Issues and answers: Suspected AR in young children how best to test and treat? How best to approach the adolescent and adult AR patient?

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1 ERN 3 FREE CPD POINTS LLERGIC RHINITIS Leader in digital CPD for Southern frican healthcare professionals Issues and answers: llergic rhinitis Introduction This review seeks to optimise allergic rhinitis (R) treatment in the dynamic environment of patients self-help approaches using over-the-counter medications and the changing clinical guidance from multidisciplinary expert groups, which have recently produced an International Consensus view of llergic Rhinitis therapy, 1 and from South frican experts and their guidelines, which are incorporated in practical clinical approaches. 2 Suspected R in young children how best to test and treat? View the Breathe Free video from QR code below Just scan the QR code with your QR reader app. The QR reader app is free from all mobile phone app stores. The highest incidence of R occurs in children; it typically does not manifest in infants until the second year of life. 1 R in children is probably caused by the rapidly evolving immune system where an overactive response of T 2 helper lymphocytes drives the systemic IgE-mediated inflammation. t this early stage, a skin-prick test or in vitro antigen-specific (sige) test can be used to confirm the diagnosis. Most children with symptoms of R in early life will have persistent symptoms for several years. Physician-diagnosed R in early childhood is also associated with a doubling of the risk of developing asthma at age 11 years. 3 llergen immune therapy (IT) has shown benefit in children with moderate-to-severe R and there is some indication that IT to grass/pollen can prevent the development of asthma for more than two years after therapy. 4 This therapy requires specialist intervention. The mainstay of treatment for R in South frica, where the disease is largely persistent and moderate to severe, is regular topical steroid use. Mometasone furoate is available for use in children over two years of age. It is vital to ensure that parents and the patient use the metered nasal spray correctly in children, the usual dose is one spray in each nostril once a day. The link below to the CIPL Breathe Free video should be viewed by all prescribing clinicians. com/watch?v=ns04hjuocu It is very useful for patients and older children too. How best to approach the adolescent and adult R patient? This report was made possible by an unrestricted educational grant from CIPL. The content of the report is independent of the sponsor. Patients typically self-manage their R symptoms suboptimally, either because they view the condition as mild and not requiring medical intervention or because their earlier experience, perhaps even from childhood, with clinical interventions was both costly and largely ineffective. 5 While R is viewed as a somewhat trivial condition, severity variation and its association with asthma provide a valid clinical reason for seeking effective treatment. 6 Obtaining an insight into how your adult patient views his/her R is a good starting point for improving clinical therapy. useful question and answer approach, Tell me about your hayfever, has been developed for clinical use (Table 1). July 2018 I 1

2 Table 1. Tell me about your hayfever? Primary question Tell me about your experience with R/hayfever (symptoms, challenges, satisfaction) Secondary questions How long have you been experiencing these symptoms? What treatments do you currently use or have previously tried for your symptoms? How would you describe the impact of these symptoms on your daily activities? The clinician using this questionnairetype approach will find that each patient s experience of R is unique, varied and that their expectations of therapy differ according to their lifestyle choices. While ongoing medication is acceptable to many people, others are willing to explore allergen identification, avoidance and immunotherapy. Is it R or another condition such as non-allergic rhinitis or rhinosinusitis? The diagnosis of R is based on a careful clinical history of typical symptoms and examination (Table 2). Table 2. Symptom evaluation ssociated with R Inflammation of the nasal mucosa Nasal hyperreactivity Nasal congestion, anterior and posterior rhinorrhoea Sneezing Nasal itching Reduced sense of smell Facial pain/pressure Fatigue Symptoms not associated with R Nasal obstruction without other symptoms Mucopurulent rhinorrhoea Post-nasal drip with thick mucus Pain Recurrent epistaxis Unilateral eye symptoms Eyes burning, but not itching Dry eyes or photophobia Itchy eyes Differentiating features of acute and chronic sinusitis are summarised in Table 3. Table 3. Diagnosis of acute and chronic sinusitis Earn free CPD Points Join our CPD community at and start to earn today! cute bacterial sinusitis (BS) Chronic rhinosinusitis without nasal polyps (CRSsNP) Chronic rhinosinusitis with nasal polyps (CRSwNP) nterior or post-nasal discharge nterior or post-nasal discharge nterior or post-nasal discharge Nasal obstruction ± Facial pain/pressure ± Change in sense of smell OR OR OR Lasts >10 days and <3 months* Severe lasting purulence or temperature Worsening in <10 days Nasal obstruction ± Facial pain/pressure ± Change in sense of smell >12 weeks and no nasal polyps Nasal obstruction ± Facial pain/pressure ± Change in sense of smell >12 weeks and documented nasal polyps *Note: cute upper respiratory tract infection (URTI) lasting <10 days, no lasting purulence, no worsening, no severe temperature = acute viral sinusitis or a cold. 2 I July 2018

3 What tests are useful and when? llergy testing Diagnostic tests based on the demonstration of allergen-specific IgE in the skin (skin tests) or blood (specific IgE) should be mandatory for all patients, but especially for patients with a clinical diagnosis of R who do not respond to treatment, when the diagnosis is uncertain or when knowledge of the specific causative allergen is required to target therapy. Measurement of total IgE is not helpful (Figure 1). 2 Symptoms: blocked nose, rhinorrhoea, sneezing, itch RHINITIS Signs: allergic facies Complications: sinusitis, chronic otitis media, obstructed breathing Evaluation for asthma llergy testing Note comorbidities Treat asthma if present Skin-prick test Selected ImmunoCap profiles Sinusitis Otitis media with effusion Obstructed breathing topic dermatitis No routine total IgE llergic rhinitis Non-allergic rhinitis Mild or seasonal (uncommon in South frica) Moderate to severe (common in South frica) Infant Evaluation for cause treat as for allergic rhinitis (vasomotor) if no other cause found Non-sedating antihistamine corticosteroid voidance Saline ll medications are off-label: urgent studies of efficacy and safety required llergens, irritants, dangerous medications (topical vasoconstrictors for longer than 7 10 days, over-the-counter preparations) Educate patients Follow-up regularly Figure 1. lgorithm for the diagnosis and management of rhinitis from South frican guidelines 2 July 2018 I 3

4 Nasal endoscopy mong adults and children with R that has been confirmed by allergy testing, no significant correlation was found between nasal endoscopy and specific nasal symptoms. Nasal endoscopy may, however, aid identification of other possible causes of symptoms such as nasal polyps or chronic rhinosinusitis. What is the impact of R on daily life? The classification of R by the RI (llergic Rhinitis and its Impact on sthma) interest group provides a clear indication of the range of R symptoms (Figure 2). This points to the value of treating R symptoms, e.g. R symptom-relief improves sleep and reduces absenteeism and interference in social and leisure activities. 7 MILD Normal sleep No impairment of daily leisure or sport activities Normal work or school functioning No troublesome symptoms Intermittent R 4 days/week Symptoms 2 consecutive days for >1 hour on most days Rhinorrhoea Blocked nose Itchy nose Sneezing Itchy eyes >4 days/week and >4 consecutive weeks Persistent R MODERTE-SEVERE One or more of the following: bnormal sleep Impairment of daily leisure or sport activities bnormal work or school functioning Troublesome symptoms Figure 2. Classification of R 7 Earn free CPD Points Join our CPD community at and start to earn today! What treatments are recommended based on clinical evidence? Table 4 summarises the most recent expert s. Table 4. ggregate grades of evidence and levels Management: pharmacotherapy Topic Oral H 1 antihistamines ggregate grade of evidence Recommendation level Strong Interpretation Newer-generation oral H 1 antihistamines are strongly recommended for the treatment of R (loratadine, desloratadine and cetirizine). They are highly selective for the H 1 receptor, lipophobic and have limited penetration across the blood-brain barrier 4 I July 2018

5 Oral H 2 antihistamines B No vailable data does not adequately address the question of benefit in the treatment of R. Most studies show intranasal antihistamines superior antihistamines Recommendation antihistamines may be used as first-line or second-line therapy for the treatment of R. Most studies show intranasal antihistamines are superior to intranasal corticosteroids for sneezing, itching, rhinorrhoea and ocular symptoms. dverse effects are minor and infrequent Oral corticosteroids B Recommend Due to the risks of oral steroid use, along with the availability of other pharmacotherapy options, this therapy is not recommended for routine R management Injectable corticosteroids B Recommend Due to the risks of injectable steroid use, along with the availability of other pharmacotherapy options, systemic or intraturbinate injection of corticosteroids is not recommended for the routine treatment of R corticosteroids (INCSs) Strong INCSs should be used as first-line therapy in the treatment of R due to their superior efficacy in controlling nasal congestion and other symptoms Oral decongestants B Option Option of pseudoephedrine for short-term treatment of R symptoms Recommend Recommend phenylephrine, as it has not been shown to be superior to placebo Topical decongestants B Option Option of topical IND in the short-term for nasal decongestion. Chronic use carries a risk of RM Leukotriene receptor antagonists (LTRs) Recommend LTRs should not be used as monotherapy in the treatment of R Cromolyn (DSCG) Option DSCG may be considered in the treatment of R, particularly for patients with known triggers who cannot tolerate INCS anticholinergic (IPB) B Option IPB nasal spray may be considered as an adjunct to INCS in PR patients with uncontrolled rhinorrhoea Omalizumab No indication Omalizumab is not approved by the FD for the treatment of R alone Nasal saline Strong Nasal saline is strongly recommended as part of the treatment strategy for R Probiotics Option Probiotics may be considered in the treatment of R Combination: oral antihistamine and oral decongestant Combination: oral antihistamine and INCS Combination: oral antihistamine and LTRs Option Option, particularly for acute exacerbations with a primary symptom of nasal congestion B Option Combination equivocal over either drug alone Option Combination is an option for R management, particularly in patients with comorbid asthma who do not tolerate INCS and are not well-managed on oral antihistamine monotherapy Combination: INCS and intranasal antihistamine Strong Strong for combination therapy when monotherapy fails to control R symptoms R = allergic rhinitis; DSCG = disodium cromoglycate; FD = Food and Drug dministration; INCS = intranasal corticosteroids; IND = intranasal decongestants; IPB = ipratropium bromide; LTR = leukotriene receptor antagonist; PR = perennial allergic rhinitis. : evidence is strong and supported by randomised clinical trials. July 2018 I 5

6 What effective therapies are available in South frica? Tables 5 and 6 lists the affective therapies currently available in South frica. Table 5. List of commonly used second-generation antihistamines ntihistamine medication Onset (hours) Duration (hours) Drug interactions Elimination (hours) Dosage for adults Dosage for children Cetirizine 0.7 >24 Unlikely mg QD 2-5 years: 2.5mg or 5mg QD; 6-12 years: 5-10mg QD Desloratadine >24 Unlikely 27 5mg QD 2-5 years: 1.25mg QD; 6-11 years: 2.5mg QD Bilastine 2 24 Unlikely mg QD 6-11 years: 10mg QD Earn free CPD Points re you a member of Southern frica s leading digital Continuing Professional Development website earning FREE CPD points with access to best practice content? Fexofenadine 1 3 >24 Unlikely mg BID or 180mg QD 2-11 years: 30mg BID Levocetirizine 0.7 >24 Unlikely 7 5mg QD 2-5 years: 1.25mg QD; 6-11 years: 2.5mg QD; 12 years: 2.5-5mg QD Loratadine 2 >24 Unlikely mg QD or 5mg BID BID = twice per day; N/ = not applicable; QD = once per day. Table 6. Currently available intranasal steroids ctive ingredient Status 2-5 years: 5mg QD; 6 years: 10mg QD Only a few clicks and you can register to start earning today Visit For all Southern frican healthcare professionals Find us at DeNovo Beclomethasone dipropionate Budesonide Ciclesonide Fluticasone propionate Mometasone furoate Triamcinolone acetonide References 1. Wise SK, Lin SY, Toskala E, et al. International Consensus Statement on llergy and Rhinology: llergic Rhinitis. International Forum of llergy & Rhinology 2018; 8(2): Green RJ. llergic rhinitis in South frica: 2012 guidelines. S fr Med J 2012; 102(8): Garden FL, et al. Simpson JM, Marks GB, for the CPS Investigators. topy phenotypes in the Childhood sthma Prevention Study (CPS) cohort and the relationship with allergic disease. Clin Exp llergy 2013; 43: Halken S, Larenas-Linemann D, Roberts G, et al. ECI guidelines on allergen immune-therapy: Prevention of Prescription and over the counter Prescription only Prescription only Prescription and over the counter Prescription and over the counter Prescription only allergy. Paediatr llergy Immunol 2017; 28(5): Cvetkovski B, Kritikos V, Yan K, Bosnic-nticevich S. Tell me about your hayfever: a qualitative investigation of allergic rhinitis management from the perspective of the patient. Npj Primary Care Resp Med 2018; 28: 3; DOI: /s Haccuria, Van Muylem, Malinovschi, et al. Small airways dysfunction: the link between allergic rhinitis and allergic asthma. Eur Respir J 2018; 51(2). pii: Bousquet J, Khaltaev N, Cruz, et al. llergic Rhinitis and its Impact on sthma (RI) 2008 Update. llergy 2008; 63 (Suppl 86): Disclaimer The views and opinions expressed in the article are those of the presenters and do not necessarily reflect those of the publisher or its sponsor. In all clinical instances, medical practitioners are referred to the product insert documentation as approved by relevant control authorities. Published by denovo Medica Reg: 2012/216456/07 70 rlington Street, Everglen, Cape Town, 7550 Tel: (021) I info@denovomedica.com 6 I July 2018