Allergic and Non-Allergic RhinitisAllergic and Non-Allergic Rhinitis

ObjectivesObjectives

• Who cares?

• Why?

• What else could it be?

• Gazoontite

• Can’t we just give them Allegra and Flonase?

• Do they really need an Allergy consult?

Allergic Rhinitis: EpidemiologyAllergic Rhinitis: Epidemiology

• In US, affects 80 million people annually– 10-30% adults affected– Up to 40% children

• 80% cases develop before age 20

• In childhood, males > females

• In adulthood, males = females

• Prevalence is increasing

Allergic Rhinitis: The ImpactAllergic Rhinitis: The Impact

• 28 million restricted activity days each year

• 2 million missed school days each year

• 3.4 million missed work days each year

• Decreased productivity in US labor force– $2.4 billion for men– $1.4 billion for women

• Estimated $3 billion per year on Rx meds

Rhinitis: The DefinitionRhinitis: The Definition

• Inflammation of the membranes lining the nose characterized by:– Nasal congestion– Rhinorrhea – Sneezing– Pruritis– Postnasal drainage

Rhinitis: ClassificationRhinitis: Classification

• Allergic– ~ 50% cases– IgE-mediated reaction due to exposure to

airborne allergens– Seasonal, perennial, episodic, occupational

• Non-allergic– Infectious– Non-infectious

• Vasomotor, atrophic, hormonal, exercise, drug, reflex-induced, occupational

Allergic Rhinitis: Risk FactorsAllergic Rhinitis: Risk Factors

• Family history of atopy

• Serum IgE > 100 IU/ml before 6 yo

• Higher socioeconomic class

• Non-Caucasians

• First born children

• Exposure to cigarette smoking in infancy

• Exposure to indoor allergens

• Presence of positive allergy prick skin tests

 

Re-exposureRe-exposure

SensitizationSensitization

Allergic Rhinitis: PathophysiologyAllergic Rhinitis: Pathophysiology

• Early allergic response, within minutes– Mast cell degranulation

• Preformed: Histamine, tryptase, chymase• Newly formed: Prostaglandins, cysteinyl leukotrienes

– Vascular leakage – edema, watery rhinorrhea– Exocytosis of mucosal glands– Vasodilation – nasal obstruction– Stimulation of sensory nerves – nasal itch,

congestion– Systemic reflexes – sneezing paroxyms

Allergic Rhinitis: PathophysiologyAllergic Rhinitis: Pathophysiology

• Late phase response– Within 4-8 hours – Inflammatory cells attracted - basophils,

eosinophils, neutrophils, mononuclear cells, T helper lymphocytes

– Nasal congestion predominates– Sneezing, rhinorrhea, pruritis

Symptoms of Allergic RhinitisSymptoms of Allergic Rhinitis

Classic• Sneezing paroxysms• Nasal pruritis• Nasal congestion• Clear rhinorrhea• Palatal itching

Associated• 20% asthma sx• Post nasal drip• Itchy, watery eyes• Ear fullness, popping• Itchy throat• Sinus pressure• Mouth breathing,

snoring

PrimingPriming

• Exposed to allergen for days to weeks

• Significant inflammation – Increase numbers of mast cells– Upregulation of IgE receptors and surface

bound IgE on mast cells– Nonspecific nasal hyperreactivity– Influx of eosinophils, other inflammatory cells

• As allergy season progresses, 10-100 fold less allergen needed to cause sx

Progression of Symptoms During Progression of Symptoms During Allergy SeasonAllergy Season

• Symptoms related to infiltration of inflammatory cells– Mucus hypersecretion– Tissue edema– Goblet cell hyperplasia– Tissue damage

• Primed mast cells• Role of histamine diminishes• Antihistamines less effective

Which plant is more allergenic?

Seasonal Allergic Rhinitis (SAR)Seasonal Allergic Rhinitis (SAR)

• Trees - Spring

• Grasses - Summer

• Weeds - Fall

• Outdoor molds – Summer and Fall

Perennial allergic rhinitis (PAR)Perennial allergic rhinitis (PAR)

• Usually indoor allergens– Dust mites– Cockroach– Perennial molds– Animal danders

• Nasal congestion and post nasal drip may predominate

Associated ConditionsAssociated Conditions

• Asthma

• Sinusitis

• Otitis media

• Nasal polyposis

• Lower respiratory tract infections

• Dental occlusions

Allergic Rhinitis and its Impact on Allergic Rhinitis and its Impact on Asthma (ARIA)Asthma (ARIA)

"One airway, one disease "

Bousquet J. et al. JACI 2001;108:S147-334.Bousquet J. et al. JACI 2001;108:S147-334.

ARIA “One airway, one disease”ARIA “One airway, one disease”

• Rhinitis and asthma are co-morbidities – Linked by epidemiologic, pathologic, and physiologic

characteristics

• AR considered a risk factor for asthma• Patients with AR should be screened for asthma

and vice versa• Combined strategy to treat upper and lower

airway disease• New classification system for AR• Stepwise therapeutic approach

Moderate-severe

one or more items. abnormal sleep. impairment of daily

activities, sport, leisure. abnormal work and

school. troublesome symptoms

Persistent . ≥ 4 days per week . and ≥ 4 weeks

Mild normal sleep& no impairment of daily

activities, sport, leisure

& normal work and school

& no troublesome symptoms

Intermittent

. < 4 days per week

. or < 4 weeks

ARIA ClassificationARIA Classification

in untreated patients

Non-Allergic Rhinitis (NAR)Non-Allergic Rhinitis (NAR)

• Sporadic or persistent perennial rhinitis sx• Not IgE-mediated• Infectious• Hormonal• Vasomotor• Non-allergic rhinitis with eosinophilia (NARES)• Occupational• Gustatory• Drug-induced

Non-Allergic RhinitisNon-Allergic Rhinitis

• Vasomotor rhinitis– Variable sx, nasal obstruction and rhinorrhea– Provoked by nonspecific irritant stimuli– Cold dry air, changes in relative humidity– Strong odors, tobacco smoke, dust, fumes– Alcohol, spicy foods, bright lights

• Food allergy rarely presents with rhinitis alone

Non-Allergic RhinitisNon-Allergic Rhinitis

• Drug induced rhinitis– Nasal congestion and/or rhinorrhea– Antihypertensives, OCPs, NSAIDs, Viagra

• Hormonal rhinitis – Hormone induced intranasal vascular

engorgement– Nasal congestion and/or hypersecretion– Pregnancy, conjugated estrogens, OCPs,

hypothyroidism

Non-Allergic RhinitisNon-Allergic Rhinitis

• Occupational rhinitis– Sneezing, nasal discharge and/or congestion– Exposure to airborne agent in workplace– Sx improve away from workplace– Non IgE mediated - irritant, cold air, chemical– IgE mediated – animals, grain, wood dusts– Frequently co-exists with occupational asthma

Non-Allergic RhinitisNon-Allergic Rhinitis

• Rhinitis medicamentosa– > 5-10 days of topical nasal decongestant use– Rebound nasal congestion after d/c– Hypertrophy of nasal mucosa– Downregulation of nasal mucosal alpha-

adrenergic receptors

Other Conditions to ConsiderOther Conditions to Consider

• Anatomic abnormalities• Benign and malignant tumors• CSF leak – refractory clear rhinorrhea• Atrophic rhinitis

– Elderly patient, nasal congestion, constant bad smell in nose (ozena), thick crusts

• Systemic diseases– Uremia, diabetes– Wegener’s, sarcoidosis, infections causing

granulomatous nasal lesions

Rhinitis HistoryRhinitis History

• Frequency, duration, and severity of Sx

• Provoking or aggravating triggers

• Environment – home, job, school

• Current/past treatments

• PMH, incl trauma

• FH, incl atopic disease

• Review of systems

Physical ExaminationPhysical Examination

• Allergic facies (shiners, nasal crease)

• Allergic salute

• Injected conjunctiva with tearing

• Nose wrinkling, grimacing, or other facial mannerisms

Physical Exam cont.Physical Exam cont.

• Long and narrow facies, high cheek bones• Injected sclera, edematous eyelids• Nasal mucosa, turbinate size, polyps• Nasal discharge, post-nasal drainage• Posterior pharyngeal cobblestoning• TM mobility, retraction, effusion• Other organ systems: eczema, wheezing

Testing for Specific IgETesting for Specific IgE

• Allergen-specific IgE • In vivo testing

– Prick skin tests– Trees, grasses,

weeds, molds, dust mite, cat, dog, cockroach

• In vitro testing– RAST

ManagementManagement

• Allergen Avoidance

• Pharmacotherapy

• Immunotherapy

AvoidanceAvoidance

• Minimize exposure to outdoor allergens– Decrease exposure during high pollen counts– Keep house and car windows closed, use A/C– Do not dry laundry outdoors– Make the bed daily– Do not lay on a bed in clothes worn outside– Hire lawn service– Keep the pets out of the bedroom

Dust Mite AvoidanceDust Mite Avoidance

• Encase bedding in allergen-impermeable covers• Wash sheets in water >130° F every 7-10 days• Remove stuffed animals, down pillows, draperies,

upholstered furniture, rugs from bedrooms• Maintain humidity <50%• Replace curtains with blinds• Vacuum weekly

Avoidance Measures cont.Avoidance Measures cont.

• Indoor animal allergens– Get rid of the pet– Keep animals away from bedrooms – Bathe pet weekly and brush frequently– Vacuum with HEPA filter– Room air cleaners

Environmental Controls cont.Environmental Controls cont.

• Indoor molds and pests– Exterminate– Decrease dampness– Improve ventilation– Increase exposure to sunlight– Use weak bleach solution to wash

baseboards and walls

AntihistaminesAntihistamines

• Competitively bind to H1 receptor

• Prevent histamine release

• Reduce sneezing, pruritis, and rhinorrhea

• Little effect on nasal congestion

First generation antihistaminesFirst generation antihistamines

• Eg: diphenhydramine (Benadryl), hydroxyzine (Atarax), chlorpheniramine (Chlor-Trimetron)

• Highly lipophilic, cross blood-brain barrier• Sedation, somnolence, incoordination• Anticholinergic side effects• Legally considered “under the influence of

drugs” in many states• Evening doses impair performance and

cognition in morning without the appreciation of sedation

Second generation Second generation antihistaminesantihistamines

• Eg., fexofenadine (Allegra), cetirizine (Zyrtec), loratadine (Claritin)

• May inhibit release of mast cell and basophil mediators

• Prolonged duration of action

• Lipophobic, poor penetration of CNS

• Minimal, if any sedative effects

They’re not all the sameThey’re not all the same

• Loratadine – Metabolized through cytochrome P450 system– Half life prolonged in elderly pts, co-admin with macrolide abx or

imidazole antifungals

• Cetirizine– Metabolite of hydroxyzine– Excreted unchanged in urine and feces

• Fexofenadine– Metabolite of terfenadine– Only 5% metabolized– Co-admin with ketoconazole and erythromycin increase GI

absorption, increased plasma levels – No sedative effects seen at doses up to 480 mg/day

Fexofenadine vs CetirizineFexofenadine vs Cetirizine

0

2

4

6

8

10

Fexofenadine Cetirizine

%%

PatientsPatients

p=0.018

17/42118/209

Howarth et al. JACI 1999.

Incidence of Drowsiness + FatigueIncidence of Drowsiness + Fatiguep= 0.018

Intranasal AntihistamineIntranasal Antihistamine

• Azelastine hydrochloride (Astelin)– 0.1% aqueous solution– 2 sprays/nostril twice daily– Onset of action 3 hours– Efficacy equal to oral antihistamines– Improves rhinitis symptoms incl congestion– Bitter taste, somnolence

Intranasal CorticosteroidsIntranasal Corticosteroids

• Most effective med at controlling rhinitis sx

• First line for moderate-severe SAR/PAR– Reduce inflammation– Mild vasoconstriction– Suppress late phase response

• Adverse effects– No evidence of atrophy– Local irritation, epistaxis, septal perforation

Leukotriene AntagonistsLeukotriene Antagonists

• Decrease vascular permeability

• Level of efficacy comparable to antihistamines

• FDA approved for AR and asthma

Oral and Nasal DecongestantsOral and Nasal Decongestants

• Stimulate α-adrenergic receptors

• Reduce nasal congestion

• Side effects: elevated BP, nervousness, insomnia, loss of appetite, palpitations, urinary retention

• Topical preparation < 3-5 days

Intranasal AnticholinergicsIntranasal Anticholinergics

• Ipratropium Nasal (Atrovent)

• Effective at reducing rhinorrhea

• 0.03% and 0.06%– Allergic/nonallergic perennial rhinitis

• 0.06% – Common cold

Nasal Saline LavageNasal Saline Lavage

• Lavage with nasal irrigator or bulb syringe

• Hydrates mucosa

• Removal of mucous and debris

• Improves sx of rhinitis

Intranasal CromolynIntranasal Cromolyn

• Prevents mast cell degranulation

• Helpful for sneezing, rhinorrhea, pruritus

• Not helpful for congestion

• Protective effect lasts 4-8 hours

• Use as pre-treatment prior to exposure

Treatment of allergic rhinitis (ARIA)AllergicAllergic Rhinitis and its Impact on Asthma

mildintermittent

mildpersistentmoderate

severeintermittent

moderatesevere

persistent

allergen and irritant avoidance

immunotherapy

intra-nasal decongestant (<10 days) or oral decongestant

local cromone intra-nasal steroid

oral or local non-sedative H1-blocker

Aeroallergen Immunotherapy (AIT)Aeroallergen Immunotherapy (AIT)

• Immunomodulation

• Candidates– Continuous pharmacotherapy required– Continued moderate-severe symptoms

despite maximal medical therapy– Multi-season symptoms – Adverse effects of pharmacotherapy

Evidence Based MedicineEvidence Based Medicine

• Trees (birch, mountain cedar)

• Grasses (timothy, orchard, rye, bermuda)

• Weeds (ragweed)

• Dust mites (D. pteronyssinus)

• Molds (Cladosporium, Alternaria)

• Animals (cat)

Immunotherapy cont.Immunotherapy cont.

• Can take several months to work• Is specific against allergens used in AIT• Treatment for 3-5 years• Relative contraindications – uncontrolled

asthma, ß-blocker therapy, co-morbid conditions

• Risk for anaphylaxis

Allergy ReferralsAllergy Referrals

• Clarification and identification of allergic/nonallergic triggers

• Unsatisfactory management of symptoms– Suboptimal control– Adverse effects

• Consideration for immunotherapy• Moderate/severe persistent symptoms • Complications of rhinitis symptoms• Patient request for further evaluation• Education/counseling

Internet SitesInternet Sites

• National Allergy Bureau – daily pollen count– www.aaaai.org/nab

• American Academy of Allergy, Asthma, and Immunology– www.aaaai.org

• American College of Allergy, Asthma, and Immunology– www.acaai.org