PR2154 IC10 Allergic rhinitis

What is rhinitis?

Symptomatic inflammation of the inner lining of the nose

* rhinorrhea
* sneezing
* nasal congestion
* nasal itch

>2 consecutive days >1h each

Which part of the nose is inflammed in rhinitis?

The inner lining

What are the types of rhinitis?

Allergic Rhinitis

Infectious Rhinitis

Non- Allergic rhinitis

What are some causes behind non-allergic rhinitis?

Drug induced

Hormonal changes (pregnancy, menstrual cycle)

Idiopathic or vasomotor (strong smell or change in temp)

Structural (septal deviation, polyps)

Traumatic

What are some drugs that can use drug induced non-allergic rhinitis?

NSAIDs

Antihypertensive

Oral contraceptive

prolonged use of topical congestants (rhinitis medicamentosa)

antidepressants

sedatives

Phosphodiesterase 5 inhibitor (for ED)

Which immunoglobulin causes allergic rhinitis?

Induced after allergen exposure by an IgE mediated inflammation of the membrane lining the nose

What are the types of allergic rhinitis?

Seasonal (SAR) → cyclical exacerbation

Perennial (PAR) → year round symptoms

What are the types of allergens?

**Outdoor allergens → seasonal**

* pollen (trees, grasses, flowers etc)
* Mould spores

**Indoor allergen**

* Dust mites (chemical in their faeces)
* animal dander
* cockroaches
* mould spore (house plants)
* cigarette smoke

**Occupational allergen**

* wood dust
* latex
* resins
* chemical (isocyanate, glutaraldehyde)

**Ingested allergens**

* wheat
* eggs
* milk
* nuts

What is the pathology underlying allergic rhinitis?

Exposure to allergen → CD4+ TH2 activated B cells activated → allergens bind to allergen specific IgE (produced by B cells) → crosslinking with IgE receptor on mast cells

→ **1. Mast cell degranulation**

* Protease
* Histamine → itching, paroxysmal sneezing, vasodilation, plasma exudation

→ 2. **Mast cell activation**

* PGDs → rhinorrhea
* Kinins (bradykinins) → itchy sore throat
* neuropeptides → vasodilation
* all contribute to nasal congestion

What are some classical symptoms of allergic rhinitis?

Rhinorrhea (clear and watery)

Nasal congestion

Sneezing (usually paroxysmal)

Puritis of ears, eyes and nose

* symptoms usually worse in the morning and at night
* gets better in day

What are some other manifestation of allergic rhinitis?

Post nasal drip (can cause sore throat)

Ophthalmic symptoms (itch, irritation, allergic conjunctivitis)

Headache

Pain

Nose bleed

What are some face features of allergic rhinitis?

Allergic shiners (black under eye)

Dennie-Morgan folds (line under eye)

Allergic crease (line on nose)

What are some indicative differences between Allergic rhinitis and non-allergic rhinitis?

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What are some risk factors for allergic rhinitis?

Environmental

* pollution
* irritants

Exposure to allergens

Genetic and family history

* Family history of atopy (asthma, atopic dermatitis)
* Filaggrin gene mutation (impaired skin protective barrier due to lack of filaggrin protein)

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What are the conditions closely related to allergic dermatitis?

Asthma

Atopic dermatitis

The atopic march → allergic triad

What are the associated conditions patients suspected of allergic rhinitis should be assessed on?

Sinusitis

Eustachian tube dysfunction

Otitis media

Sleep apnea (due to nasal congestion)

Dentofacial abnormalities

What are the classifications of allergic rhinitis?

Mild Intermittent, Moderate to severe Intermittent (IAR)

Mild persistent, Moderate to severe persistent (PER)

What is classified as Mild intermittent allergic rhinitis?

What is classified as Moderate to severe intermittent allergic rhinitis?

What differentiates between mild and moderate to severe?

As long as it affects QOL, it is moderate to severe

What is classified as mild persistent allergic rhinitis?

>4 days per week **AND** > 4 weeks per stretch

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**NO impairment on quality of life:**

* normal sleep
* no impairment of daily activities, sport, leisure
* Normal work and school
* No troublesome symptoms

What is classified as a moderate to severe persistent rhinitis?

>4 days per week **AND** > 4 weeks per stretch

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**Affects one or more Quality of life:**

* Abnormal sleep
* Impaired daily activities, leisure, sports
* Impacts school and work
* troublesome symptoms

What differentiates between intermittent and persistent?

4 days per week 4 weeks per stretch rule

How do we diagnose allergic rhinitis?

History

* symptoms
* temporal patterns
* **allergen history and family history**

Examinations

Allergy testing

* prick test
* radioallergoabsorbent tests for specific IgE (RAST)
* Nasal allergen challenge

According to ARIA 2008, what is suggestive of allergic rhinitis?

2 or more of the following symptoms for >1hr on most days:

watery rhinorrhea

Sneezing, esp paroxysmal

Nasal congestion

Nasal pruritis

conjunctivitis

When should you refer the patient to the specialist/physician?

**Special population**: Children<12y, pregnant women (unless approved by doctor)

**Symptoms of non-allergic rhinitis**

Symptoms of other associated conditions

Undiagnosed or uncontrolled **asthma, COPD** or other lower resp tract infection **LRTI**

Moderate or severe persistent allergic rhinitis

**Not responding** to treatment

Severe or unacceptable side effects of treatment

Medication induced rhinitis

What are some non-allergic rhinitis symptoms that render referral?

Unilateral symptoms

Mucopurlent discharge

facial pain

anosmia

Fever>38

Infection

Nasal obstruction with no other symptoms

What do you need to do when assessing a patient suspected of allergic rhinitis?

1. Assess signs and symptoms


1. Nature
2. Severity
3. Duration
4. Onset
5. location
6. Aggravating / remitting factors
7. Presence of other associated symptoms
2. Gather age, history of allergen exposure, family history of atopy, medical history
3. Check for pregnancy and lactation

What are some questions to ask on the nature of the symptoms?

Sneezing? → how much

Rhinorrhea? → nature of discharge

Itchy eyes? Nose? ears?

Nasal congestion?

Bilateral or Unilateral

What are the situations that require urgent referral?

Shortness of breath (SOB)

Uncontrolled asthma

High fever

Severe headache or eye pain

What are the options for allergic rhinitis management?

1. Allergen avoidance & Environmental control
2. Pharmacotherapy
3. Immunotherapy

What are some ways patients can avoid and control **House dust mites allergen?**

Remove dust

* no dust collecting items (carpet, soft toys)
* no carpets

Protect patients

* encase bedding with impermeable covers

Control mites

* wash bedding with hot cycles >55
* vaccuum with HEPA filter
* Acaricides
* Maintain humidity 35-50%

What are some ways patients can avoid and control **cockroaches allergens?**

Careful food prep

Put food away, wash dishes, garbage tightly sealed

Use cockroach trap

Professional help

What are some ways patients can avoid and control **pets danders allergens?**

Remove pet

if not:

* keep pet out of house
* keep pet out of bedroom
* keep pet in uncarpeted room with HEPA filter
* Wash pet frequently
* Wash hands after handling animal

What are some ways patients can avoid and control **moulds allergen?**

Remove potted plants

Remove visible molds

Dry or remove wet carpets

Fix leaks

Ensure adequate ventilation

Control humidity

What are the pharmacotherapy available for allergic rhinitis?

What are the topical pharmacotherpy options available?

Intranasal H1 antihistamine (as combination)

Intranasal Corticosterioids (INC) → most effective

Intranasal decongestants

Intranasal cromones (not in SG)

Intranasal anticholinergics (exemption item)

What are the oral pharmacotherpy options available?

Oral H1 antihistamine ( 2nd gen preferred)

Oral corticosteroids (short course 5-7 days)

Oral decongestants

leukotriene antagonist

What are the options for topical intranasal H1 antihistamine?

Azelastine (+ fluticasone)

Olopatadine (Mometasone)

Both POM items

What are some side effects of Intranasal H1 antihistamines? (Azelastine, olopatadine)

Somnolence (Aze>olo)

Bitter taste

headache

Nasal discomfort

epistaxis (nose bleed)

Dizziness

Fatigue

What are some side effects of Intranasal corticosteroids?

Minimal systemic side effects

Local: Dryness, nasal irritation, occasional epistaxis

What are some precaustions for intranasal corticosteroids?

May worsen patients with cataract, glaucoma

What are the options of Intranasal corticosteroids available?

First gen: Systematic bioavailbility 10-50%

* Triamcinolone

Second gen: systemic bioavailability <1% or undetectable

* mometasone
* Fluticasone fuorate/proprionate

What is a special consideration for P+ item?

>18 YEAR OLD

What is the intranasal anticholinergic given as adjunct for rhinorrea?

Ipratropium

What is the adjunct option for uncontrolled rhinorrea?

Intranasal anticholinergic → Ipratropium

What is Leukotriene antagonist used in?

Not firstline anymore

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Used in children and adolescents with asthma and allergic rhinitis

IT might have a place in patient with asthma

Why is leukotriene no longer firstline?

Neuropsychiatric effects

need to inform patients and caregivers to be alert to changes in behaviour or new neuropsych symptoms

What are the agents considered for **mild intermittent AR?**

Oral H1 antihistamine

Intranasal H1 antihistamine+ decongestant

What are the agents considered for **moderate to severe intermittent AR?**

Intranasal Corticosteroids INCs

Intranasal H1 antihistamine + decongestants

Oral H1 Antihistamine

What are the agents considered for **mild persistent AR?**

Intranasal Corticosteroids INCs

Intranasal H1 antihistamine + decongestants

Oral H1 Antihistamine

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review patients after 2-4 weeks

What is the monitoring for mild persistent AR?

review patients after 2-4 weeks

* failure → step up
* improved → continue for 1 month

What are the agents considered for **moderate to severe persistent AR?**

Firstline: Intranasal corticosteroids (INCs)

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Review patient after 2-4 weeks

* improved→ continue for 1 mo
* failed → review
* Add or increase INC dose
* Rhinorrhoea→ add ipratropium
* Nasal congestion → Decongestant or Oral CS
* Still failed → refer

What to do when patient also has conjunctivitis?

Intraocular H1 antihistamine (eyedrops)

oral H1 antihistamine

What do the T1 T2 T3 T4 T5 stand for?

T1→ Oral/intranasal/ocular h1 antihistamine

T2→ Intranasal CS

T3 → Intranasal CS + Intranasal H1 antihistamine

T4→ short course CS (5-7 days)

T5→ Referral for Immunotherapy

How do you do step up treatment?

What should you give acc to ARIA?

How do you do step down?

What is the safest option for pregnant woman?

Saline nasal rinse

INCs→ Budesonide

Oral antihistamine → Loratadine, cetirizine preferred after 1st trimester after discussion with obstetrician (avoid 1st gen)

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What is contraindicated for pregnant woman?

Oral and nasal decongestant

What is the safest option for lactating woman?

saline nasal rinse

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All intranasal CS are probably safe

What is contraindicated in lactating women?

Avoid oral and nasal decongestant → limit breast milk secretion

What are the patient education points?

1. Environmental control measures
2. Appropriate use of device
3. Common side effects
4. When to seek medical assistance


1. new symptoms
2. doesnt get better

What is the monitoring for allergic rhinitis?

Review response to therapy after 2-4 weeks of treatment

Who is suitable for immunotherapy for AR?

Patient with moderate to severe rhinitis

* not adequately controlled
* experienced unacceptable adverse events
* want to reduce long term use of med
* able to comply with protocol
* Allergic asthma

Who is not suitable for immunotherapy for AR?

Uncontrolled asthma

Patient taking beta blockers

What are the score and grade of AR control? Visual Analogue scale

>50mm uncontrolled AR

20-50mm partially controlled

<20mm well controlled

How do you administer nasal spray?

Administration of intranasal Steroid Sprays


1. Wash your hands well with soap and water.
2. Remove the packaging from the nasal spray pump.
3. Some nasal sprays need to be **primed before use**. As well, some nasal sprays **need to be shaken**. If your spray needs to be primed before using, squeeze it a few times into the air as directed until a fine mist appears.
4. Gently blow your nose to clear your nostrils
5. **Tilt you head forward**, depress one nostril, insert the tip into other nostril. Aim the **nozzle away from the nasal septum** and gently squeeze the nozzle. Inhale gently and breathe out through the mouth after each spray
6. If more than 1 spray is required per nostril, alternate the spray between nostrils one by one to prevent medication wastage.
7. If **taste** of medicament is present, **rinse mouth after use.**
8. Put the cap back onto the nasal spray container.
9. Try not to blow your nose for several minutes after using the spray.