I have no disclosures to make other than I too suffer from allergic rhinitis Allergic Rhinitis Betsy Close, MD Assistant Professor UT College of Medicine, Department of Family Medicine Clinical and Economic Impact Clinical and Economic Impact Number of visits to physicians office with primary diagnosis of allergic rhinitis- 11.1 million Number of children with respiratory allergies in past 12 months-7.8 million Number of children with hay fever in past 12 months-6.6 million Number of adults with diagnosed hay fever in the past 12 months- 17.6 million Roughly 7.8% of people age >18yo in the US have allergic rhinitis (prevalence estimates range from 15-30% in many studies) Total direct medical cost is 3.4 Billion with half of this being the cost of pharmacotherapy! A 2010 study of Florida Medicaid children showed a significant decrease in healthcare costs in children with a new diagnosis of Allergic Rhinitis who subsequently received immunotherapy. Up to 40% of people with allergic rhinitis have or will have asthma and most people with asthma have allergic rhinitis http://www.cdc.gov/nchs/fastats/allergies.htm Genetic/Environmental factors Symptoms Having a parent with allergic rhinitis more than doubles risk A family history of atopic disease (eczema, asthma, rhinitis,etc) increases risk Having multiple older siblings and growing up in a farming environment seem to be protective Seasonal, perennial, episodic Mild to severe (QOL issues) Intermittent (four days a week), persistent (four weeks a year) Ocular pruritus/watering, rhinorrhea, nasopharyngeal pruritus, nasal congestion, sneezing 1
PE Findings Violaceous nasal mucosa Postnasal drip Allergic shiners Morgan Denie Folds Allergic salute Middleton's Allergy: Principles and Practice Environmental Measures No clear data for HEPA filters, dust mite covers, etc. Avoidance of known allergy triggers is helpful Breastfeeding, delayed exposure to foods has not been proven to prevent allergies Pharmacotherapy Nasal corticosteroids Antihistamines (oral and intranasal) Leukotriene antagonist Intranasal cromolyn Decongestants Intranasal anticholinergics Immunotherapy Nasal corticosteroids FDA Pregnancy Category Triamcinolone Category C 2yo Beclomethasone Category C/lactation OK Minimum age for use 4yo Budesonide Category B 6yo Ciclesonide Category C 6yo Flunisolide Category C 6yo Fluticasone furoate Category C 2yo Fluticasone propionate Category C 4yo Mometasone Category C 2yo 2
Antihistamines oral, nasal, ophthalmic Leukotriene Antagonists 1 st generation-diphenhydramine, chlorpheniramine, hydroxyzine 2 nd generation-loratidine, cetirizine, azelastine, olopatadine 3 rd generation-fexofenadine, desloratidine, levocetirizine Azelastine and olopatadine sprays can be used on demand with onset of action in 15 minutes If allergic rhinitis with allergic conjunctivitis an ophthalmic antihistamine is very helpful to add to a nasal corticosteroid Montelukast is the only leukotriene inhibitor approved for allergic rhinitis Not intended as first-line therapy for allergic rhinitis Nice add-on therapy, especially with concomitant asthma or nasal polyposis Side effects-behavior mood/changes, dream abnormalities, sleep disturbance, depression, and suicidal thoughts Rare but a consideration Decongestants, nasal cromolyn, and intranasal anticholinergics Immunotherapy Do not use decongestants under age 4 and cautiously in older children Standard is injection Provide symptom relief in combo with antihistamine but SEs are limiting Sublingual for Timothy grass (Grastek) Five grass extract (Oralair) and Ragweed (Ragwitek) Cromolyn is very safe, OTC, fast onset BUT frequent dosing and less efficacy Nasal Ipratropium-only effective for rhinorrhea symptoms/vasomotor rhinitis Importantly, early immunotherapy in children with allergic rhinitis decreases the development of asthma (The Preventive Allergy Treatment Study) Duration of therapy 3-5 years, effects last 7-12 years Nasal Saline Irrigation Proper Technique Use previously boiled, distilled, or sterilized water due to a few cases of amebic meningoencephalitis-rare but usually fatal condition Patients can make their own buffered saline easily or buy prepared packets (1tsp salt with pinch of baking soda in 8 oz of water) If congestion is a prominent issue, hypertonic saline helps decrease mucosal edema via osmotic gradient 3
Proper use of nasal sprays Pregnancy Prime before first use Shake before each use Blow nose and/or use saline irrigation prior to use Tilt head forward, point spray away from septum Do not inhale forcefully or most will end up in oropharynx Do not blow nose after spraying Clean after use Cetirizine or Loratadine-category B Montelukast-category B Budesonide nasal-category B (other nasal steroids-category C) Pseudoephedrine is trimester and condition specific Saline nasal/sinus rinse-neti Pot Lactation Children under 2yo Very little data-most say infant risk cannot be ruled out Fexofenadine, loratadine, pseudoephedrine, and beclomethasone considered likely safe Age <2yo are unlikely to have had enough exposure to have allergic rhinitis Differential- adenoidal hypertrophy, chronic sinusitis If no other cause found, second generation antihistamines-certirizine and desloratidine are approved down to 6mo nasal steroids with low bioavailability-fluticasone, mometasone -approved at >2yo but may be used younger if resistant symptoms saline nasal sprays/rinses cromolyn nasal spray is very safe but less effective than nasal corticosteroids, the dosing is also inconvenient at 1-2 sprays 3-4 times a day Montelukast also approved down to 6 months for perinneal allergic rhinitis Children over 2 yo Geriatric Considerations Treatment is essentially similar to adults If episodic/predictable exposure, you can administer a second generation antihistamine 2-5 hours before exposure or cromolyn 30 minutes prior. Nasal steroids would require administration two days before through two days post exposure-mometasone, fluticasone, and triamcinolone are approved 2yo and older Antihistamine nasal spray azalastine is approved for use in 5yo and older and olopatadine in 12yo or older. Saline nasal rinses Avoid first generation antihistamines due to anticholinergic effects Intranasal steroids are the first line therapy followed by second generation antihistamines (low and slow) Also remember that several of the second and third generation antihistamines have renal and hepatic dosing considerations 4
Side effects of Intranasal Steroids CAM Modalities Accupuncture/Accupressure- possibly effective Drying of nasal mucosa Epistaxis Bitter taste/medicine draining into throat-beclomethasone and ciclesonide HFA avoid this (aerosol delivery) Alcohol or propylene glycol containing sprays (OTC fluticasone) are more irritating than aqueous preparations HPA effects/bone density/intraocular pressure-very unlikely, use lowest dose possible for shortest duration possible Saline irrigation- moderate evidence Local honey- no convincing evidence Quercetin, spirulina, intranasal capsacin- insufficient evidence Butterbur- fair evidence (potential crossreactivity with ragweed) Probiotics- possibly effective Choosing Wisely References Economic impact of allergic rhinitis and current guidelines for treatment. Annals Allergy Asthma and Immunology, 2011;106 (Supp):S12-16. AAAAI Recommendation Don t perform unproven diagnostic tests, such as immunoglobulin G (IgG)testing or an indiscriminate battery of Immunoglobulin E (IgE) tests in the evaluation of allergy AAO-HNSF Recommendation Don t routinely perform sinonasal imaging in patients with symptoms limited to a primary diagnosis of allergic rhinitis alone Hankin, Cheryl S. et al. Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study. Annals of Allergy, Asthma & Immunology, 104;1:79 85. Sur,Denise and Plesa, Monica. Treatment of Allergic Rhinitis. Am Fam Physician. 2015 Dec 1;92(11):985-992. Wheatley, Lisa and Togias, Alkis. Allergic Rhinitis. NEJM, 2015;372;5: 456-463. NCCIH Clinical Digest. Seasonal Allergies and Complementary Health Practices. April 2013. Accessed 2/8/2016. Wallace DV, Dykewicz MS, Bernstein DI, et al. The Diagnosis and Management of rhinitis: an updated practice parameter. Journal of Allergy and Clinical Immunology 2008;122:Supp:S1-S84. Brożek, Jan L. et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. Journal of Allergy and Clinical Immunology, 2010;126: 466 476. 5