Everything You Ever Cared to Know About

Allergic RhinitisNneoma Nwachuku, PGY2

April 16, 2015

“MAY I REMIND YOU…It’s just your career”

Burden of Allergic Rhinitis

• Affects 10 to 30 percent of people in the United States

• 2.4 billion dollars spent on prescription and over-the counter medication per year

• Two million• lost school days per year; six million lost

workdays per year

A. Allergic Rhinitis1. Describe the signs and symptoms of allergic rhinitis.

(MK)

2. Obtain a history and perform a targeted physical examination to diagnose allergic rhinitis. (PC, ICS, P) • Primary and Preventive Ambulatory Health Care 21

3. Describe the differential diagnosis of allergic rhinitis. (MK)

4. Counsel patients about the effect of environmental allergens and initiate basic medical treatment for allergic rhinitis. (P, PC, ICS)

Rhinitis

• Rhinitis is an inflammation of the nasal mucosa

• Allergic rhinitis is an immunoglobulin E–mediated disease– Thought to occur after exposure to indoor and

outdoor allergens such as dust mites, insects, animal danders, molds, and pollens

Rhinitis

• Important to distinguish allergic rhinitis from other forms of rhinitis because the treatments for one may not be as effective for the other– Key is the history and

physical exam– Extensive differential

diagnosis

Differential Diagnosis

Side Note

• Hormonal causes include – Pregnancy – improves

after delivery– OCPS– Hypothyroidism

• Drug induced– ACE-I– Methyldopa– Prazosin– Beta-blockers– Thorazine– Tocial nasal

decongestants– Aspirin– NSAIDs

Clues from History that Suggest Allergic Rhinitis

• Identifiable triggers• Seasonal variations• Constitutional symptoms (headache, malaise,

and fatigue• Onset at a young age (80% start before the

age of 20)• Family history of allergic symptoms or asthma

Three Types of Allergic Rhinitis

• Seasonal– Tree, grass, and weed pollens, mold spores

• Perennial– Mold spores, indoor allergens

• Occupational– Laboratory animals, grains, coffee beans, wood

dust– Distinguish from irritants – tobacco smoke, cold

air, formaldehyde, and hair spray

Signs and Symptoms

• Excessive mucous production

• Congestion• Sneezing• Watery Eyes• Nasal pruritis• Ocular pruritis• Systemic symptoms

– Asthma– Eczema– Chronic sinusitis

Physical Exam FindingsGeneral Constitutional symptoms suggest allergic rhinitis. Mouth versus nose breathing is a symptom of chronic congestion.

Eyes Allergic shiners (i.e., dark areas under the eyes) suggest allergic rhinitis.Conjunctivitis suggests allergic rhinitis.

EarsAir fluid levels can suggest chronic congestion.

Nose A deviated or perforated septum and polyps are structural causes of rhinitis. Purulent or bloody discharge can be a sign of sinusitis. Fiberoptic visualization can detect structural causes of rhinitis.

Physical Exam FindingsMouth Enlarged tonsils and pharyngeal postnasal discharge are associated with nonallergic rhinitis.

NeckLymphadenopathy suggests an infectious cause of rhinitis.

Chest Allergic or atopic disease (e.g., asthma) supports the diagnosis of allergic rhinitis.

SkinAllergic or atopic disease (e.g., eczema) supports the diagnosis of allergic rhinitis.

Diagnostic Testing

• Percutaneous skin test• Allergen-specific immunoglobulin E (IgE)

antibody test• Less commonly used– Nasal provocation testing– Nasal cytology– Nasolaryngoscopy

Oral Antihistamines

• Stabilize and control nasal and ocular symptoms

• Less effective with nasal congestion (compared to intranasal corticosteroids)

• Onset of action is 15-30minutes

Oral Antihistamines

• First generation medications (e.g. Benadryl) had significant side effects– Excessive drowsiness,

impaired school and work performance

• Second generation includes:– Desloratidine (Clarinex);

Fexofenadine (Allegra), Loratidine

– Do not easily cross blood-brain barrier

Intranasal Corticosteroids

• Mainstay of treatment for allergic rhinitis

• Decreasing influx of inflammatory cells, inhibit release of cytokines

• Note: only Budesonide (Rhinocort) is category B

Intranasal Corticosteroids

• Side effects: Headache, epistaxis, nasal dryness; restrict growth in children

Nasal Decongestants

• Acts on adrenergic receptors and produce local vasoconstriction

• Long-term use leads to impaired mucociliary function; rebound congestion

Intranasal Anticholinergics

• Such as Atrovent – relief of excessive rhinorrhea

• BID dosing

For Severe to Persistent Symptoms Consider Addition of:

• Leukotriene Receptor Antagonist (Singulair)– Minimal improvement

• Intranasal Cromolyn– Inhibits degranulation of mast cells– Decreased effectiveness

• Immunotherapy– Providing a small amount of allergen administered

over an extended period of time with a maintenance period

Thanks…and any questions?