환자에게 1년간 beclomethasone을비강내로투여하였을때, 통계적으로유의한성장저하가발생하였다는보고이후 [42], 비강내스테로이드제사용과소아성장및시상하부-뇌하수체축의영향과관련된여러연구가시행되었다. 최근주로사용되는제제인 mometasone, fluticasone, ciclesonide 등을 1년간사용한경우, 통계적으로유의한성장저하및시상하부-뇌하수체축의이상은보고된바없다 [43-46]. 그러나 1년이상사용시전신적부작용여부에대한근거는부족하다. 핵심질문 8. 비강내스테로이드제의전신부작용은없는가? 치료용량의비강내스테로이드제의전신흡수가거의없어시상하부-뇌하수체축에영향을주지않는다. ( 근거수준 A) 치료용량의비강내스테로이드제는소아의최종신장에영향을미치지않는다. ( 근거수준 A) 비강내스테로이드제의가장흔한부작용은국소자극증상이다. 재채기등의국소자극증상이초기에나타날수있으나, 지속적으로사용하면수일내에사라진다 [47,48]. 그외에도비강내작열감, 건조감, 가피, 코피등이발생할수있다. 또한아주드물게비중격천공이발생할수있다 [49]. 통년성알레르기비염이있는소아환자에게비강내 beclomethasone을사용하였을때, 성장속도가감소하였다 알레르기비염내과적치료지침 187
J Korean Med Assoc 2017 February; 60(2):183-193 는연구논문이발표되기도하였지만 [42], 최근개발된약제 (mometasone, fluticasone, ciclesonide) 는전신적인흡수가거의없고시상하부-뇌하수체축에영향을주지않으며, 단기간의성장속도에는차이가있더라도최종성인신장에는영향을미치지않는것으로보고되었다 [46]. 핵심질문 10. 알레르기비염치료에경구스테로이드제를사용할수있나? 비강내스테로이드제의사용에도조절되지않는알레르기비염에서경구스테로이드제를단기간사용할수있다. ( 근거수준 C, 권고를고려할수있음 ) 핵심질문 9. 알레르기결막염이동반된알레르기비염환자에서비강내스테로이드제와스테로이드점안액을함께사용할수있나? 비강내스테로이드제와다른비염치료약제를사용하였음에도결막염증상이조절되지않는경우스테로이드점안액을단기간사용할수있다. ( 근거수준 B, 권고를고려함 ) 스테로이드점안액을장기간사용할경우녹내장, 백내장, 눈감염등의부작용을초래할수있어안과적추적관찰이필요하다. ( 근거수준 B, 권고를고려함 ) 알레르기결막염은알레르기비염의흔한동반질환중하나이다. 경구항히스타민제, 비강내항히스타민제, 류코트리엔수용체길항제, 비강내스테로이드제및알레르겐면역요법은모두알레르기결막염의증상을호전시킨다 [17]. 무작위대조군연구들을바탕으로한체계적문헌고찰에의하면비강내스테로이드제는경구항히스타민제, 비강내항히스타민제와동등하게알레르기결막염의증상을호전시켰다 [21,50,51]. 성인계절성알레르기비염환자에서 fluticasone 비강내스테로이드제는통계적으로유의하게알레르기비염에동반된알레르기결막염의증상을호전시켰다 [52,53]. 고령에서비강내스테로이드제사용과백내장발생사이의관련성이보고된바있어주의를요한다 [54]. 알레르기비염에동반된알레르기결막염에서알레르기비염치료제를사용함에도불구하고결막염의증상이조절되지않는경우일차적으로항히스타민제또는비만세포안정제점안액을추가할수있다. 그럼에도조절되지않는심한증상을호소하는경우약한강도의스테로이드점안액을단기간 (1-2주) 사용할수있다 [55]. 스테로이드점안액을장기간사용할경우녹내장, 백내장, 눈감염을초래할수있으므로이에대한안과적추적관찰이필요하다. 기존의치료에반응이없는알레르기비염에서경구스테로이드제의사용에대한체계적문헌고찰이나무작위대조군연구는없으며, 스테로이드제의용량이나투여경로, 용량반응관계에대한비교논문도없다. 알레르기비염의치료에서경구스테로이드제의일상적인사용은권고되지않는다. 다만, 기존의약물에반응이없거나약물부작용으로다른약물의사용이곤란한경우에증상조절을위해단기간경구스테로이드를사용할수있다 (prednisolone 0.5 mg/kg, 5-7일 ). 알레르기비염에서경구스테로이드제는위약에비해서통계적으로유의한치료효과를보였다 [56]. 전신스테로이드제는비강내스테로이드제가도달할수없는부분까지효과를나타낼수있어단기간경구스테로이드제의사용은중증알레르기비염및비용종환자에게도움이될수있다 [57,58]. 단기간전신스테로이드의사용에대한부작용발생의증거는없다. 그러나소아, 임산부및스테로이드제금기환자의경우는주의하여사용한다. 핵심질문 11. 중증알레르기비염치료에고용량스테로이드근주를사용할수있나? 알레르기비염치료에서고용량스테로이드근주는권장하지않는다. ( 근거수준 D, 권고하지않음 ) 알레르기비염에서스테로이드 1회근주가다른치료제들에비해서더효과적이라는근거는부족하다. 주사부위통증, 생리불순, 안면홍조, 피로, 신경과민, 주사부위피부위축, 위궤양, 근육경련, 포도막염등이부작용으로보고되었다 [59,60]. 비록드물지만스테로이드근주의부작용및합병증의발생을고려하면고용량스테로이드근주의사용은권고되지않는다. 특히반복적인주사는금기다. 188 대한의사협회지
Kim YH et al. Treatment guideline for allergic rhinitis 핵심질문 12. 국소혈관수축제의부작용을피하려면어떻게해야하나? 국소혈관수축제는일주일이내로사용해야의인성비염등의부작용을피할수있다. ( 근거수준 A, 강하게권고함 ) 국소혈관수축제는특히코막힘을호소하는환자에서혈관을수축시킴으로써증상을신속히호전시키는데도움이된다 [61,62]. 그러나국소혈관수축제의 3-7일이상지속적사용은 α-교감신경수용체의하향조절로인해반동성비갑개비대를유발하므로장기적인치료제로서추천되지않는다 [63]. 비갑개비대로인하여코막힘이심한환자의경우비강내스테로이드제의효과적인사용을위해, 또한코막힘으로인해수면을방해받는환자에서효율적인수면을위해국소혈관수축제를일주일이내로단기간사용가능하다. 6세이하소아에서는특히사용에주의를요한다 [32,63]. 핵심질문 13. 알레르기비염약물치료는지속적으로유지해야하나? 지속유지치료가간헐적치료보다알레르기염증과증상조절에더효과적이다. ( 근거수준 B, 권고를고려함 ) 무조건적인지속유지치료보다는환자의특성에따른맞춤치료를권고한다. ( 근거수준 D, 강하게권고함 ) 치료는유병기간, 중증도, 연중증상지속기간, 약제선호도, 약제반응등을고려하여개인별맞춤치료를권고한다. 핵심질문 14. 알레르기비염치료중감기에걸렸을때어떻게치료하나? 기존의알레르기비염치료를유지하면서증상에따라대증적치료를추가한다. ( 근거수준 B, 권고를고려함 ) 알레르기비염환자에서감기증상이심해지는경우코막힘, 콧물등의증상정도에따라기존의치료를유지하면서대증적치료를추가한다. 중이염이나부비동염이동반되면필요에따라항생제를사용할수있다 [32,70]. 핵심질문 15. 알레르기비염에서코막힘이심한환자를어떻게치료하나? 비강내스테로이드제는코막힘의치료에가장효과적이다. ( 근거수준 A, 강하게권고함 ) 경구혹은국소혈관수축제, 또는비강내항히스타민제를 3-4일이내로단기간사용함으로써, 코막힘증상을빠르게해결하고비강내스테로이드제의치료효과를높일수있다. ( 근거수준 B, 권고를고려함 ) 약물치료에반응하지않는만성코막힘의경우, 하비갑개부피를감소시키기위한수술적치료를고려할수있다. ( 근거수준 B, 권고를고려함 ) 항히스타민제의경우지속적유지치료가간헐적치료에비해알레르기염증과증상조절에모두효과적이다 [64-66]. 지속적유지치료가간헐적치료보다삶의질과증상의개선에모두효과적이나의료비용이더높아비용효과분석에대한연구가필요하며, 장기간사용시안전성입증이필요하다 [67]. 약제안전성과부작용을고려하였을때, 혈뇌장벽을최소한으로통과하는 2세대항히스타민제를지속유지치료에권고한다 [67]. 비강내스테로이드제의효과는분무후최소 4-7일이후에나타나므로간헐적치료는적합하지않다 [68]. 계절성알레르기비염에서는꽃가루가비산하기 2-4주전부터끝날때까지지속적으로치료를유지할것을권고한다 [69]. 비강내스테로이드제와 2세대항히스타민제의장기간유지 항히스타민제는주로재채기, 코가려움증, 콧물등히스타민에의해매개되는증상에대해효과를보이나코막힘에대한효과는적은편이다 [71]. 비강내스테로이드제는코막힘을포함한알레르기비염의모든증상에대해가장효과적이다. 그러나심한코막힘증상을호소하는환자의경우하비갑개가크게비대되어있는경우가흔하며, 이로인해비강이완전히폐쇄되어있어비강내스테로이드제약물이점막에골고루분사되기어렵다. 또한비강내스테로이드제는치료시작후대개 5-7일이후에최대효과를나타내므로, 증상이심한환자의경우이기간동안의코막힘을해결하기위한다른치료방법이필요하다. 우선경구용또는국소혈관수축제를단기간 (3-4일이내 ) 알레르기비염내과적치료지침 189
J Korean Med Assoc 2017 February; 60(2):183-193 사용하여코막힘증상을해소하고, 비강내스테로이드제약 물이비강점막에골고루분포할수있도록도움을줄수있 Research-based Pharmaceutical Industry Association (grant no. NA14-00118). 다. 비강내항히스타민제는작용시간이매우빠르며, 코막힘 을효과적으로개선할수있다 [70]. 류코트리엔수용체길항제 역시다소코막힘개선효과가있는것으로보고되었다 [72]. 찾아보기말 : 알레르기비염 ; 가이드라인 ; 약물 ; 치료 알레르기비염이만성적으로지속됨에따라하비갑개조직 의비대및섬유화가진행되면, 약물치료에도불구하고호전되지않는만성코막힘을호소하게된다. 이경우하비갑개의부피를감소시키기위한수술치료를고려할수있다 [70,73]. 결론 알레르기비염의치료에있어, 적절한회피요법과함께 2세대항히스타민제, 비강내스테로이드제또는류코트리엔수용체길항제등을단독혹은병용하여사용할수있다. 비강내스테로이드제는전신흡수가거의없어시상하부- 뇌하수체축에영향을주지않으며, 소아의최종신장에영향을미치지않는다. 따라서 1년정도지속적으로사용하여도안전하다. 위의치료제들을사용하였을때조절되지않는알레르기비염에서경구스테로이드제를단기간사용할수있으나, 고용량스테로이드근주는권장하지않는다. 국소혈관수축제는의인성비염등의부작용을피하기위해일주일이내의짧은기간동안만사용할것을권장한다. 이러한알레르기비염치료의지속적유지여부는환자의특성에따라맞춤형으로결정하는것이바람직하며, 치료중감기, 중이염, 부비동염등이동반되었을때에는증상에따른대증적치료, 또는항생제를추가할수있다. 특히코막힘을심하게호소하는환자의경우, 증상을빠르게해소하기위해경구혹은국소혈관수축제, 비강내항히스타민제, 그리고수술적치료등을고려할수있다. Acknowledgement This study was supported by a grant of Korean ORCID Young Hyo Kim, http://orcid.org/0000-0002-3623-1770 Mi-Ae Kim, http://orcid.org/0000-0003-1253-6075 Hyeon-Jong Yang, http://orcid.org/0000-0002-7287-4300 Jeong-Hee Choi, http://orcid.org/0000-0002-0599-875x Dong-Kyu Kim, http://orcid.org/0000-0003-4917-0177 Young Yoo, http://orcid.org/0000-0003-3354-6969 Bora Lee, http://orcid.org/0000-0002-6322-5712 Bong-Seong Kim, http://orcid.org/0000-0002-3562-3916 Won-Young Kim, http://orcid.org/0000-0003-1767-9999 Jeong Hee Kim, http://orcid.org/0000-0002-7054-8552 So Yeon Park, http://orcid.org/0000-0002-0236-7610 Woo Yong Bae, http://orcid.org/0000-0001-5578-0225 Keejae Song, http://orcid.org/0000-0002-8817-8537 Min-Suk Yang, http://orcid.org/0000-0002-9861-0530 Sang Min Lee, http://orcid.org/0000-0002-9568-2096 Young-Mok Lee, http://orcid.org/0000-0003-4039-0456 Hyun Jong Lee, http://orcid.org/0000-0003-0849-0684 Jae-Hong Cho, http://orcid.org/0000-0002-2407-4894 Hye Mi Jee, http://orcid.org/0000-0003-0128-065x Yang Park, http://orcid.org/0000-0003-1058-5383 Young-Il Koh, http://orcid.org/0000-0002-5100-9473 REFERENCES 1. Nurmatov U, van Schayck CP, Hurwitz B, Sheikh A. House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review. Allergy 2012;67:158-165. 2. Terreehorst I, Hak E, Oosting AJ, Tempels-Pavlica Z, de Monchy JG, Bruijnzeel-Koomen CA, Aalberse RC, Gerth van Wijk R. Evaluation of impermeable covers for bedding in patients with allergic rhinitis. N Engl J Med 2003;349:237-246. 3. Custovic A, Murray CS, Gore RB, Woodcock A. Controlling indoor allergens. Ann Allergy Asthma Immunol 2002;88:432-441. 4. Kilburn S, Lasserson TJ, McKean M. Pet allergen control measures for allergic asthma in children and adults. Cochrane Database Syst Rev 2003;(1):CD002989. 5. Bjornsdottir US, Jakobinudottir S, Runarsdottir V, Juliusson S. The effect of reducing levels of cat allergen (Fel d 1) on clinical 190 대한의사협회지
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