Allergic rhinitis also referred to as allergic rhinosinusitis affects 10 to 30 percent of patients yearly in the U.S. and other industrialized nations. Over the years, the number of children and adults afflicted has increased. The number of patient visits and dollars spent in purchasing related medications for adults and children has also grown. These ascents have subsequently impacted quality of life. Consequently, the aggregate of missed school days per year related to allergic rhinitis is 2.5 million and that of missed work days per year is 6 million. This article will endeavor to discuss the clas- sification, symptoms and treatment options associated with allergic rhinosinusitis
In defining allergic rhinitis, two classifications are used. The first, established by the World Health Organization (WHO), delineates it based on temporal pattern and severity. The temporal pattern is further categorized into intermittent and persistent. Intermittent symptoms last less than four days per week or less than four weeks. Persistent symptoms lasts four days per week and more than four weeks. The severity of the symptoms is broken down into mild or moderately severe. Moderately severe symptoms may interfere with school or work performance. They may also impede daily sports or leisure activities. Finally, they may impair sleep. Mild symptoms would hinder none of the aforementioned functions or activities.
The second classification, preferred by the Food and Drug Adminis-tration (FDA), distinguishes allergic rhinosinusitis based on its timing during the year. Perennial symptoms occur year round and seasonal symptoms occur at certain predictable times of the year. Seasonal symptoms usually are triggered by pollen from trees, grass, and weeds. Perennial symptoms typically are initiated by household al- lergens such cockroaches, mold, and pet dander.
Certain preexisting factors raise one’s risk of developing allergic rhinitis. These include: being male, being born during pollen sea- son, having a positive family h/o allergies, being a firstborn, being exposed to a mother who smokes within the first year of one’s life; early use of antibiotics and exposure to indoor allergens such as dust mites.
To develop allergic rhinitis, one has to be exposed to the allergen over several years. Consequently, it is improbable for someone younger than 2 years of age to have allergic rhinosinusitis. Unless the environment has changed significantly, it is also uncommon for someone to develop allergic rhinitis for the first time later in life.
Symptoms of rhinosinusitis may include nasal congestion, runny nose, itchy throat, itchy eyes, itchy nose itchy palate, watery eyes, cough, feeling of liquid running in the back of the throat, fatigue, moodiness, clearing of the throat, sniffling or snorting and intermit- tent sneezing.
Upon evaluation, patients with rhinosinusitis can be found to have darkening under the eyes, swelling under the eyes, a line across the mid-section of the external aspect of their nose, breathing through an open mouth, swelling inside the nasal cavity, clear nasal discharge, and dull eardrums from fluid accumulation behind the drum.
Diagnosis of allergic rhinitis is based upon history and physical exam. Although diagnostic testing is typically not required, there are circumstances in which it is indicated. Skin testing
(Prick skin test) is a fast, safe, economical, and accurate method of diagnosing allergic rhinitis. It is presently the method most com- monly used and classically performed by an allergist. Indications for skin testing may include recalcitrant or poorly controlled symptoms. Patients who desire to know what allergen precipitate their symp– toms in order to use avoidance therapy or immunotherapy as their treatment option can also undergo skin testing.
The most effective single maintenance treatment option for aller–
gic rhinosinusitis is intranasal glucocorticoids. Although divided into first and second generation agents, both classes are equally ef– fective. Due the manner in which they are processed by the body, second generation preparations have less side effects. Examples of first generation sprays include beclomethasone (beclonase) and budesonide (Rhinocort). Second generation intranasal sprays in- clude fluticasone propionate (Flonase) and Mometasone Furoate (Nasonex). The onset of action of both class is usually within several hours, although maximal relief can take several days to weeks in previously untreated patients.
The side effects typically reported by patients are minimal and can include nose bleed, traces of blood in nasal discharge, burning of the nose and irritation of the throat from the medication trickling down. The dose usually vary for children and adults with children requiring a lower dose.
Because intranasal glucocorticoids are derivatives of hydrocorti- sone, concerns usually associated with hydrocortisone, such as effects on growth, bone density, and vision, also exists with these nasal sprays. Studies have shown that these effects are inconsistent or clinically not pertinent as it relates to the steroid nasal sprays. Caution is still advised however and in children once daily prepara– tions are preferred.
Nasal decongestants, such as oxymetazoline (Affrin), are over the counter products patients can use in treating their symptoms. They are not advised to be used in isolation in the long term treatment of allergic rhinosinusitis. When used more than 3 to 7 days, they can worsen the underlying nasal congestion by causing a rebound effect. Nasal decongestants combined with steroid nasal sprays however have been shown to improve nasal symptoms in patients who do not respond well to intranasal steroid sprays alone. Ideally each spray should be used once daily and the nasal decongestant should be used no more than four weeks to avoid rebound effect.
Other nasal sprays that are used in conjunction with steroid nasal sprays in patients who do not obtain proper relief of their nasal con– gestion are antihistamine. These antihistamine sprays include astelin (azelestine) and olopatadine (patanase). Unlike the nasal deconges- tants, these agents can also be used alone and typically provide relief in less than 15 minutes. Possible side effects include mild drowsiness and an after taste.
Nasalcrom is an OTC intranasal spray that is well tolerated, works by
decreasing nasal inflammation and is effective when used within 30
minutes prior to exposure of the allergen. Its main drawback is that it is a four times a day spray. One of its advantages however is that it can be used immediately prior to exposure to a known allergen and provide relief within half hour.
One last nasal decongestant to consider is atrovent (ipratropium bromide) which decreases runny nose but overall is less effective than the intranasal glucocorticoids.
Oral Anti histamines are also used in the treatment of allergic rhinitis. This class consists of first, second, and third generation medica- tions. The first generations include diphenhydramine (Benadryl) and hydroxyzine (Atarax) The second generation anti histamines include cetirizine (Zyrtec),loratadine(Claritin), and fexophenadine( Allegra).,Third generation antihistamines include levocertrizine (xyzal) desloratadine (clarinex).The medications within a class should be equally effective, they all target the same symptoms, and tolerance does not develop, although patients do complain of this. This group of medications work best on itching, sneezing, and runny nose and provide minimal relief for nasal congestion. The first generation meds typically cause sedation and may impair cognitive function in both adults and children. Subsequently, they are typically not advised especially in children and the elderly. The second and third generation antihistamines are less sedating and are safer for use in children.
Oral antihistamines combined with oral decongestants provide bet- ter relief than antihistamines alone. The common oral decongestants used are pseudoephedrine and phenylephrine. Concerns regarding abuse as a stimulant in athletes and as a component in the produc- tion of the illegal recreational drug methamphetamine has caused a decreased usage of pseudoephedrine. Phenylephrine consequently is currently more commonly used when manufacturing these com- bination medications but is not as effective as pseudoephedrine. Other concerns regarding decongestants in general include seda- tion, adverse effects on patients with hypertension, and certain types of glaucoma and thyroid disorders. Thus making this combination drug a less than ideal choice in the treatment of rhinosinusitis.
Other medications used in the treatment of allergic rhinosinusitis include Singulair (monteleucast) which can be used alone or in combination with an antihistamine to help alleviate nasal conges- tion. When combined with an antihistamine it alleviates the same symptoms as an antihistamine plus a decongestant without the as- sociated sedation. The combination of Singulair and an antihista- mine may be used in patients who do not tolerate intranasal steroid sprays or in lieu of using an antihistamine oral decongestant combi- nation. Although safe, Singulair’s side effects may include insomnia, depression, and anxiety.
In summary allergic rhinosinusitis is a common medical condition which particularly around this time of the year can impact numerous people. There are numerous therapeutic options available, including some not discussed here, to provide symptomatic relief for patients. A visit to your local primary care provider – among the many op- tions available – is all that is necessary to begin the process of feeling better.
Thank you and breathe well.