The Nosology of the Runny Nose from Someone Who Knows: An

Allergist’s Perspective on Rhinitis in Older Persons

Suzanne Teuber, MD Professor of Medicine

Training Program Director, Allergy & Immunology

UC Davis School of Medicine ssteuber@ucdavis.edu

Sonnet About A Nose Appeared in the Irish Penny Journal, Nov. 28, 1840

'Tis very odd that poets should suppose There is no poetry about a nose, When plain as is the nose upon your face, A noseless face would lack poetic grace. Noses have sympathy: a lover knows Noses are always touched when lips are kissing: And who would care to kiss where nose was missing? Why, what would be the fragrance of a rose, And where would be our mortal means of telling Whether a vile or wholesome odour flows Around us, if we owned no sense of smelling? I know a nose, a nose no other knows, 'Neath starry eyes, o'er ruby lips it grows; Beauty is in its form and music in its blows.

What we will cover today

• Definition and epidemiology • Effect of “prolonged passage of time” on The

Nose • Common nasal disorders in older people • Common therapies • Common side effects of therapies

Rhinitis

From MedlinePlus

Prevalence: 10-30% of adults in various studies At least 1/3 NON-allergic, proportion goes up with age

My Nose Is Growing Old Yup. A long lazy September look in the mirror says it’s true. I’m 31 and my nose is growing old. It starts about ½ an inch below the bridge and strolls geriatrically down for another inch or so: stopping. Fortunately, the rest of my face is comparatively young. I wonder if girls will want me with an old nose. I can hear them now the heartless bitches! “He’s cute but his nose is old” Richard Brautigan, American, 1935-1984

Common Nasal Changes • Sun damage – watch for skin cancers! • Decreased connections between cartilage tissue

plates results in drooping of tip and narrowing of “nasal valves” (nostrils narrow with breathing)

• More fullness to tip of nose and sides of nose

• Airflow changes from the “drooping” can sometimes result in changes in the shape/growth of tissues in the nose – the turbinates, and cause obstruction.

More Changes • Changes in nervous system control of the

glandular secretions – Runny thin mucus when getting up in the morning – Can become a severe nuisance with many triggers

• Changes in mucus: thicker in some people (more noticeable ‘post-nasal drip’), crusting

• Changes in immune function: more susceptible to bacterial growth in sinuses

Case1: Drippy Dan Dan, age 72, reports onset of runny nose about 10 years ago “like a faucet”. Sneezes up to 5 times in a row, especially in the morning. Has 3 cats and 2 dogs indoors. Nonsmoker. History of very mild seasonal nasal allergy symptoms in spring since childhood, but the current problem is year-round. Especially severe with eating – can’t eat anything, even a piece of bread, without his nose running – but not congested. Can’t/won’t go out to dinner any longer – too embarrassing! Has tried all the over-the-counter pills with no help.

Allergies? Or Something Else? • On exam, nose looks normal inside • Skin tests to common allergens were positive to

grass – But grass is seasonal, not year round

• Diagnostic clue from history: eating causes severe runny nose – This is Gustatory Rhinitis, a type of non-allergic

Vasomotor Rhinitis • Due to overactivation of nerves to the glands that have the

thin, clear type of mucus (inhibition of the nerves goes down with age in some people) at the same time there is stimulation of gastric secretions and contractions

• Other kinds of Vasomotor Rhinitis include runny nose and congestion from varied triggers: temperature, spices, alcohol, irritants, exercise

Treatment • Ipratropium bromide 0.03% or step up to 0.06%

– Start high if “faucet”, “humiliated”, “go through a box of Kleenex a day”, “can’t go out to eat”

– 1-2 whiffs each nostril (waiting a few minutes between whiffs if using 2 whiffs) up to 3 times/day, time 30-60 minutes before meals if gustatory component

• Specifically blocks the nervous system overactive stimulation of those glands!

• People with ALLERGIC rhinitis who have trouble controlling the faucet may also find this helpful

• Drippy Dan was very pleased with this medication and sent a thank-you note

Case 2: Stuffy Sue Sue, age 80, and her husband took in their daughter’s cat 4 years ago when she was assigned to the American Embassy in India. Sue reports that as a teen, she couldn’t be around such critters at all without itchy eyes, sneezing, runny nose and wheezing. She hasn’t been around felines in many years until now. She noticed onset of nasal congestion, mild nasal itching, occasional sneezing, and post nasal drip sensation when Peanut moved in. She takes diphenhydramine 25 mg AM and PM. This has helped stop the sneezing, itching, and post-nasal drip sensation, but not the congestion which bothers her enough to seek advice. Photo by Yumi Kimura

PEANUT

Allergies or Something Else?

• On exam, nasal mucosa is glistening and pale • Blood testing (IgE – the allergy antibody) is +

for cats, and several pollens • She has been in 2 fender-benders in parking

lots in the past year that were her fault; nobody was hurt.

New Onset of Allergic Rhinitis is Uncommon past 60

• When of new onset, we often see dust mite allergy (several studies and our local data supports this)

• Allergic rhinitis can last from childhood through to 100+ – BUT MOST people experience some improvement as

they age, or even complete resolution – Clinically, this fits with cat allergy that is dramatically

less severe than in youth • The nasal changes with age can make congestion

more noticeable and antihistamines don’t work that well for congestion compared to other effects.

Local Data: Major allergens – Sacramento Area Kaiser Morse, Rancho Cordova, Roseville, 566 patients Of patients with a diagnosis of allergies, what were they positive to on skin testing?

• Grass pollens: 65 - 70% • Olive tree pollen: 60% • Cat: 40% • Dog: 25% • Dust mites: 50% • Weeds, other trees: about 33% • Molds: Alternaria 24%, Aspergillus 3%,

Cladosporium 6%, Penicillium 9%

0

10

20

30

40

50

60

70

80

Grass: Rye Olive D. pteron. D. farinae Cat

0-9 years old, n=52 10-19 years old, n=8820-29 years old, n=87 30-39 years old, n=12340-49 years old, n=103 50-59 years old, n=6160+ years old, n=52

% positive skin test

• Sleep problems – Restless sleep, daytime sleepiness, not getting enough

sleep • Headache • Emotional limitations

– Frustration, anxiety – Irritability, embarrassment

• Activity limitations • Tremendous economic toll

– Estimates: Missed work – 3.5 million work days – Decreased productivity while at work

• School performance decreased – Estimates: 2 million school days missed

Allergic Rhinitis Impairs Quality of Life

Treatments • AVOIDANCE

– Can be best therapy if someone knows for certain to what they are allergic

– Dust mites: • Hot water washing of bedding every 1-2 weeks • Dust mite pillow encasings • Dust mite mattress encasings

– Animals: out of house, thorough cleaning • Can take MONTHS for cat dander to go down

Another option is to enlist the aid of the family dog Or wash the cat daily in cold water…

Treatments • MORE AVOIDANCE

– Masks/change clothes/shower after exposures – HEPA filters may help – 90% decrease in dog dander, - Consumer Reports – GREAT to prevent rip-offs!

Treatments: Non-medication Approaches

• SALINE : can be helpful in nonallergic or allergic rhinitis – Many, many delivery devices now – Neti pot, “sinus rinse kits” (~5 brands now), saline

sprays – Use in shower or over sink – High patient satisfaction, esp. in chronic sinusitis – Evidence-based therapy for chronic rhinosinusitis

• Warm, moist air – steam treatment, sometimes with eucalyptus oil. No studies.

Over-the-Counter Herbal Derivative

• Cromolyn sodium (Nasalcrom). Originally derived from Amni visnaga, a plant used by the Egyptians for respiratory ailments, now commercially produced in a pure form, approved by FDA. Inhibits release of allergic mediators from cells. – More effective than placebo, less than corticosteroids – Equal in efficacy to terfenadine (Seldane) over a 4 week

period • Dose: 1 whiff 4x/day – may need 6x/day to be effective • Works for early and late phase of the allergic response

– Thus, can use PRE-exposure (cat house, horseback riding, lawn mowing)

• Can be a good choice for older patients on multiple meds, patients intolerant of intranasal corticosteroids, and patients reluctant to take medications in general but who like the idea of a medication originally isolated from an herb

• Will not help non-allergic rhinitis

Other Herbals

• Butterbur: weak evidence, one small trial • Traditional Chinese medicine: potentially

dangerous (see next slide) • Multiple others without clinical trials

Adulteration of Asian herbal combination meds common

• The California Department of Health Services Food and Drug Branch tested 243 Asian herbal meds available over-the-counter: – 7% had undeclared pharmaceuticals

• Ephedrine, chlorpheniramine, methyltestosterone, phenacetin were the most common

– 10% lead, median 29.8 ppm, mean 54.9 – 14% mercury, median 329 ppm, mean 1046 ppm – 14% arsenic, median 180.5 ppm, mean 14,553 ppm

“The remaining products, which contained no detectable

adulterants, cannot be assumed to be safe and free of toxic ingredients, in view of their batch-to-batch inconsistency, as well as limitations in our detection methods”

Richard J. Ko, Pharm. D., Ph.D. California Dept. of Health Services, Sacramento, CA New England Journal of Medicine; 1998;339:p847

NEJM 1998;339:847

Major Over-the-counter Meds besides Antihistamines

• Decongestants – Decongestant Sprays (e.g., oxymetazoline)

• REBOUND RISK • Occas. use not associated with rebound and usually

well tolerated (using lowest dose that works for maximum of only 3 days)

– Tablets • insomnia, jitteriness, urinary obstruction risk,

increased blood pressure, increased pulse • Pseudoephedrine shown effective by air-flow studies

(“D” in combination pills on market) BUT RISKS GO UP WITH AGING

• PHENYLEPHRINE NOT EFFECTIVE – would not be approved by current FDA standards!!! (“PE” on cold medications)

Over-the-counter Antihistamines

• Sedating antihistamines like diphenhydramine (Benedryl) , chlorpheniramine (Chlor-trimeton): still HUGE share of market – Don’t have US data, in UK ~39% of OTC users

• “Nonsedating” antihistamines – Loratidine – sedates 6-8%. No better than placebo in some

studies, better than placebo in most studies • Note- used at higher dose abroad: can cause sedation at higher

doses – Cetirizine – sedates 10-15%. Effective. Rare strange

dreams. – Fexofenadine: nonsedating Effective.

• Must adjust dose in kidney disease – lower doses may work well (and save money!!)

RED FLAG

• Sue is taking diphenhydramine – Touted on the radio as a great allergy medication

in cheery song to help you go out and face an active day!

– Advertised on late night TV in another branded product as a sleep aid

– Could easily have contributed to the car accidents

– Can also cause dry mouth, increased heart rate or palpitations, nausea, confusion, nervousness, low blood pressure, and urinary obstruction in men

“Recommended” dose: 400 mg ibuprofen, 76 mg diphenhydramine citrate (50 mg equivalent

to what is used in branded Benedryl)

“Advil® PM caplets combine the trusted pain relieving power of Advil® with a gentle sleep aid to help you get a good night’s sleep. Whether backache, minor arthritis and other joint pain, or other minor nighttime aches and pains are keeping you up, Advil® PM caplets help you fall asleep faster and stay asleep longer.* *Compared to placebo or no treatment.”

Sedation from Antihistamines

• It is against the law to drive under the influence of any drug

• Sue has been in 2 minor accidents • Studies show we may be impaired and not

know it • Elderly, people on many meds, and sleep-

deprived people are more at risk

Sedation vs. Somnolence – how can someone be impaired and not know it?

• In this context, sedation refers to impairment of cognition and fine motor activity/reflexes

• Somnolence refers to drowsiness – measure objectively by how fast someone can fall asleep in a laboratory

• Sedation can exist SEPARATE from somnolence and BOTH are side effects – Unless someone is reading a specialized journal

though, either term is OK

Industrial accidents: increased with first generation antihistamines Group Health Cooperative of Puget Sound study 1996 Am J Ind Med 1996;30:234-9.

These include diphenhydramine, chlorpheniramine, brompheniramine and others

Rx: Nasal Corticosteroids • Over 50 trials showing superiority to

antihistamines for all symptoms including congestion

• ALL are effective; main risk nose bleeds – Many patients find they are effective just used

“as needed” so the risk for side effects is lower Rx: more antihistamines • Levocetirizine (Xyzal): 5-6% sedation • Desloratidine (Clarinex): 2.1% sedation

Other Rx Nasal antihistamine sprays • Azelastine (Astelin) approved for nonallergic

rhinitis also – Bitter taste 20%, sedation 11.5%: – Astepro formulation a little better tolerated

• Olopatadine (Patanase) – Advantage: better taste, less somnolence – 12% bitter (70% mild, 30% moderate), 0.9% sedation

Other: montelukast (Singulair) tablet not as effective as nasal corticosteroid sprays, nonsedating, can also help asthma

Allergen Immunotherapy

• Effective in older patients too • Always a balance of risks vs benefits

– Risk of a severe allergic reaction vs benefit of symptom control with reduced need for medication

– Underlying medical conditions like heart disease would mean the risk outweighs the benefit

• SAFER therapies on horizon: Sublingual immunotherapy, not approved yet by FDA

• Sue did not want to wash the cat with cold water…

• She decided to stop diphenhydramine and tried fexofenadine (Allegra) at a daily dose of ½ tablet (90 mg): felt more alert and actually had better sleep

• She also got a prescription for generic fluticasone (brand: Flonase) and found that 1 whiff about every other day controlled the congestion

Case 3: Triple Crown Winner

KP Belmont, 72 years of age, reports 15 years of nasal congestion, some runny nose and post-nasal drip. The congestion is severe and makes it difficult to breathe through his nose at night. He has tried antihistamines – no help. Tried saline flushes – no help. Tried a few brands of nasal corticosteroids – about 20% improvement. He also has high blood pressure, obesity, erectile dysfunction, enlarged prostate gland and is on multiple medications for these conditions, including lisinopril, tamsulosin (Flomax) and sildenafil (Viagra). He says he can now “pee like a racehorse”.

• On exam, reddish, swollen nasal mucosa • Allergy screening negative (knew it would be, but

Mr. Belmont really wanted to make sure) • This is due to the combination of medications,

any one of which could cause symptoms, but when we see all three….TRIPLE CROWN WINNER! – ACE inhibitors – Prostate meds – Erectile dysfunction meds (he uses at night)

Treatment

• Mr. Belmont’s primary doctor worked with him to change the lisinopril and tamsulosin to other agents with less potential for this adverse effect.

• He still had some congestion, but now found that if he used the nasal corticosteroid spray in the evening with a better technique, he could control it well.

Take away points • Rhinitis is common! • Allergic rhinitis tends to decrease with age • Nonallergic rhinitis increases with age • The conditions of, and treatments for, allergic and

nonallergic rhinitis may overlap – But oral antihistamines and cromolyn sodium spray

are not helpful in nonallergic rhinitis • Some medications can cause rhinitis, especially

certain prostate medications • Over the counter pseudoephedrine and older

types of antihistamines are NOT RECOMMENDED AT ALL FOR OLDER PEOPLE

Thank you!!