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allergic rhinitis (hay fever, ragwood allergy)

Etiology: 1) IgE-mediated hypersensitivity to nasally-inhaled allergens 2) seasonal allergens a) ragweed: mid August until 1st frost* b) tree pollen: March to May c) grass pollen: May to July 3) perennial allergens a) dust mites b) molds c) animal dander or saliva* d) cockroach antigen 4) see 'allergens causing allergic rhinitis' * seasonal allergic rhinitis & allergic conjunctivitis in late summer & early fall are most likely to be caused by weed pollen even in pet owners with dogs or cats [17] Epidemiology: - 15-30% of U.S. population [11] - may be seasonal or perennial Pathology: 1) IgE-mediated reactions against inhaled allergens [11] 2) irritation & inflammation of the nasal mucous membranes driven by type 2 helper T (Th2) cells - eyes & upper respiratory tract may also be involved 3) generally requires about 3 seasonal exposures for a patient to develop clinically significant symptoms to a new aeroallergen 4) nasal polyps may cause refractory nasal obstruction Genetics: - defects in IL13 may be a cause of susceptibility to allergic rhinitis - implicated genes: SDAD1, FOXJ1 Clinical manifestations: 1) sneezing 2) rhinorrhea (thin, clear nasal discharge) 3) postnasal drip a) erythematous, sore throat b) inflamed tonsils 4) nasal congestion a) pale, swollen nasal mucosa b) turbinate edema c) may lead to loss of taste &/or smell d) may lead to sinusitis, acute or chronic 5) allergic conjunctivitis often accompanies allergic rhinitis 6) cough 7) pruritus 8) frequent nose rubbing (allergic salute) 9) dry mouth 10) halitosis 11) fatigue 12) sleep disturbances 13) dark circles under the eyes (allergic shiners) Laboratory: 1) nasal cytology (smears) may show eosinophils 2) skin testing for allergen-specific IgE (preferred testing method) [9] 3) radioallergosorbent [RAST] testing * clinical diagnosis [9] Radiology: - computed tomography of paranasal sinuses * clinical diagnosis [9] Complications: 1) bronchitis 2) asthma (coexisting asthma not uncommon) [11] 3) pollen-food allergy syndrome [22] Differential diagnosis: 1) infectious agents a) viral, bacterial or fungal rhinitis b) sinusitis 2) non-infectious a) vasomotor rhinitis - smoke - air pollution - perfumes - detergents & soaps - solvents or fumes - changes in temperature, light, or atmospheric pressure - emotion - not seasonal, negative skin testing b) rhinitis medicamentosa - sympathomimetic nasal drops or sprays - cocaine - antihypertensives - reserpine - guanethidine - hydralazine - oral contraceptives - antidepressants c) nasal obstruction - nasal polyps - asthma, aspirin intolerance -> nasal polyps with asthma - deviated nasal septum - nasal neoplasm - foreign body - hypertrophic turbinates or adenoids d) systemic disorders - rhinitis of pregnancy - hypothyroidism - Wegener's granulomatosis - sarcoidosis - ciliary - cystic fibrosis - Sjogren syndrome e) cerebrospinal fluid leak (CSF rhinorrhea) f) atrophy of nasal mucosa Management: 1) also see allergic rhinoconjunctivitis 2) avoidance of allergen 3) intranasal glucocorticoids (most effective agents) [9,12] a) also reduces ocular symptoms of allergic conjunctivitis [12] b) intranasal glucocorticoids 1] beclomethasone (Beconase, Vancenase) - 1 spray (42 ug) BID-QID 2] flunisolide (Nasalide) - 2 sprays (50 ug) BID 3] triamcinolone (Nasocort) - 2 sprays (110 ug) QD 4] budesonide [3] c) monotherapy with intranasal glucocorticoids initial treatment [15] d) as-needed intranasal glucocorticoids might not be quite as good as daily, but glucocorticoid exposure will be less [20] e) intranasal glucocorticoid plus antihistamine combination may be better than glucocorticoid alone [7] f) intranasal glucocorticoids do not improve asthma control [13] 4) antihistamines a) azelastine (Astelin) 2 sprays/nostril BID (nasal spray) - intranasal antihistamine 1st add on treatment to intranasal glucocorticoid [15] b) loratadine (Claritin) 10 mg PO QD c) fexofenadine (Allegra) 60 mg PO BID d) astemizole (Hismanal) 10 mg PO QD e) chlorpheniramine 4 mg PO TID/QID 5) nasal ipratropium 6) decongestants - effective but associated with rebound congestion (rhinitis medicamentosa) - pseudoephedrine (Sudafed) 30-60 mg QID - oxymetazoline (Afrin) intranasal enhances effectiveness of intranasal glucorticoids without rebound congestion - used alone may be associated with rhinitis medicamentosa [9] - phenylephrine no better than placebo for nasal congestion [14] 7) montelukast (Singulair) 10 mg PO QD (adults) - NOT more effective than antihistamines or decongestants - NOT first line [12] 8) prednisone 40 mg PO QD for 5 days for very severe symptoms 9) nasal chromolyn (Nasalchrom) a) one spray (5.2 mg) TID/QID b) prophylactic dosing c) variable response 10) tolerance induction (immunotherapy) a) injection of allergen defined by RAST or skin testing b) best response with seasonal allergies c) patients with severe rhinitis not well controlled with intranasal glucocorticoids, antihistamines, decongestants [10] d) contraindicated with beta blocker therapy 1] systemic or ocular 2] increases likelihood of adverse systemic reaction 3] diminished response to epinephrine rescue e) subcutaneous immunotherapy (SCIT) or 'allergy shots' may someday be replaced by daily sublingual-dissolving tablets that contain allergens [11,14] f) sublingual therapy for allergic rhinitis in U.S. limited to treatment of grass & ragweed allergy [11] 11) pregnancy a) oxymetazoline nasal spray for 5 days b) pseudoephedrine c) intranasal cromolyn d) intranasal beclomethasone e) chlorpheniramine if unresponsive to cromolyn f) treat sinusitis 12) acupuncture of little of no benefit [8] 13) patient education a) dust mites 1] keep humidity < 50% 2] wash sheets in hot water every week 3] encase mattress, boxspring & pillows in plastic 4] remove carpet, dust floors frequently b) mold 1] keep humidity < 50% 2] vent bathrooms & clean with fungicidal agent 3] remove books & plants from the bedroom 4] install air filters c) animal dander 1] remove pets from house 2] bathe pets frequently (at least every week) 3] shampoo carpets d) pollen 1] avoid outdoors during pollen season 2] keep windows closed (use air conditioning) 3] install air filter units for air conditioning 14) Refer to allergist if response to treatment is poor & diagnosis of allergic rhinitis seems probable - empiric treatment failure prior to referral [9] 15) Refer to ENT specialist if response to treatment is poor & diagnosis of allergic rhinitis is questionable. 16) turbinate surgery is an option for patients refractory to medical therapy - improvement in congestion lasts at least one year [21]

Related

allergen skin testing allergens causing allergic rhinitis allergic conjunctivitis; Angelucci's syndrome radioallergosorbent [RAST] testing

Specific

allergic rhinoconjunctivitis (hayfever)

General

type 1 hypersensitivity; immediate hypersensitivity (allergy) rhinitis

Database Correlations

OMIM 607154

References

  1. Singulair (Montelukast) for Seasonal Allergic Rhinitis Prescriber's Letter 10(2):9 2003 Detail-Document#: 190210 (subscription needed) http://www.prescribersletter.com
  2. Meltzer EO. Evaluation of the optimal oral antihistamine for patients with allergic rhinitis. Mayo Clin Proc. 2005 Sep;80(9):1170-6. PMID: 16178497
  3. Prescriber's Letter 13(4): 2006 Drug Treatments for Allergic Rhinitis Detail-Document#: 220414 (subscription needed) http://www.prescribersletter.com
  4. Prescriber's Letter 16(8): 2009 GUIDELINES: The Diagnosis and Management of Rhinitis: An Updated Practice Parameter Detail-Document#: 250805
  5. Prenner BM et al. Mometasone furoate nasal spray reduces the ocular symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol 2010 Jun; 125:1247 PMID: 20434199 http://dx.doi.org/10.1016/j.jaci.2010.03.004
  6. Baroody FM et al. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol 2011 Apr; 127:927. PMID: 21377716
  7. Carr W et al. A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol 2012 May; 129:1282. PMID: 22418065
  8. Brinkhaus B et al. Acupuncture in patients with seasonal allergic rhinitis: A randomized trial. Ann Intern Med 2013 Feb 19; 158:225 PMID: 23420231
  9. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  10. Calderon MA, Alves B, Jacobson M, Hurwitz B, Sheikh A, Durham S. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001936. PMID: 17253469
  11. Wheatley LM, Togias A Clinical practice. Allergic Rhinitis N Engl J Med 2015; 372:456-463. January 29, 2015 PMID: 25629743 PMCID: PMC4324099 Free PMC article http://www.nejm.org/doi/full/10.1056/NEJMcp1412282
  12. Seidman MD et al Clinical Practice Guideline. Allergic Rhinitis. Otolaryngol Head Neck Surg. Feb 2015 152(1): suppl S1-S43 PMID: 25645524 http://oto.sagepub.com/content/152/1_suppl/S1.full
  13. Dixon AE et al. Efficacy of nasal mometasone for the treatment of chronic sinonasal disease in patients with inadequately controlled asthma. J Allergy Clin Immunol 2015 Mar; 135:701. PMID: 25174863 http://www.jacionline.org/article/S0091-6749%2814%2900957-9/abstract - Greenberger PA. Will a nasal corticosteroid improve control for patients with step 3 or higher persistent asthma? J Allergy Clin Immunol 2015 Mar; 135:710. PMID: 25630938 http://www.jacionline.org/article/S0091-6749%2814%2903710-5/abstract
  14. Meltzer EO et al. Oral phenylephrine HCl for nasal congestion in seasonal allergic rhinitis: A randomized, open-label, placebo-controlled study. J Allergy Clin Immunol Pract 2015 Sep/Oct; 3:702 PMID: 26143019
  15. Wallace DV, MD; Dykewicz MS, Oppenheimer J et al Pharmacologic Treatment of Seasonal Allergic Rhinitis: Synopsis of Guidance From the 2017 Joint Task Force on Practice Parameters. Ann Intern Med. 2017. Nov 28. PMID: 29181536 http://annals.org/aim/fullarticle/2664375/pharmacologic-treatment-seasonal-allergic-rhinitis-synopsis-guidance-from-2017-joint
  16. Anello J, Feinberg B, Lindsey R et al Seasonal Allergic Rhinitis Clinical Practice Guidelines, December 2017 Medscape. Dec 6, 2017 https://reference.medscape.com/viewarticle/889632_13 - Harrison P. New Guidelines for Allergic Rhinitis Change Treatment. Medscape News. WebMD Inc. November 9, 2017. https://www.medscape.com/viewarticle/888269 - Dykewicz MS, Wallace DV, Baroody F, et al. Treatment of Seasonal Allergic Rhinitis: An Evidence-Based Focused 2017 Guideline Update. Ann Allergy Asthma Immunol. 2017 Nov 2. PMID: 29103802 http://www.annallergy.org/article/S1081-1206%2817%2930656-7/addons
  17. NEJM Knowledge+ Question of the Week. Nov 27, 2018 https://knowledgeplus.nejm.org/question-of-week/1275/
  18. Shah R, Grammer LC. Chapter 1: an overview of allergens. Allergy Asthma Proc 2012 Jul 20; 33 Suppl 1:S2. PMID: 22794674
  19. NEJM Knowledge+ Question of the Week. Dec 3, 2019 https://knowledgeplus.nejm.org/question-of-week/1236/ - Bernstein DI et al. Allergic rhinitis: mechanisms and treatment. Immunol Allergy Clin North Am 2016 May; 36:261 PMID: 27083101 - Sur DK, Plesa ML. Treatment of allergic rhinitis. Am Fam Physician 2015 Dec 1; 92:985 PMID: 26760413 Free full text
  20. Thongngarm T et al. As-needed versus regular use of fluticasone furoate nasal spray in patients with moderate to severe, persistent, perennial allergic rhinitis: A randomized controlled trial. J Allergy Clin Immunol Pract 2021 Mar; 9:1365. PMID: 33049392 https://www.sciencedirect.com/science/article/abs/pii/S2213219820311077
  21. Park SC et al. Long-term outcomes of turbinate surgery in patients with allergic rhinitis. JAMA Otolaryngol Head Neck Surg 2023 Jan; 149:15 PMID: 36394879 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2798896
  22. NEJM Knowledge+ Allergy/Immunology