ANNALS Allergic Rhinitis

7/29/2019 ANNALS Allergic Rhinitis

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Allergic Rhinitis

Diagnosis page ITC4-2

Treatment page ITC4-6

Practice Improvement page ITC4-14

CME Questions page ITC4-16

Section EditorsChristine Laine, MD, MPHDavid Goldmann, MD

Science WriterChristine Bahls

The content ofIn the Clinic is drawn from the clinical information and

education resources of the American College of Physicians (ACP), including

PIER (Physicians Information and Education Resource) and MKSAP (Medical

Knowledge and Self-Assessment Program). Annals of Internal Medicine

editors develop In the Clinic from these primary sources in collaboration with

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MKSAP provide expert review of the content. Readers who are interested in these

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resources referenced within each issue ofIn the Clinic.

The information contained herein should never be used as a substitute for clinical

judgment.

2007 American College of Physicians

wnloaded From: http://annals.org/ by Jose Roel on 10/04/2012


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Which symptoms and signsshould prompt clinicians toconsider AR?Clinicians can often make the di-agnosis of AR from the patientshistory (5). The symptoms of ARinclude sneezing, rhinorrhea,postnasal drainage, nasal conges-tion, and sometimes loss of sense

of smell. Many patients also com-plain of itchy, watery eyes. Thehistory should be used to estimatethe frequency and severity of dis-ease and how it affects the pa-tients quality of life. Validatedquestionnaires are also available tohelp measure these variables (seePractice Improvement).

Allergic rhinitis often first devel-ops in childhood or in the teen-

age years (6). Personal and familyhistories are often positive for ARand other atopic diseases, such aseczema and asthma (7).

It is important to differentiate be-tween seasonal and perennial AR.As the nomenclature implies, sea-sonal AR is most bothersome at

certain times of the year whenparticular allergensusually spe-cific tree and grass pollensarepresent in the environment.Perennial AR tends to causesymptoms on an ongoing basiswhenever the patient is exposed tomore common allergens, such asmold or dust mites.

Nasal obstruction, smell distur-bance, chronic sinusitis, otitis me-dia, and asthma are more com-mon in perennial than in seasonalAR (8). Eye symptoms, includingpruritus and conjunctival irrita-tion, are more common in sea-sonal AR than in perennial AR.Both types of AR can presentwith malaise, weakness, and fa-tigue (7) (Table 1).

The history should be used to tryto identify triggers for AR. Thepatient should be asked not onlyabout specific symptoms and sea-sonal occurrence but also abouthome and workplace environ-ments and specific events; for ex-ample: What changes, if any, have

1. Bauchau V, DurhamSR. Prevalence andrate of diagnosis ofallergic rhinitis. EurRespir J. 2004;24:758-64. [PMID: 15516669]

2. Arbes SJ Jr, Gergen PJ,Elliott L, Zeldin DC.

Prevalences of posi-tive skin test respons-es to 10 common al-lergens in the USpopulation: resultsfrom the Third Na-tional Health and Nu-trition ExaminationSurvey. J Allergy ClinImmunol.2005;116:377-83.[PMID: 16083793]

3. Fineman SM. The bur-den of allergic rhini-tis: beyond dollarsand cents. Ann Aller-gy Asthma Immunol.2002;88(4 Suppl 1):2-7. [PMID: 11991546]

4. Crystal-Peters J,

Crown WH, GoetzelRZ, Schutt DC. Thecost of productivitylosses associatedwith allergic rhinitis.Am J Manag Care.2000;6:373-8. [PMID:10977437]

5. Slavin RG, ReismanRE. Expert Guide toAllergy and Im-munology. Philadel-phia: American Col-lege of Physicians;1999:23-40.

2007 American College of Physicians ITC4-2 In the Clinic Annals of Internal Medicine 3 April 2007

Allergic rhinitis (AR), an inflammatory disease of the upper airways,is one of the most common problems seen in outpatient practice.Although sometimes trivialized by patients and physicians, AR is a

major source of morbidity. According to the National Health InterviewSurvey, 18.6 million adults and 6.7 children were diagnosed with hayfever in 2004 (www.cdc.gov/nchs/fastats/allergies.htm), and the NationalAmbulatory Medical Care Survey showed that there were 14 millionphysician office visits for AR that year (www.cdc.gov/nchs/fastats/allergies.htm). Exact prevalence figures for AR are difficult to determine.

A recent study estimated that it affects 23% of the population of WesternEurope (1), and data from the third National Health and Nutrition Ex-amination Survey (NHANES III) showed that about 55% of all U.S.citizens test positive to at least 1 allergen, a significant increase over theprevalence in the previous survey (2).

In addition to its effect on quality of life, AR imposes a significant eco-nomic burden on society. With an approximate 20% prevalence, it carriesdirect and indirect medical costs associated with diagnosis and treatmentof about $2 billion a year (3). This figure more than doubles when indi-rect costs related to absence from work and decreased productivity atwork largely due to the use of sedating antihistamines are added (3, 4).

Diagnosis



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occurred at home or at work? Hasthe patient recently moved or trav-eled? Did the patient visit a friendwho has a pet? Can the patientidentify any place, activity, or ex-posure that makes the rhinitisworse?

Triggers that may not be true al-

lergens include irritating toxins,hormones, drugs, tobaccosmoke, cold air, and hairspray(7); these triggers can causesymptoms in patients with ARas well as in others who do nothave allergies. Persons in the lat-ter group may have nonallergicnoninfectious rhinitis.

Patients with AR frequently treatthemselves either by avoiding sit-uations that trigger symptoms orby using over-the-counter anti-histamines and decongestants asneeded. Estimating the severity ofdisease and determining what hasor has not been useful in the pastallows for optimum patient man-agement. It is also important toask about preexisting conditionsand associated treatments. Suchconditions as hypertension or

glaucoma limit the use of drugsthat are effective against AR, in-cluding oral decongestants orantihistamines.

On examination, the nasal mu-cosa is frequently edematous andpale but can be normal if the pa-tient is asymptomatic. The nasal

passages may be partially or com-pletely obstructed. The patientshould be evaluated for a deviatednasal septum, polyps, and ulcera-tion. Injection and watering ofthe eyes suggest allergic conjunc-tivitis. Examination of the phar-ynx may reveal enlarged tonsils orpharyngeal injection from post-nasal drip.

Look for otitis, sinus tenderness,and wheezing. Between 20% and40% of patients with AR haveasthma (9), and chronic sinusitishas been associated with AR in40% to 80% of adult patients (10).Fever should be absent and, ifpresent, suggests an upper respira-tory infection.

What other similar conditionsshould clinicians consider inpatients with symptomssuggestive of AR?

Nasal symptoms in patients withAR are nonspecific. Although asimple upper respiratory infectionand AR are usually easily differ-entiated by history, more pro-longed symptoms in a patientwith a history of allergies may be

more difficult. It is important tolook for sinusitis in patients withpurulent rhinorrhea, facial pain,and sinus tenderness. In fact, ARoften precedes development ofrecurrent or chronic sinusitis be-cause the accompanying nasalobstruction and inflammationinterrupts normal mucociliary

6. Schoenwetter WF. Al-lergic rhinitis; epi-demiology and natu-ral history. AllergyAsthma Proc. 2000;21:1-6. [PMID:10748945]

7. Quillen M, Feller DB.Diagnosing Rhinitis:

Allergic vs. Nonaller-gic. Am Fam Physi-cian. 73:1-6. [PMID:16719251]

8. van Cauwenberge P,Bachert C, Passalac-qua G, et al. Consen-sus statement on thetreatment of allergicrhinitis. EuropeanAcademy of Allergol-ogy and Clinical Im-munology. Allergy.2000;55:116-34.[PMID: 10726726]

9. Palma-Carlos AG,Branco-Ferreira M,Palma-Carlos ML. Al-lergic rhinitis andasthma: more similar-

ities than differences.Allerg Immunol(Paris). 2001; 33:237-41. [PMID: 11505808]

10. Spector SL, Bern-stein IL, Li JT, BergerWE, et al. PracticeParameters for theDiagnosis and Man-agement of Sinusitis- J. Allergic Rhinitis. JAllergy Clin Im-munol. 1998;102:S107-44. [PMID:9847450]

2007 American College of PhysiciansITC4-3In the ClinicAnnals of Internal Medicine3 April 2007

Table 1. Characteristics of Allergic Rhinitis*

Characteristic Seasonal Perennial

Obstruction Variable Always, predominantSecretion Watery, common Seromucous, postnasal drip, variableSneezing Always VariableSmell disturbance Variable CommonEye symptoms Common RareAsthma Variable CommonChronic sinusitis Occasional Frequent

* Data from reference 8.



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clearance, leading to retention ofmucopurulent secretions withinthe sinuses (10).

It is also important to considerother nonallergenic, noninfectious,and mechanical causes of rhinitisin the differential diagnosis, in-cluding hormone changes in preg-

nancy and hypothyroidism causingnasal congestion. Vasomotorrhinitisthe cause of which isstill unknownmay be a hyper-sensitive response to a dry atmos-phere, air pollutants, spicy foods,alcohol, emotions, or some med-ications. Overuse of topical nasaldecongestants containing oxymeta-zoline or phenylephrine can pro-duce refractory nasal congestionand, consequently, rhinitis medica-mentosa. Other medications thatcan cause rhinitis include an-giotensin-converting enzyme in-hibitors, chlorpromazine, aspirinand other nonsteroidal anti-in-flammatory drugs, and cocaine.

Careful examination of the noseand rhinoscopy will help excludemechanical causes of rhinitis (5),including nasal polyposis. A devi-

ated nasal septum may cause uni-lateral symptoms. Foreign objects,particularly in children, may alsobe a cause.

Cystic fibrosis, although lesscommon, is also in the differen-tial diagnosis. A sweat chloridetest should be considered if ayoung patient presents with nasalpolyposis or chronic sinusitis.Other rare disorders that mimic

AR include sarcoidosis, Wegenergranulomatosis, and cerebral fluidrhinorrhea.

Which diagnostic tests areuseful in confirming thediagnosis of AR?

Diagnosis of seasonal ARcan usually be made clinically.

11. Gendo K, Larson EB.Evidence-based di-agnostic strategiesfor evaluating sus-pected allergic rhini-

tis. Ann Intern Med.2004;140:278-89.[PMID: 14970151]

12. Pumhirun P, Jane-Trakoonroj S, Wa-suwat P,. Compari-son of in vitro assayfor specific IgE andskin prick test withintradermal test inpatients with allergicrhinitis. Asian Pac JAllergy Immunol.2000.3:157-60.[PMID: 11270471]

13. Sheikh A, Hurwitz B.House dust miteavoidance measuresfor perennial allergicrhinitis: a systematic

review of efficacy. BrJ Gen Pract.2003;53:318-22.[PMID: 12879834]

14. Fuhlbrigge AL,Adams RJ. The effectof treatment of aller-gic rhinitis on asth-ma morbidity, in-cluding emergencydepartment visits.Curr Opin AllergyClin Immunol.2003;3:29-32. [PMID:12582311]


Medical history combined with ahigh baseline prevalence of ARsupport the common practice ofempirical treatment since manyof the medications used to treatAR have minimal toxicity andside effects (11).

Diagnostic testing is usually re-

served for patients with more se-vere disease who do not respondto empirical avoidance of knownallergens and pharmacologictreatment. Tests include allergysensitivity testing to identify specificallergens, often in preparation forimmunotherapy, and/or radiologicimaging to identify other underly-ing anatomical conditions.

Allergy sensitivity tests, including

skin testing and IgE-specific anti-body level determination, may behelpful in identifying allergens,confirming the diagnosis of AR,and choosing treatment. How-ever, sensitivity to an allergen ontesting does not necessarily meanthat that allergen is causing clini-cal disease or can be easily avoid-ed (8). Moreover, reported sensi-tivities and specificities of skin

tests (which may sometimes notbe well standardized) and sero-logic tests (of which there aremany) vary widely; consequently,it may be difficult to confidentlycalculate the posttest probabilityof AR in some cases (11).

The 3 most frequently used skintesting methods are puncture,prick, or scratch; intradermal; andpatch. In the first method, tiny

drops of purified allergen extractsare pricked or scratched onto theskins surface. Such allergens in-clude pollen, mold, pet dander,dust mites, foods, and insect ven-om. In intradermal testing, the al-lergen is introduced under theskin using a syringe and a narrow-gauge needle. Patch testing, in

Diagnosis of seasonal

allergic rhinitis can usually

be made clinically.



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which an allergen is applied to apatch and then placed on theskin, is not usually used in pa-tients with AR but is instead usedto test for substances that causecontact dermatitis.

Medications taken for preexistingconditions can interfere with test

results. These agents include theprescription antihistamines fexofe-nadine and cetirizine; over-the-counter antihistamines, such as di-phenhydramine hydrochloride andchlorpheniramine; tricyclic antide-pressants, such as amitriptyline anddoxepin; and H

2-antagonists, such

as cimetidine and ranitidine (11).Other factors can lead to false-positive and false-negative results(Table 2).

Administering skin tests if thepatient has severe skin diseaseshould be avoided, and in rarecases small amounts of substancesadministered to highly sensitivepatients can lead to anaphylaxis.

Immunoglobulin E antibody test-ing, also referred to as radioaller-gosorbent testing (RAST), is rec-ommended for patients who findskin tests impractical or who aretaking medications that will inter-fere with the results. In vitro IgE-specific antibody testing is moreexpensive than skin testing but has

a specificity of 80% to 90%. Al-though specific operating charac-teristics for skin prick testing andspecific in vitro IgE antibodytesting depend on the allergenused, they are generally similar andyield excellent results (12). Skintesting generally requires consulta-tion with an allergist.

Unlike IgE-specific antibody test-

ing, serum total IgE levels, al-though often elevated in patientswith allergic disease, are not par-ticularly helpful in confirming thediagnosis of AR. The same is truefor eosinophilia in the peripheralblood count and for eosinophilson nasal cytology, which can beseen in patients with nonallergicrhinitis.

Radiologic studies may be valu-

able to confirm or exclude coex-isting or complicating mechanicalobstruction. Consider radiographsand computed tomography in pa-tients with symptoms lasting formore than a few months to lookfor chronic sinusitis with obstruc-tion, nasal polyps, or otheranatomical abnormalities that re-quire attention.

When should clinicians considerconsultation with an allergist or

otorhinolaryngologist to make

an accurate diagnosis?

Clinicians should consider con-sulting an allergist if the cause ofthe patients symptoms remainselusive, especially if skin testingmay be useful or when rhinitis is

15. Skoner DP, Rachelef-sky GS, Meltzer EO,

et al. Detection ofgrowth suppressionin children duringtreatment with in-tranasal be-clomethasone dipro-pionate. Pediatrics.2000;105:E23. [PMID:10654983]

16. Schenkel EJ, SkonerDP, Bronsky EA, et al.Absence of growthretardation in chil-dren with perennialallergic rhinitis afterone year of treat-ment with mometa-sone furoate aque-ous nasal spray.Pediatrics.

2000;105:E22 [PMID:10654982].

17. Weiler JM, Bloom-field JR, WoodworthGG, et al. Effects offexofenadine,diphenhydramine,and alcohol on driv-ing performance. Arandomized, place-bo-controlled trial inthe Iowa drivingsimulator. Ann InternMed. 2000;132:354-63. [PMID: 10691585]


Table 2. Causes of False-Positive and

False-Negative Skin Test Results*

Causes of false-positive skin test results

Test sites too close together (0.05 mL of testing solution (in-

tradermal tests)Using high-concentration testing solution

(intradermal tests)

Causes of false-negative skin test results

Use of antihistamines, tricyclic anti-

depressants, long-term oral steroidtherapy, or topical steroidsInsufficient penetration of skin with needleLow potency of testing extractAge >50 yChronic renal insufficiencySpinal cord injuryPeripheral nerve injuryTesting in the week after anaphylaxisSubcutaneous injection (intradermal tests)

* Data from reference 11.

Diagnostic testing is usually

reserved for patients with

severe disease who do not

respond to treatment.



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associated with sinusitis, otitis

media, or asthma.

An otorhinolaryngologist should

be consulted for patients in whom

nasal endoscopy or other diagnos-tic procedures requiring special-ized instrumentation is needed toidentify an underlying anatomicalabnormality.

What allergen control measuresare effective in reducing

symptoms of AR?

The most effective measure forreducing symptoms of AR wouldlogically be to avoid offending al-lergenswhich is probably easierfor patients who are only season-ally affected than for those whoare affected year-round.

Nearly all studies evaluate the effectsof allergen avoidance in patients with

asthma rather than in those with AR. A

systematic review of 4 small studies

suggested that air cleaners, vinyl mat-

tress covers, and HEPA filtration sys-

tems reduce dust mite allergen burden

but did not conclusively demonstrate

long-term reduction in clinical symp-

toms of allergic rhinitis (13).

Current guidelines recommend

allergen avoidance measures inpatients with AR to improvesymptoms and reduce the needfor pharmacologic therapyand should avoid any otherparticular irritant or situationknown to exacerbate symptoms(see the Box).

What pharmacologic measuresshould clinicians consider for

patients with AR?

Most patients will not get com-plete relief from allergen-controlmeasures and will need pharmaco-therapy or immunotherapy.Physicians should base theirchoice of pharmacotherapy oneffectiveness and safety as well asthe patients specific symptoms,severity, and duration. For nasalsymptoms, physicians should alsoconsider the patients preferencefor oral or intranasal agents, co-morbid conditions, and responseto prior treatment. Observationalstudies of patients with both asth-ma and AR show that treating ARdecreases asthma exacerbations byone third to one half (14).

In tailoring drug therapy, it is

useful to determine which symp-toms are most troublesome to thepatient to decide which drugs aremost likely to treat those symp-toms and to classify symptomseverity and frequency (see the Boxon next page). For example, pa-tients with mild seasonal AR mayneed to take an oral antihistamine

18. Condemi J, Schulz R,Lim J. Triamcinoloneacetonide aqueousnasal spray versusloratadine in season-al allergic rhinitis: ef-ficacy and quality of

life. Ann AllergyAsthma Immunol.2000;84:533-8 [PMID:10831008]

19. Weiner JM, Abram-son MJ, Puy RM. In-tranasal corticos-teroids versus oral H

1

receptor antagonistsin allergic rhinitis:systematic review ofrandomised con-trolled trials.BMJ.1998;317:1624-29 [PMID: 9848901].


Steps for Allergen Avoidance

Reduce exposure to dust mites

Remove carpeting from thehome (especially the bedroom)

Use allergy encasements forbedding

Reduce the relative humidity inthe home to 120 F)water

Control exposure to outdoorpollens and molds

Close windows and doors

Use an air conditioning systemwith a small-particle filter

Control exposure to pets andanimals

Diagnosis... Clinicians should base the initial clinical diagnosis of AR on the pa-tients history and consider laboratory testing to identify specific allergens if thediagnosis is unclear, symptoms are severe enough to affect quality of life, the pa-tient does not respond to empirical drug therapy, and/or immunotherapy is beingcontemplated. Base the choice between skin testing and IgE-specific antibodytesting on physician and patient preference. Obtain imaging studies only for pa-tients in whom an underlying anatomical abnormality may influence management.

CLINICAL BOTTOM LINE

Treatment



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20. Yez A, Rodrigo GJ.Intranasal corticos-teroids versus topi-cal H

1receptor an-

tagonists for thetreatment of allergicrhinitis: a systematicreview with meta-analysis. Ann AllergyAsthma Immunol.2002;89:479-84.

[PMID: 12452206]21. Pullerits T, Praks L,

Ristioja V, Ltvall J.Comparison of anasal glucocorticoid,antileukotriene, anda combination of an-tileukotriene and an-tihistamine in thetreatment of season-al allergic rhinitis. JAllergy Clin Im-munol.2002;109:949-55.[PMID: 12063523]


for a few weeks at specific timesduring the year or may be able tocontrol their symptoms with over-the-counter antihistamines orantihistaminedecongestantcombinations. In persons withseasonal disease, it is sometimeshelpful to start drug treatment aweek or two before the begin-

ning of allergy season. On theother hand, patients with peren-nial AR may require long-termmultidrug therapy.

Available pharmacologic drugclasses include oral, nasal, andocular antihistamines; nasal, oral,and parenteral corticosteroids;nasal and ocular cromolyn; oraland nasal decongestants; nasalanticholinergics; and oralleukotriene-receptor agonists(Table 3). All nasal symptoms, in-cluding sneezing, rhinorrhea, nasalcongestion, and nasal itch, can betreated with oral and nasal antihis-tamines, nasal steroids, nasal cro-molyn, and oral antileukotrienes.Oral and nasal decongestants,however, treat only nasal conges-tion. In addition to the topical oc-ular agents, oral antihistamines,

antileukotrienes, and even nasalsteroids to some extent treat theeye symptoms.

A comprehensive evidence report from

the Agency for Health Care Research

and Quality in 2002 (www.ahrq.gov/

clinic/tp/rhintp.htm) reviewed over 228

articles and found that nasal corticos-

teroids were most effective in the treat-

ment of both seasonal and perennial

AR. Sedating and nonsedating anti-

histamines were similarly effective,

although less so than nasal corticos-

teroids. Cromolyn was also found to be

effective in seasonal and perennial dis-

ease. None of the agents caused

more than mild side effects, aside from

sedation in first-generation antihista-

mines. No studies were identified

comparing pharmacologic treatment

with immunotherapy.

Treatment Based on Chronicity and Severity of Symptoms

Mild, intermittent disease may require only monotherapy with nonsedating oral ornasal antihistamines or decongestants as needed.

Mild but more persistent disease can be treated with monotherapy with a nonsedat-ing oral or nasal antihistamine, nasal cromolyn, or an oral decongestant, dependingon the predominant symptoms. A second of these agents can be added after amonth if needed. Nasal decongestants should not be used for more than 3 days toavoid rhinitis medicamentosa.

Treatment of moderate to severe, intermittent disease can begin with monotherapywith an oral or nasal antihistamine, oral decongestant, nasal cromolyn, or nasalsteroid depending on specific symptoms.

Patients with moderate to severe persistent disease are candidates for initial therapywith intranasal steroids. If symptoms do not improve within a month, consideradding an antihistamine for itching and sneezing, nasal ipratropium for rhinorrhea,an oral decongestant for congestion, or if necessary a short course of oral steroids(Table 4).

Intranasal Steroids

Intranasal corticosteroids, thedrug class most effective for dailytreatment of AR (especially inpatients with significant persist-

ent disease) (18), includes beclo-methasone, ciclesonide, triamci-nolone, budesonide, mometasone,flunisolide, and fluticasone. Com-parative trials have not convinc-ingly shown superiority of oneover the other. However, severalrandomized trials and 2 systemat-ic reviews attest to their superiori-ty over both topical and oralantihistamines.

In a meta-analysis of 16 randomized,

controlled trials including 2267 patients

with AR, intranasal steroids provided

greater relief than oral antihistamines of

nasal blockage, nasal discharge, sneez-

ing, postnasal drip, and total nasal

symptoms. The odds ratio for the global

rating for deterioration of symptoms

was 0.26 (95% CI, 0.08 to 0.8). There were

no differences between the treatments

for nasal discomfort, resistance, or eye

symptoms (19).

In another meta-analysis of 9 random-

ized, controlled trials including 648

patients with AR, intranasal steroids pro-

vided greater relief than topical antihist-

amines in total nasal symptoms, sneez-

ing, rhinorrhea, itching, and nasal

blockage but no difference in ocular

symptoms (20).



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Table 3. Drug Treatment for Allergic Rhinitis*

Agent* Mechanism Dosage Benefits Side Effects Notes of Action

Intranasal corticosteroids

Beclomethasone, Broad anti- 2 puffs each Effective agent Should be used every day; Can be used astriamcinolone, inflammatory nostril once for blockage, small for corticosteroid first-line agent;budesonide, action or twice rhinorrhea, side effects can stuntfluticasone, per day and sneezing growth inmometasone children (15,16)flunisolide, andciclesonide

Oral antihistamines, first-generation

Diphenhydramine Blocks 2050 mg Effective for Can be sedating or interfere First-generationH

1-receptor 3+ mg per day rhinorrhea and with the ability to drive or antihistamines may

sneezing; can be operate machinery; less cause drivingeffective when effective for congestion; impairment (17)used as needed or not as effective asin conjunction intranasal corticosteroidswith intranasalcorticosteroids

Chlorpheniramine Blocks 4 mg every Effective for rhinorrhea Can be sedating or interfere First-generationand others H

1-receptor 46 h and sneezing; can be with the ability to drive or antihistamines may

effective when used operate machinery; less cause drivingas needed or in con- effective for congestion impairment (17)junction with intra-nasal corticosteroids

Oral antihistamines, second-generationLoratadine, Blocks 10 mg once per day Effective for rhinorrhea Can be sedating or interfere Nonsedatingfexofenadine, H

1-receptor 60 mg twice per and sneezing; can be with the ability to drive or antihistamines

day, or 180 mg effective when used operate machinery; less preferredonce per day as needed or in con- effective for congestion

and cetirizine 510 mg once junction with intra-per day nasal corticosteroids

Oral decongestants

Phenylephrine Sympathomimetic 10 mg every Effective for treating Can cause sympathomimetic Most often used in46 h nasal blockage; can side effects; can cause combination with

be used as needed or bladder outlet obstruction antihistamines and/orin conjunction with in men; effective for only nasal corticosteroidsintranasal corticosteroids 1 symptomand/or antihistamines

Oral antihistamine/ H1-antagonist/ Varies Effective for nasal See adverse effects listed Many prescription

decongestant sympathomimetic blockage, rhinorrhea, for antihistamines and nonprescriptioncombinations and sneezing; can be and decongestants products available

used as needed and inconjunction withintranasal corticosteroids

Oral montelukast Leukotriene 10 mg once Effective for nasal Headachereceptor per day blockage, rhinorrhea,antagonist and sneezing

Intranasal cromolyn Mast cell 2 puffs, 3 or Effective for nasal Not as effective as intranasal Nonprescriptionstabilizer 4 times blockage, rhinorrhea, corticosteroids; must be used

per day and sneezing; very every day, 4 to 6 times per daylow risk for adverseeffects

Intranasal antihistamines

Azelastine H1

antagonist 2 puffs each As effective as oral Can be sedating First-line therapy

hydrochloride nostril twice antihistamines;per day some patients

prefer as-needednasal spray

Intranasal Anticholinergic 2 puffs each Effective for Not effective for symptoms Not consideredipratropium nostril 2 or rhinorrhea; low risk other than rhinorrhea first-line therapy

3 times per day for side effects

Systemic Broad anti- Varies; prednisone Highly effective for Risk for corticosteroid For severe, acutecorticosteroids inflammatory 40 mg daily for 5-7 severe, acute allergic adverse effects symptomsPrednisone days with tapering rhinitis

for acute, severe,allergic rhinitis

* Not a comprehensive list.



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Other trials have shown thesuperiority of intranasal steroidswhen used as monotherapy overantileukotriene agents, such asmontelukast and antihistamineantileukotriene combinations(21). Moreover, adding an anti-histamine or an antileukotrieneagent to fluticasone does not seem

to be more effective than the in-tranasal steroid itself (22).

In a randomized, controlled study of 100

patients with seasonal AR, researchers

compared fluticasone propionate aque-

ous nasal spray, given alone or with ei-

ther cetirizine or montelukast, with a

combination of the latter two. Patients

treated with fluticasone alone and with

fluticasone/cetirizine showed signifi-

cantly better total symptom scores and

less nasal itching than those treatedwith cetirizine/montelukast. Patients

treated with fluticasone/cetirizine had

significantly better total symptom scores,

less nasal congestion on waking, less

daily nasal congestion, less rhinorrhea,

and less nasal itching. The authors con-

cluded that fluticasone is highly effective

for treating patients with AR and that ef-

ficacy exceeded that of cetirizine and

montelukast. Combining fluticasone with

either cetirizine or montelukast did not

offer a substantial advantage over usingfluticasone alone (25, 54).

When AR is being treated withintranasal steroids, the risk forsuch side effects as glaucoma and

cataracts is small. However, nasalirritation and bleeding can occurwith significant frequency, and itis wise to examine the nasal sep-tum periodically in long-termusers for erosions that may pre-cede perforation. There are nodata to suggest that intranasalsteroids have a systemic effect in

suppressing the hypothalamicpituitaryadrenal axis. Unlikeorally inhaled steroids used inasthma, mucosal candida infec-tion is uncommon.

AntihistaminesAlthough they may not be as ef-fective as intranasal steroids, oralantihistamines are often includedin guidelines for use in combina-tion with steroids in patients withmoderate to severe persistent AR.More often they are used as mono-therapy in patients with less se-vere disease and work rapidly torelieve symptoms. Antihistaminesblock the H

1-histamine receptor

and are effective in treating rhin-orrhea, nasal itching, sneezing,and eye symptoms but have littleeffect on nasal congestion.

The first-generation oral antihist-amines, including diphenhy-dramine and chlorpheniramine,are widely available over thecounter. However, because theyare sedating, minimize reaction

22. Di Lorenzo G, PacorML, Pellitteri ME, etal. Randomizedplacebo-controlledtrial comparing fluti-casone aqueousnasal spray in mono-therapy, fluticasoneplus cetirizine, fluti-casone plus mon-telukast and ceti-rizine plus

montelukast for sea-sonal allergic rhinitis.Clin Exp Allergy.2004;34:259-67.[PMID: 14987306]

23. Kakutani C, Ogino S,Ikeda H, Enomoto T.[Comparison of clini-cal efficacy and cost-quality of antihista-mines in earlytreatment for Japan-ese cedar pollinosis].Arerugi. 2006;55:554-65. [PMID: 16883093]

24. Rodrigo GJ, Yaez A.The role of an-tileukotriene therapyin seasonal allergicrhinitis: a systematic

review of random-ized trials. Ann Aller-gy Asthma Immunol.2006;96:779-86.[PMID: 16802764]

25. Wilson AM, OByrnePM, ParameswaranK. Leukotriene re-ceptor antagonistsfor allergic rhinitis: asystematic reviewand meta-analysis.Am J Med.2004;116:338-44.[PMID: 14984820]


Table 4. Effects of Medications on Symptoms*

Medication Symptoms

Sneezing Rhinorrhea Nasal Congestion Nasal Itch Eye SymptomsAntihistamine, oral ++ ++ + +++ ++Antihistamine, nasal ++ ++ + ++ 0Antihistamine, ocular 0 0 0 0 +++

Nasal steroids +++ +++ +++ ++ ++Cromolyn, nasal + + + + 0Cromolyn, ocular 0 0 0 0 ++Decongestants, oral 0 0 + 0 ++Decongestants, nasal 0 0 ++++ 0 0Anticholinergics, nasal 0 ++ 0 0 0Antileukotrienes 0 + ++ 0 ++

* Data from references 8 and 34. Note: Consult package insert for cautions and constraints. 0 = not effective forsymptoms; + = mildly effective for symptoms; ++ = moderately effective for symptoms; +++ and ++++ = veryeffective for symptoms.



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time, and are especially problem-atic in elderly patients, theyshould be avoided.

In 1 randomized crossover study com-paring the effects of alcohol, diphenhy-dramine (a first-generation antihistamine),fexofenadine (a second-generation anti-histamine), and placebo, participants ina driving simulation test performed

worst after taking a single 50-mg dose ofdiphenhydramine (16).

The second-generation oral anti-histamines, including loratadine,cetirizine, and fexofenadine, areless sedating because they arelarger charged molecules thathave a greater affinity for periph-eral H

1-receptors and less readily

penetrate the central nervous sys-tem. They include oral cetirizine,

fexofenadine, loratadine, andastemizole. Astemizole and terbina-fine, which was withdrawn fromthe market in the late 1990s, pro-long the QT interval and maycause cardiovascular side effects.

Although numerous trials com-pare various oral antihistamines toother classes of drugs used to treatAR, there are few head-to-headtrials comparing them to each oth-

er. Effectiveness is believed to besimilar.

One randomized trial compared 175 pa-tients with Japanese cedar pollinosistreated with 1 of 7 types of antihistaminemonotherapyazelastine, cetirizine,ebastine, epinastine, fexofenadine, lo-ratadine, or oxatomidewith 510 pa-tients who received placebo. There wasno significant difference in sneezing, rhi-norrhea, ocular itching, or overall healthbetween the treated and the nontreated

groups (23).

The topical antihistamine azelas-tine is available as a nasal sprayfor treating seasonal AR. How-ever, it may cause drowsiness andanticholinergic side effects. Topi-cal azelastine, olopatadine, andlevocabastine can also be used totreat the ocular symptoms of

seasonal allergic conjunctivitis.Allergic conjunctivitis can also betreated with the topical non-steroidal anti-inflammatory agentketorolac and the topical formula-tions of the mast cell stabilizerscromolyn and nedocromil.

Decongestants

Oral decongestants, such as pseu-doephedrine, only treat nasalblockage; however, they causesympathomimetic side effects,such as nervousness and tachy-cardia, and should be avoided inpatients with hypertension andhyperthyroidism.

Nasal decongestants act by con-tracting the vascular sphincters

near the venous plexuses of theturbinates. Although they aremore effective than their oralcounterparts, they should not beused more than once weekly be-cause more frequent use can causerhinitis medicamentosa.

Mast Cell Stabilizers

The mast cell stabilizers cromolynand nedocromil work at the sur-face of the mast cell to inhibit de-

granulation and prevent release ofhistamine and other inflammatorymediators. They can be adminis-tered intranasally to patients withmilder forms of AR to preventand treat all manifestations andare best started early before sea-sonal triggers have caused symp-toms. They must be used severaltimes daily.

Cromolyn and nedocromil are

also available as eye drops for treat-ment of ocular symptoms associ-ated with allergic conjunctivitis.

Although there are relatively fewdata on use of these agents in pa-tients with AR, neither appears tobe as effective as intranasalsteroids or antihistamines. Theyhave few side effects.

26. Plaut M, ValentineMD. Clinical practice.Allergic rhinitis. NEngl J Med. 2005;18:1934-44 [PMID:

16267324].27. Cols C, Monzn S,

Venturini M, LezaunA. Double-blind,placebo-controlledstudy with a modi-fied therapeutic vac-cine of Salsola kali(Russian thistle) ad-ministered throughuse of a clusterschedule. J AllergyClin Immunol.2006;117:810-6.[PMID: 16630938]

Patients with severe symp-

toms who do not respond to

or are intolerant of other

medications may be treated

with systemic corticosteroids.



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Leukotriene Inhibitors

Release of leukotrienes from mastcells has been implicated in devel-opment of some of the symptomsof AR, such as sneezing, nasalitching, rhinitis, and late-stagecongestion. Montelukast, usuallyused in asthma, is an oral leuko-triene receptor antagonist that isavailable in oral form to treatthese symptoms. Because theyare less effective than intranasalsteroids, antileukotrienes are usu-ally reserved as second-line treat-ment for patients with milder ARwho cannot tolerate other drugs.

In 1 systematic review of 17 studies in-cluding 6231 adults with seasonal AR,oral leukotriene antagonists improveddaytime and nighttime nasal symptoms,eye symptoms, and overall quality of lifecompared with placebo. However, no dif-

ferences were found when leukotriene an-tagonists were compared with histamineH

1-antagonists, and they were less effec-

tive in decreasing daytime and nighttimenasal symptoms than intranasal steroids.Intranasal steroids were also more effec-tive than leukotriene antagonists com-bined with histamine H

1-antagonists (24).

In another systematic review of 11 ran-domized trials (8 evaluating leukotriene-receptor antagonists alone or in combi-nation with other drugs vs. placeboor other treatments, and 3 evaluating

leukotriene-receptor antagonists) plus anantihistamine, antihistamines reducednasal symptoms scores 2% more thanleukotriene-receptor antagonists, andnasal steroids improved the score by 12%more (25).

Other Agents

In patients with moderate to se-vere persistent AR, nasal iprat-ropium can be used to treatpersistent rhinorrhea. It may alsobe useful in patients with vaso-

motor rhinitis.

When should clinicians prescribesystemic corticosteroids forpatients with AR?Patients with severe symptomswho do not respond to or areintolerant of other medications maybe treated with either oral or in-jected systemic corticosteroids (26).

Systemic corticosteroids actquickly and effectively in reducingmucosal inflammation. A courseof prednisone (40 mg/d for 5 to 7days) is usually sufficient. Pa-tients who respond quickly canbe switched to long-term thera-py with intranasal corticosteroidsor other medications.

Continuous daily oral prednisoneat a dose of 10 to 20 mg/d shouldbe considered only when rhinitisdoes not respond to intranasal cor-ticosteroids, oral antihistamines,oral decongestants, and immuno-therapy. Although there are nostudies on the long-term side ef-fects of systemic corticosteroids inpatients with AR, therapy withsupraphysiologic doses of steroidsshould be avoided whenever

possible.What are the indications forallergen immunotherapy? What

are the pros and cons of thistype of treatment?Allergen immunotherapy shouldbe considered in patients whocontinue to have moderate-to-severe symptoms despite allergenavoidance and maximum pharma-cologic therapy, in those who re-quire courses of systemic corticos-teroids, and in those who havesuch coexisting conditions as si-nusitis, asthma, or both (26). Im-munotherapy is more appropriatein patients with ongoing symp-toms that affect quality of life thanin those with relatively mild sea-sonal disease who are affected by asingle allergen.

Immunotherapy comprises sub-cutaneous injections of allergenic

extracts to which the patient hasbeen shown to be sensitive duringIgE-specific antibody testing.Injections are administered bygradually increasing the doseweekly and then continuing thatdose every few weeks for about ayear. If effective after that time,treatment is continued for a totalof approximately 3 to 5 years.


28. Durham SR, WalkerSM, Varga EM, et al.

Long-term clinicalefficacy of grass-pollen immunother-apy. N Engl J Med.1999;341:468-75.[PMID: 10441602]

29. Immune ToleranceNetwork Group. Im-munotherapy with aragweed-toll-like re-ceptor 9 agonistvaccine for allergicrhinitis. N Engl JMed. 2006;355:1445-55. [PMID: 17021320]

Allergen immunotherapy

should be considered in

patients with moderate to

severe symptoms despite

allergen avoidance and maxi-

mum pharmacologic therapy.



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Some patients who complete asuccessful course of allergen im-munotherapy find that ARsymptoms do not worsen whenthe immunotherapy is discontin-ued. However, others benefitfrom more prolonged treatment.The magnitude of symptom re-duction during immunotherapy

varies but has been shown to besignificant in some studies and isassociated with improvement inquality-of-life measures.

In 1 double-blind, randomized, placebo-controlled study, 60 patients with mod-erately severe seasonal AR were random-ly assigned to 1 or 2 doses of Alutardgrass pollen or placebo over 1 allergyseason. During the study, mean symp-tom and medication scores were 29%and 32% lower, respectively, in the high-dose group and 22% and 26% lower,respectively, in the low-dose groupcompared with placebo (P value for both< 0.001). In addition to reduced symp-toms and medication use, quality of lifeimproved (27).

Investigators randomly assigned pa-

tients who had been successfully treated

with immunotherapy for 3 to 4 years to

continue or to stop therapy. They fol-

lowed the patients for 3 years, compar-

ing them to a matched group who had

not received immunotherapy. At the end

of the study, symptom scores in both

treatment groups for the 504 patients

who discontinued therapy and the 921

patients who continued therapy were

significantly lower than for those who

did not receive immunotherapy, sug-

gesting induction of prolonged clinical

remission even after immunotherapy is

stopped (28).

More recently, newer approaches toimmunotherapy have shown prom-ise in small studies of patients withseasonal AR. Such approaches in-

clude conjugation of native aller-gens to other substances, such asimmunostimulatory sequences ofDNA (29), and use of recombinantmonoclonal antibodies to formcomplexes with free IgE to blockits interaction with mast cells anddecrease symptoms (30).

Allergen immunotherapy shouldgenerally be avoided in elderly pa-tients with significant cardiovas-

cular or pulmonary disease and inthose receiving -blockers whomay be less able to tolerate sys-temic reactions. It should alwaysbe managed by an experienced al-lergist or immunologist. The riskfor systemic reactions to allergenimmunotherapy ranges from0.05% to 3.5%. Such reactions in-clude increased nasal and ocularallergic symptoms, urticaria, an-gioedema, and hypotension (31).

In addition, immunotherapy car-ries a small risk for anaphylaxisand should be administered in asetting by clinicians prepared tomanage such reactions (Table 5).

30. Omalizumab Sea-sonal Allergic Rhini-tis Trail Group. Effectof omalizumab onsymptoms of sea-sonal allergic rhinitis:a randomized con-trolled trial. JAMA.2001;286:2956-67.[PMID: 11743836]

31. Huggins JL, LooneyRJ. Allergen im-munotherapy. AmFam Physician.

2004;70:689-96.[PMID: 15338781]

32. Mller C, Dreborg S,Ferdousi HA, HalkenS, Hst A, JacobsenL, et al. Pollenimmunotherapy re-duces the develop-ment of asthma inchildren with sea-sonal rhinoconjunc-tivitis (the PAT-study). J Allergy ClinImmunol.2002;109:251-6.[PMID: 11842293]

Table 5. Pros and Cons of Allergen Immunotherapy for Allergic Rhinitis

Pros Cons

Proven effective in reducing Requires allergy consultationsymptoms in most carefully and allergy testingselected patients

Proven effective in reducing Requires weekly or monthlymedication use travel to physicians office

for injections

Effective for coexistingallergic asthma Involves needles

Nonpharmacologic Risk for systemic reaction0.1%1% per injection

Can reduce development of Pharmacologic therapy easierasthma in children (32) to prescribe and administer

Considerations in Cases of

Suboptimum Symptom Control

Incorrect diagnosis

Inadequate allergen controlmeasures

Allergens not properly identified

Insufficient pharmacologic agentsor dosages

Inappropriate medication class

Need for combination of

medications Need for intranasal corticosteroids

Poor patient adherence

Need for systemic corticosteroids

Need for immunotherapy

Upper airway anatomicalabnormality



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What should clinicians tell

patients who ask about

complementary-alternative

medicine treatments for AR?

Although some complementaryalternative medicine methods forAR and asthma have been stud-ied, evidence on efficacy andsafety is insufficient.

A systematic review (33) of published

randomized trials of complementary

medicine treatments for AR and asthma

from a search of MEDLINE and the

Cochrane Library evaluated for quality

found no clear evidence for the efficacy

of acupuncture. Both positive and neg-

ative studies of homeopathy were

found. There were too few studies

on herbal remedies to make any

recommendation.

When should clinicians

consult an allergist or

otorhinolaryngologist to help

manage patients with AR?

Although most patients can bemanaged by generalist physicianswith allergen avoidance and drugtherapy, consider consulting anallergist or immunologist for pa-tients who:

Have had a suboptimum re-sponse to allergen avoidanceand drug therapy

Might benefit from skin test-ing or IgE-specific antibodytesting to identify triggers

Are candidates for allergenimmunotherapy

Require episodic systemic cor-ticosteroid therapy

Have such complications assinusitis, otitis media, and/orasthma

Have significant impairmentin daily activities or decreasedquality of life

The clinician should consult anotorhinolaryngologist when thereare suspected anatomical abnor-malities of the upper respiratorytract, such as nasal polyposis,nasal septal deformities, and/orrecurrent sinusitis, that may re-quire surgical intervention.

What is the appropriate

follow-up for patients with AR?

Clinicians should see patients withAR at least once a year. Patientsshould be seen more frequently de-pending on disease severity, successof symptom control, and develop-ment of treatment side effects.The symptom assessment scalesin the Practice Improvement sec-tion may be useful in followingpatients with AR.

Clinicians should tell patients who

are receiving immunotherapy toreport any reactions or changes inhealth status or medications, newupper respiratory tract infections,and development or worsening ofother underlying diseases.

33. Passalacqua G, Bous-quet PJ, Carlsen KH,Kemp J, Lockey RF,Niggemann B, et al.ARIA update: I-Sys-tematic review ofcomplementary andalternative medicinefor rhinitis and asth-ma. J Allergy Clin Im-

munol. 2006;117:1054-62. [PMID:16675332]

34. World Health Orga-nization. Allergicrhinitis and its im-pact on asthma. Incollaboration withthe World Health Or-ganization. Executivesummary of theworkshop report. 7-10 December 1999,Geneva, Switzerland.Allergy. 2002;57:841-55. [PMID: 12169183]

Treatment... Drug options effective in treating 1 or more AR symptoms include oral second-generation or nasal antihistamines, intranasal corticosteroids, oral or nasal decongestants, in-tranasal cromolyn, or leukotriene-receptor antagonists. For patients with mild or intermittentAR, clinicians should base the choice on the predominant symptoms. Nasal decongestants andsystemic steroids should be used for short duration and only in patients unresponsive to other in-terventions. Intranasal steroids should be the first-line therapy in patients with moderate to severe,or chronic AR and in those with asthma, rhinosinusitis, or otitis media. Immunotherapy may beuseful in selected patients with moderate to severe AR unresponsive to drug therapy or with compli-cated asthma or sinusitis in whom allergy testing has identified specific inciting allergens.

CLINICAL BOTTOM LINE



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Tool Kitin the clinic

in

thec

linic

Allergic Rhinitis

Additional Online Resources for Patientsfrom The American Academy of Allergy,Asthma and Immunology

www.aaaai.org/patients/resources/easy_reader/rhinitis.pdf

A 2-page patient handout on the definition,causes, signs and symptoms, and treatment

of AR.www.aaaai.org/patients/publicedmat/tips/rhinitis.stm

Simple tips for patients on the treatment ofallergic and nonallergic rhinitis.

Useful Online Material for Patients fromMedlinePLUS

www.nlm.nih.gov/medlineplus/ency/article/

00813.htm

What do professional organizations

recommend regarding the care of

patients with AR?

A comprehensive listing of avail-able guidelines is availablethrough the National Guidelines

Clearinghouse (www.guidelines.gov). The following guidelinesfrom the American Academy ofAllergy, Asthma and Immunolo-gy are especially useful resourcesin caring for patients with aller-gic rhinitis:

www.aaaai.org/members/

resources/practice_guidelines/

rhinitis.asp (a complete listing of pro-

fessional guidelines for diagnosis and

management of allergic rhinitis and in-

formation on pharmacotherapy)

www.aaaai.org/professionals/

resources/pdf/rhinitis_symptom

_severity2003.pdf(a full set of aller-

gic rhinitis symptoms severity scales, in-

cluding questionnaires about medica-

tions and quality of life)


Practice

Improvement



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in

th

ec

linic


Tool Kitin the clinic

Key to symptoms1 = None: No symptoms to an occasional limited episode23 = Mild: Steady but easily tolerable symptoms45 = Moderately bothersome: Symptoms hard to tolerate, may interfere

with activities of daily living and/or sleep67 = Unbearably severe: Symptoms so severe person cannot function all

the time

Severely affected Excellent

1 | 2 | 3 | 4 | 5 | 6 | 7

1 | 2 | 3 | 4 | 5 | 6 | 7

1 | 2 | 3 | 4 | 5 | 6 | 7

Global Assessment of Nasal and

Nonnasal Symptom Severity

Eye symptoms

Throat symptoms

Chonic cough

Ear symptoms

Headache

Mental function

Assessment of Nonnasal Symptom Severity

Allergic Rhinitis Symptom Severity Scales*

The Joint Task Force on Practice Parameters of the Ameri-can Academy of Allergy, Asthma and Immunology; theAmerican College of Allergy, Asthma and Immunology;and the Joint Council on Allergy, Asthma and Immunologyhas developed 7-point visual analogue scales to assess indi-vidual nasal and nonnasal symptoms, global assessment ofsymptoms, quality of life, and effectiveness and side effectsof present and past medications over specific time intervals.Part of this instrument is excerpted here and can be givento patients before and during treatment to assess symp-toms at regular intervals. The complete instrument can beviewed at www.aaaai.org/professionals/resources/pdf/rhinitis_symptom_severity2003.pdf.

Sneezing

Runny nose

Congestion (stuffiness)

Itchy nose

Postnasal drip

Total nasal symptoms

Assessment of Nasal Symptom Severity

*Reproduced with permission from Spector SL, Nicklas RA, Chapman JA , et al. Symptom severity assessment of allergic rhinitis: part 1. Ann Allergy Asthma Immunol. 2003;91:11114.



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CME Questions

A 53-year-old man is evaluated forchronic nasal congestion, rhinorrhea,postnasal drip, and sneezing. He does nothave itchy or watery eyes. His medicalhistory includes hypertension. Skin test-ing showed that he is allergic to grassand weeds. He hired someone to mowhis lawn and used chlorpheniramine forhis allergy, but he stopped the medica-tion because it made him drowsy.

On physical examination, he is afebrilewith patent nares; pale turbinates; andclear, watery secretions. He has no nasalpolyps, septal deviation, or conjunctivalerythema.

Which of the following is the best long-term management for this patient?

A. Leukotriene inhibitor

B. Topical nasal decongestantC. Topical nasal corticosteroidD. Nonsedating oral antihistamineE. Oral decongestant

A 63-year-old woman is evaluated in theoffice because of a long history of inter-mittent, nonpurulent rhinorrhea, oftenprovoked by spicy foods and perfumeodors. She has no sneezing, nasal con-gestion, or eye symptoms. Over-the-counter diphenhydramine has beenineffective.

On physical examination, she has noconjunctival injection, nasal septaldeviation, mucosal abnormalities, ormaxillary sinus tenderness. The pharynxis normal.

Which of the following is the best treat-ment for her symptoms?

A. Leukotriene inhibitorB. Topical nasal decongestantC. Topical nasal corticosteroidD. Nonsedating oral antihistamineE. Oral decongestant

A 23-year-old man comes to the officein June with a 10-year history of spring-time hay fever characterized by sneez-ing; runny nose; nasal congestion; anditchy, watery eyes. Despite combinationtreatment with a nasal corticosteroid, a

nonsedating antihistamine, and an oraldecongestant, his symptoms have re-sulted in lost sleep and several days oflost work. He believes that he is allergicto trees and grass but has never hadallergy testing.

On physical examination, he is afebrilebut has marked conjunctival watering anderythema and boggy edema of the nasalmucosa. There is no sinus tenderness.

In addition to allergen avoidance, whichof the following is the most appropriatenext step?

A. Nasal cromolynB. Skin testing and immunotherapyC. Tapering course of oral

corticosteroidsD. A leukotriene inhibitor

E. Topical nasal ipratropium

A 28-year-old man with perennial aller-gic rhinitis, recurrent sinusitis, and mod-erate persistent asthma is treated for anexacerbation of his asthma with a taper-ing course of oral corticosteroids. He be-lieves that his asthma is made worse byhis rhinitis, which is only partially con-trolled by nasal corticosteroids, non-sedating antihistamines, and deconges-tants. In addition, he requires dailyinhaled corticosteroids and a long-acting

2-agonist with occasional use of a

short-acting 2-agonist inhaler for con-trol of his asthma.

On examination, his conjunctivae arenormal, and there is no sinus tenderness.The nasal mucosa is pale and slightlyboggy. There are faint wheezes in bothlung fields.

Which of the following is the best optionfor long-term management of this pa-tients rhinitis?

A. Daily low-dose oral corticosteroidsB. Addition of oral leukotriene

inhibitorC. Addition of topical nasal cromolynD. Referral for skin testing and

immunotherapyE. Addition of nasal ipratropium

A 34-year-old man has recurrent inter-mittent sneezing, rhinorrhea, mild nasalcongestion, and occasionally itchy eyes,but he cannot determine what causeshis symptoms. He lives in a high-riseapartment in an urban metropolitanarea and works as an accountant in adowntown office. He is unmarried andhas no pets. He takes no medicationsexcept for an occasional over-the-counter oral antihistamine.

The physical examination is normal withno abnormalities of the conjunctivae ornasal mucosa.

Which of the following studies is mostlikely to confirm the diagnosis?

A. Nasal swab for eosinophilsB. Absolute eosinophil count

C. Total serum IgE levelD. In vitro IgE-specific antibody testingE. Sinus radiographs

A 28-year-old man with a long history ofnasal congestion, postnasal drip, de-creased sense of smell, and moderatepersistent asthma is treated for an exac-erbation of his asthma with a taperingcourse of oral corticosteroids. He usesnasal corticosteroids, nonsedatingantihistamines, and oral decongestantsfor his nasal symptoms. He requires dailyinhaled corticosteroids and a long-

acting 2-agonist and a short-acting

2-agonist as needed for control of his

asthma. He has had several episodes ofsinusitis in the past.

On examination, his conjunctivae arenormal. The nasal mucosa is pale andslightly boggy, but there is no sinus ten-derness. There are a few wheezes in bothlung fields.

Which of the following best character-izes this patients nasal symptoms?

A. Vasomotor rhinitisB. Rhinitis medicamentosaC. Perennial allergic rhinitisD. Recurrent sinusitisE. Seasonal allergic rhinitis

1.

2.

4.

3.

5.

6.

Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/

to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

ANNALS Allergic Rhinitis

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