Allergic Rhinitis

Allergic Rhinitis (AR) Overview

❖The most common atopic disease
❖The hallmark of ~: a temporal relationship between
the exposure to allergens & the development of nasal
symptoms
❖It takes at least 2 years of exposure to
aeroallergens (airborne environmental allergens)
to develop AR (thus, very rare in children <1 year)
❖The prevalence of AR: lowest in children < 5 yrs
highest 2nd---- 4th decades
❖Most patients develop symptoms before age 30
❖Genetic predisposition (60%)....FH of atopy
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 Definitions
Allergic Rhinitis (AR) is defined as inflammation of the inside
lining of the nose that occurs when a person inhales
something he/she is allergic to, such as animal dander(hair) or
pollen

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 examples of the
symptoms of AR
 Rhinorhoea
 Nasal blockage
 Postnasal drip
 Itchiness
 Sneezing
 Associated health
effects ([Link]
drip, cough, irritability, and
fatigue )

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 Classification

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Features of Common Rhinitis Symptoms
Allergic Infectious Vasomotor rhinitis Rhinitis
rhinitis rhinitis Medicamentosa
Etiology Allergen Viral or Unknown Tachyphylaxis to
bacterial topical decongestants
Symptoms Rhinorrhea, Fever (more Rhinorrhea, Congestion
congestion, common in congestion
sneezing, children),
pruritis, cough mucupurulent
with postnasal rhinorrhea,
drip, ocular scratchy throat,
itching etc congestion,
cough
Pattern Perennial or Any time Any time Temporal relationship
seasonal with use of topical
decongestant
Associated Concurrent None Affects women Overuse of topical
Factors atopic disease, primarily, strong decongestants,
family history odours, alcohol, stress, concurrent use of
change in humidity antihypertensive
and temperature therapy……etc
• AR is classified as seasonal or perennial
• Seasonal: repetitive and predictable symptoms
(severe(
• Perennial: symptoms persist throughout the year
without any obvious seasonal pattern
• WHO: replace terms with intermittent or persistent

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Overview Pathophysiology Classification/Diagnosis Co-morbidities Management
Perennial Allergic Rhinitis
 Caused by continuous exposure to many different types
of allergens
 Dust Mite→ the most common cause of perennial
allergic rhinitis
 Commonly: household dust mites, molds,
cockroaches, house pets
 Less commonly: cottonseed & flaxseed (found in
fertilizers, hair setting preparations and foods); some
vegetable gums (found in hair setting prep & foods)
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Perennial Allergic Rhinitis
 Dust mite: thrive in carpets, beddings & reproduce best in
warm (18-21ºC) humid (>50%) environment found in most
homes.
 Mites feed on human skin scales and their own faeces.
 Mite itself is not allergen, the main allergen is the
glycoprotein that coats their faeces.
 Dust mite remain airborne for about 30 minutes after being
disturbed.
 Molds: grow best in warm, moist environment.
 Cat-derived allergens: light small proteins secreted
through the sebaceous glands in the skin. May remain
airborne for up to 6 hrs. Can be detected at home even 6
months after removal of the cat.
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Seasonal Allergic Rhinitis
 Caused by wind-borne plant pollens
(e.g. tree, grass. etc).
 “hay fever”, and “rose fever” are
terms related to seasons associated
grass pollinosis and NOT
associated with FEVER!
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 Chronic Rhinitis Not Related to Allergies
 Nasal Polyps
 soft, fluid-filled sacs
 impede mucus
drainage and restrict
airflow
 develop from sinus
infections, do not
regress on their own
and may multiply and
cause considerable
obstruction
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 Drug-Induced Rhinitis
Chronic Rhinitis Not Related to Allergies
 Medications and Illegal Drugs
 overuse of decongestant sprays can, over time (three to
five days), cause inflammation in the nasal passages
and worsen rhinitis, Rhinitis Medicamentosa
 Oral contraceptives, hormone replacement
therapy, anti-anxiety agents, some
antidepressants, and some blood pressure
medications, including beta-blockers and
vasodilators
 Sniffing cocaine damages nasal passages and can
cause chronic rhinitis
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Overview Pathophysiology Classification/Diagnosis Co-morbidities Management
Diagnosis in Primary Care Setting
Allergic shiners is a dark
discoloration below the eye
Arched palate because of
mouth breathing

Periorbital
edema
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Diagnosis of Allergic Rhinitis
Demonstration of IgE allergy

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 Immunoassay vs Skin Test for
Diagnosis of Allergy

Immunoassay Skin test

 Not influenced by  Higher sensitivity
medication
 Immediate results
 Not influenced by skin
disease  Requires expertise
 Does not require  Cheaper
expertise Skin testing is particularly useful among patients with:
 Quality control possible An unclear diagnosis based upon the history and physical
examination
Poorly controlled symptoms, such as persistent nasal
 Expensive symptoms and/or an inadequate clinical response to nasal
glucocorticoids
Coexisting persistent asthma and/or recurrent
sinusitis/otitis
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 Allergy can affect different children in
different ways

Food Allergy

Atopic Dermatitis

Allergic Rhinitis

Allergic Childhood Asthma

Atopy is the inherited tendency to
develop harmful immune
responses to harmless substances Adult Asthma

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➢ AR commonly presents in childhood as
recurrent sore throats and upper
respiratory tract infections

➢ Diagnosis of AR is often missed in children,

who are thus treated inappropriately with
multiple doses of antibiotics.

➢ Chronic cough is common symptom of AR

or sinusitis in children resulting from postnasal
drip and irritation of the larynx.

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Lack G. J Allergy Clin Immunol 2001;108:S9-15

Complications

Patients who develop:

 fever,
 purulent nasal discharge,
 frequent HA, refer to Dr. for evaluation
and treatment
 earache

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 When to refer?
When? Why?
Wheezing and shortness of Possibility of asthma attack
breath (seasonal)
Tightness of chest
Painful ear Secondary bacterial infection in
the middle ear
Painful sinuses Secondary bacterial infection
Purulent conjunctivitis (redness, Secondary bacterial infection
with coloured and sticky eye
discharge)
Failed medication -For advanced stage therapy
-To suggest ideas for the next
season
 Management/Non pharmacological therapy
House dust mite allergen avoidance
 Provide adequate ventilation to decrease humidity
 Wash bedding at least weekly in hot 130 F ( 45.4 C)
 Encase pillow, mattress and quilt in allergen impermeable covers
 Use vacuum cleaner with HEPA filter
 Dispose of feather bedding
 Remove carpets
 Remove curtains, pets and stuffed toys from bedroom
 Indoor mold exposure is minimized by lowering house hold humidity, removing
house plants, and frequently applying fungicide to moldy areas
 Cat derive allergen
 Trees pollinate in march to April

Nasal wetting agents ( saline, propylene, PEG sprays) relieve nasal mucosal irritation and
dryness, decreasing nasal stuffiness, rhinorrhea and sneezing

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Management/pharmacological therapy
Therapeutic options for AR

Immunotherapy helps prevent the development of asthma in children with allergic

rhinitis, and thus should be given special consideration in the pediatric population.

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 Step ladder treatment of AR: ARIA

moderate
severe
mild persistent
moderate persistent
severe
intermittent
mild
intermittent
Intra-nasal steroid
Local cromone

Oral or local non-sedative H1 blocker

Intra-nasal decongestant (< 5 days) or oral decongestant
Allergen and irritant avoidance

Immunotherapy

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Management of Allergic Rhinitis: ARIA

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 Second-Generation (Nonsedating) Antihistamines
 The newer second-generation antihistamines do not usually
cause drowsiness to the extent that the first generation
antihistamines do.
 Loratadine is approved for children age two years and
over. OTC
 Desloratadine is similar to Loratadine but significantly
more potent and longer lasting. It is available only by
prescription.
 Cetirizine (Zyrtec) is approved for both indoor and outdoor
allergies. It is the antihistamine to date approved for infants
as young as six months. OTC
 Fexofenadine (Telfast) OTC
 Levocetirizine (Xyzal) only by prescription.
 Studies suggest that cetirizine (Zyrtec) is more effective than either of
these other agents in improving symptoms, including in children,
although cetirizine causes more drowsiness at higher doses.
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Second-Generation (Nonsedating) Antihistamines
 First line treatment for mild allergic rhinitis
 Effective for
 Rhinorrhea
 Nasal pruritus
 Sneezing
 Less effective for
 Nasal blockage
 Possible additional anti-allergic and anti-inflammatory
effect
In-vitro effect > in-vivo effect

 Minimal or no sedative effects
 Once daily administration
 Rapid onset and 24 hour duration of action
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 Topical antihistamines
 Azelastine (potent, second-generation, selective
histamine antagonist)

 Nasal spray for mild and intermittent symptoms of

allergic rhinitis in adults and children > 5 years

 Start using 2-3 weeks before the hay fever season

 Instruction for administration: Keep the head

upright during use to prevent the liquid trickling
into the throat
 Decongestants
 Can be oral or topical

 Preferred to be used in combination with

antihistamines, nasal corticosteroids or
sodium cromoglycate

 Be aware of “rebound congestion” when

topical decongestants are used for > 3 days
→ They should NOT be used for > 1 week

Pseudoephedrine is a common oral

decongestant. Nasal Phenylephrine,
Oxymetazoline, Xylometazoline
 Corticosteroid Nasal Sprays
Benefits:
 The most effective agents currently available for treating
moderate-sever allergic rhinitis.
 Blocks the inflammatory response that triggers an allergic
attack. They do not relieve symptoms immediately but may
take several hours before their effects are felt.
 They reduce inflammation and mucus production.
 They improve night sleep and daytime alertness in
patients with perennial allergic rhinitis.
 Beneficial in treating polyps in the nasal passages.

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 Nasal Corticosteroids
• Most potent anti-inflammatory agents
• Effective in treatment of all nasal symptoms
including obstruction
• Superior to anti-histamines and anti-leukotienes
• First line pharmacotherapy for persistent allergic
rhinitis
 Nasal Corticosteroids
Beclomethasone dipropionate, Budesonide(Rhinocort),
Ciclesonide, Flunisolide, Mometasone furoate (Nasonex),
Triamcinolone (Nasacort), Fluticasone (Flonase).
 Instructions:
-Regular use is essential for full benefit of the
treatment
-Treatment should be continued throughout the
hay fever season, up to 3 months
-Several days delay in response
-Not preferred for patients < 18 years old
-Contraindicated in glaucoma and other
disorders
•Overall safe to use
•Adverse Effects
Nasal irritation, Epistaxis, Septal perforation (extremely rare), HPA axis
suppression,Suppressed growth
 Sodium cromoglycate (cromoglicate)
 Mast cell stabiliser. Available as:
Nasal drops, nasal sprays, and eye drops

 Best use: prophylactic

 Administration: 1 week before the hay fever season, and

continuously

 Side effects: occasional nasal irritation, sneezing, nasal stinging

& burning
 Safe to use during pregnancy, advanced age, children 6 years
 Eye drops: second line after the antihistamines, 4 times daily
 Nasal Antihistamines
 Efficacious and equal to or superior to oral
antihistamines for treatment of SAR
 Clinically significant effect on nasal congestion
 Improved nasal symptoms in patients who
failed oral antihistamines
 Onset of action: 30 vs. 60-180 minutes for oral
antihistamine

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 Topical corticosteroids and oral antihistamines
(non-sedating) form the mainstay of treatment
 The newer topical steroids e.g. Mometasone furoate
and Fluticasone propionate were highest
recommended
 Other drugs should only be considered as second-line
treatment.

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 Anti-Leukotriene Treatment in Allergic
Rhinitis-NOT OTC
Efficacy
• Equipotent to H1 receptor antagonists but with
onset of action after 2 days
• Reduce nasal and systemic eosinophilia
• May be used for simultaneous treatment of allergic
rhinitis and asthma
Safety
• Dyspepsia (approcimately 2%)

FDA Panel Rejects OTC Use of Montelukast

(SingulairAllergy)
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 SPECIAL CIRCUMSTANCES
PAEDIATRIC ALLERGIC RHINITIS
 4 years and older should be treated as for adults
 Children (>4) with AR and Asthma can be treated
with combination of newer generation topical
and inhaled corticosteroids with low risk of
complications
 Diagnosis in smaller children is difficult as can
have up to 6 to 8 colds per year
 Small children – oral antihistamines, saline
sprays and corticosteroids if symptoms severe
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ALLERGIC RHINITIS IN PREGNANCY
 One in five pregnant women will
experience rhinitis symptoms (2nd or
3rd trimester)
 Hormonally induced
 Spontaneously resolves within few
weeks after delivery
 Limited therapeutic options
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 Nasal Saline
 Women with mild rhinitis may be able to control symptoms
using only saline nasal sprays or irrigation.
▪ Saline (salt water) washes the mucus and irritants from the
nose.
▪ The sinus passages are moisturized.
▪ Studies have also shown that a nasal irrigation improves cell
function (the cells that move the mucus work better).

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 Nasal corticosteroids – all Category C except
Budesonide which was recently reassigned B – nasal
steroid of choice
 Triamcinolone (category C) should be avoided in the
first trimester, may increase the risk of congenital
respiratory defects.

 Oral steroids…. C

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 Decongestants
 Pseudoephedrine should be avoided during the first
trimester of pregnancy if possible, because its safety has not
been confirmed.
 After the first trimester, it should be used only when
needed and only as directed.
 it should not be used at all by women with high blood
pressure or preeclampsia.
 Phenylephrine should be avoided altogether during
pregnancy

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 During breastfeeding
 Intranasal corticosteroids: while studies of intranasal use are
limited, systemic use does not appear to pose significant risk.
 Topical use should be safer since absorption is less in comparison.
 Similarly, untoward effects on a breastfed infant are not expected.
 Beclomethasone has been in use longer, thus having a greater
amount of evidence of safety
 Second-generation antihistamines: these are generally considered
safe in breastfeeding.
 The safety data is most proven for loratadine.
▪ Intranasal sodium cromoglycate: these are considered safe for use
in breastfeeding
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