Allergic Rhinitis & Asthma

Rhinitis

Characterised by 1 or more of the following:

Nasal congestion

Rhinorrhoea (anterior & posterior)

Sneezing

Itch

Allergic rhinitis – 50-70%

Non-allergic rhinitis

Infectious – viral (98%), bacterial

Drug-induced

ACE-inhibitor, NSAIDs

Rhinitis medicamentosa

Non-allergic rhinitis with eosinophilia syndrome (NARES)

Perennial symptoms, >20% eosinophils on nasal smears. Occasionally reduced sense of smell

Vasomotor (idiopathic)

Chronic nasal symptoms not immunologic or infectious in origin.

Occupational

Other

Food/alcohol, hormonal, atophic

Conditions that mimic rhinitis

Nasal polyps

Anatomical abnormalities

Cleft palate

Nasal septal deviation

Nasal tumours

Hypertrophy of adenoids/nasal turbinates

Trauma/foreign body

Laryngopharyngeal reflux

CSF rhinorrhoea

Ciliary dysfunction

Allergic Rhinitis

Affects 1 in 5 children in Australia/NZ

Prevalence of AR trebled over last 3 decades in UK serial

health surveys

Can lead to impaired concentration, impaired sleep,

reduced work/school performance

Typically requires a few years of allergen exposure to

develop

Risk Factors

Family history of atopy

Male

Birth during pollen season

Firstborn

Early use of antibiotics

Maternal smoking in first year of life

Exposure to indoor allergens eg. House dust mite

Pathophysiology of AR

Classification of AR

History

Nasal symptoms

Sneezing, itchy nose/palate

Rhinorrhoea, nasal obstruction

Colour: clear, purulent, blood

Unilateral or bilateral

Mouth-breathing, snoring, nasal voice, anosmia

Eye symptoms

Itch, hyperaemia, watering, periorbital oedema

Timing & frequency

Seasonal vs perennial, triggers

Severity

Troublesome symptoms

Sleep disturbance

Functional impact on school/work

Asthma

Examination

Pale, oedematous nasal turbinates

Excoriation of external nares

Transverse nasal crease

Allergic shiners (infraorbital oedema & darkening)

Dennie-Morgan lines (accentuated folds below lower eyelids

High arched palate, mouth breathing

Dental malocclusion

Investigations

Allergens tested dependent on basis of age, history & environment

Skin prick testing

Specific IgE (in vitro testing)

Perennial – HDM

Seasonal – grasses

Management

1. Allergen Avoidance

2. Pharmacotherapy

3. Immunotherapy

Allergen Avoidance

House dust mite avoidance

HDM allergen contained within its body parts & faecal particles

HDM feed on skin flakes contained within dust

Greatest exposure usually in sleep

Allergen-impermeable covers for mattresses, duvets & pillows

Remove sheepskin or woolen underlay

Remove reservoirs (toys, clothing, furnishings, drapes)

Weekly:

Wash all bed linen in hot water (> 60 °C)

Vacuum carpet

? Acaricide sprays

Allergen Avoidance

Pollen Avoidance

Avoid activities with high exposure to pollens

Avoid going outdoors before midday, on windy days or after thunderstorms

Avoid mowing the lawn

Wear sunglasses

Shower after arriving home

Home

Keep windows closed

Remove weeds or trees outside bedroom if sensitive

Keep pets outside

Oral Antihistamines

Antihistamines

Block H1 receptor

Effective against histamine-mediated symptoms

Second generation AH preferred

1st gen: sedation, anticholinergic effects

Paediatric suspensions

Cetirizine (zyrtec) > 12 mo

Loratadine (Claratyne) > 12 mo

Desloratadine (Aerius) > 12 mo; > 6mo for hives

Decongestants

Α-adrenenergic agonists = Pseudoephedrine &

phenylephrine

Can reduce nasal congestion

Side effects: insomnia, irritability, palpitations

Use with caution in young children

SHORT-TERM or intermittent/episodic therapy

NOT for regular daily use (> 4 days) due to risk of rhinitis

medicamentosa

Intranasal Steroids

Act by suppressing inflammation at multiple points in inflammatory cascade

Most efficacious drug available for both allergic & non-allergic rhinitis

Effective against both nasal congestion & ocular symptoms

Superior to antihistamines

Onset of action: 7-8 hours after dosing, but maximum efficacy takes up to 2 weeks

PRN use may not be as effective as continuous use

Local side effects typically minimal

Nasal irritation, bleeding

Rare: nasal septal perforation

Intranasal Steroids

Immunotherapy

First introduced in treatment of respiratory allergy since

1911

Gradual administration of increasing quantities of an

allergen extract to an allergic subject

Ameliorates the symptoms associated with subsequent

exposure to the causative allergen

Subcutaneous or sublingual administration

Immunotherapy

Indications:

History indicating exposure to particular allergen precipitates symptoms

Documented sensitivity to aeroallergen

Further exposure unavoidable or only partially avoidable

An effective allergen extract is available

Poor response to previous pharmacotherapy for allergic rhinitis

Contraindications

Unstable/severe asthma

Concomitant illness

Pregnancy

Beta-blocker treatment

Poor adherence

Mechanism of Immunotherapy

Immunotherapy

SCIT SLIT

Administration Subcutaneous

injections

Drops/tablets held for

2 minutes

Setting Doctor’s office Home

Maintenance 4-weekly doses 3x/week or weekly

doses

Cost $250-

300/allergen/year

$600-

750/allergen/year

Systemic AE 0.05 – 3.2% of doses 0.06% of doses

Fatalities 1 in 2-2.5 million None reported

Efficacy Beneficial for adults

with AR & asthma.

Inconclusive for

children (few trials)

Beneficial for AR in

adults & children.

When to refer?

Allergy Specialist

Significant symptoms despite compliance with regular

intranasal corticosteroids >3-6/12

Ensure correct technique

Asthma & AR

‘one airway, one disease’

AR & asthma frequently co-exist

75% patients with asthma have AR

In rhinitis patients, asthma prevalence 10-40%

Patients without rhinitis, asthma prevalence < 2%

AR increases risk of developing asthma by 2-3 times

Increases risk of asthma attacks, GP & emergency visits &

hospitalisations for asthma

Higher asthma drug costs & increased work absence

Treating AR can reduce asthma-related emergency

department visits & hospitalisations

Treatment of rhinitis & asthma

using a single approach

Oral H1-antihistamines are not recommended, but not

contraindicated in the treatment of asthma.

Intranasal steroids are at best moderately effective in

asthma.

may be effective in reducing asthma exacerbations and

hospitalizations.

The role of intrabronchial steroids in rhinitis unknown.

Montelukast is effective in the treatment of allergic rhinitis

and asthma in patients over 6 years of age.

Subcutaneous immunotherapy is recommended in both rhinitis

and asthma in adults

Summary

Rhinitis – allergic & non-allergic

Look up the nose!

Mild/intermittent: oral antihistamines

Moderate/severe/persistent: IN corticosteroids (use regularly)

If failed treatment, consider referral for possible immunotherapy

Asthma

Majority have rhinitis

Always ask about and optimise rhinitis treatment in patients with asthma