Allergic Rhinitis: When to Refer to an Allergist Kirsten Kloepfer, MD, MS Assistant Professor of Pediatrics Section of Pulmonary, Allergy and Sleep Medicine
Disclosures NIH K23 American Academy of Allergy, Asthma and Immunology (AAAAI) Foundation Faculty Development Award Showalter Trust Award
Objectives Determine when skin testing is needed. Distinguish allergic rhinitis from cold symptoms
5 year old with asthma. Jason Started wheezing around 12 months of age. Triggers: Fall season, URIs, exertion, pets? One hospitalization overall; 3 courses of oral steroids in past year Runny, stuffy nose in spring and fall. On Fluticasone HFA 110 mcg, 2 puffs BID with spacer, and Montelukast 5 mg daily.
What is the likelihood that Jason has environmental allergies? 25% 50% 75% 90% Jason
Jason s family wants to get a dog. They have noticed that Jason needs his albuterol when they visit his grandmother who has a dog. Which of the following is true? Short-haired dogs are hypo-allergenic. Dogs that shed less are hypo-allergenic. Certain breeds of dogs are hypo-allergenic. Cleaning and vacuuming will remove the dog allergens effectively. None of the above Jason
30-60 million Americans Epidemiology 40% of children 10-30% of adults 5 th most common chronic disease in the U.S. Medical costs to treat AR in 2005: $11.2 BILLION Indirect costs: School and work absences Impaired school and work performance Negative impact on quality of life Bernstein JA. Allergy Asthma Proc. 2010;31:365-9 Blaiss MS. Allergy Asthma Proc. 2010; 31: 375-80
Asthma and Allergic Rhinitis 70% of children between 3-16 years with asthma have IgEmediated seasonal allergies. 250% increased rate of asthma hospitalizations vs. asthmatic children w/o AR. Treating AR decreases the risk of ER visits and hospitalizations for asthma by 50%.
Inflammation of the nasal mucosa leading to one or more of these symptoms: Nasal congestion Sneezing Rhinorrhea Itching Post-nasal drip What is Rhinitis? Wallace, et al. J Allergy Clin Immunol 2008;122:S1-84
Types of Rhinitis Infectious Acute Chronic Nonallergic (vasomotor) Idiopathic Hormonal Atrophic Occupational Gustatory Rhinitis medicamentosa Allergic Seasonal Perennial
Pollen Animal Dander Dust Cockroach Allergic Rhinitis Triggers Wallace, et al. J Allergy Clin Immunol 2008;122:S1-84
Symptoms Chronic congestion, sneezing, rhinorrhea and watery itchy eyes Recurrent otitis, sinusitis Seasonality: Spring: Trees Summer: Grass Fall: Weeds, Mold Winter: Indoor Cat, dog, dust mites, mouse, roach
Nasal Salute and Nasal Crease
Allergic Shiners amd Dennie s Lines
Nasal Mucosa
Allergic Rhinitis Severity Intermittent Symptoms < 4 days / week or < 4 weeks Persistent Symptoms > 4 days / week or > 4 weeks Mild Sleep: normal Daily activities (incl. sports): normal Work-school activities: normal Severe symptoms: no Moderate- severe Sleep: disturbed Daily activities: Restricted Work and school activities: disrupted Severe symptoms: yes
Diagnosis HISTORY, HISTORY, HISTORY Skin prick testing Immunocap (specific IgE testing)
Skin Prick Testing
Skin Prick Testing Number of and type of skin tests done depends on: Patient age (can be done as young as age 3 months) Geography History Skin prick testing Negative predictive value >90%. Positive predictive value <50% (not highly specific) Chapman, et al. Annals of Allergy, Asthma and Immunology. March 2006; Supplement: S33-39
Specific IgE Testing When are specific IgE tests for inhalants done? When antihistamines cannot be stopped Dermatographism precludes skin prick testing Patient does not cooperate with skin testing Negative predictive value >90% Sensitivity compared with skin prick testing: 70-75% Positive predictive value <50% Chapman, et al. Annals of Allergy,Asthma and Immunology. March 2006; Supplement: S33-39
Specific IgE Testing Higher values may suggest increased likelihood of reactivity, but not the severity of that reaction. Specific IgE values vary by age 15% of non-allergic individuals can show presence of specific IgE Class not as helpful as actual IgE value Can be performed on infants
Allergic Rhinitis Co-morbidities 70% of children between 3-16 years with asthma have IgE-mediated seasonal allergies. (<50% in adults) Accounts for: 30% of acute sinusitis 80% of chronic sinusitis
Treatment Environmental controls Avoidance, if possible Minimize exposure to irritants Smoking Fumes/ aerosols Medication Immunotherapy
Environmental Control Dust mites Covers over the mattress, pillow and comforter HEPA vacuuming of carpets Keep indoor humidity below 50% Acaricides are not highly effective Remove stuffed toys from the bed - freeze Remove carpeting and upholstered furniture if possible Wash beddings weekly. At water temps of 130ºF, mites are killed, and re-accumulation is slowed Dogs and Cats Rehome Out of bedroom
Medications Saline Rinse Antihistamines Nasal Steroids Leukotriene Receptor Blockers Ophthalmic Drops
Antihistamines All effective in treating sneezing, itching, rhinorrhea, and eye symptoms. Loratadine, desloratadine, and fexofenadine are considered nonsedating. 13% of adults and 5-6% of children have sedation with Zyrtec. No clinical advantage to switching a patient from loratadine/cetirizine to desloratadine/levocetirizine.
Nasal Steroids Decrease all four symptoms of AR including congestion. Not addictive More effective than antihistamines. Usually work best when used regularly, but can be used PRN. Remember to start a week before the onset of various pollen seasons. Can help with nonallergic rhinitis.
Nasal Steroids NAME STRENGTH (MCG/SPRAY) STARTING DOSE (q day) AGE INDICATION NASACORT (triamcinolone acetonide) FLONASE (fluticasone propionate) NASONEX (mometasone furoate) VERAMYST (fluticasone furate) OMNARIS (ciclesonide) 55 1-2/ nostril 6y 50 2/ nostril 4y 50 2/ nostril 2y 27.5 1-2/nostril 2y 50 2/ nostril 6y Qnasl (beclomethasone) 80 2/nostril 12y
Nasal Steroids Adverse Effects Epistaxis Smell/ taste issues Spray volume issues Nasal perforation Flovent 44mcg 1 puff in each nostril daily (Modify with baby bottle nipple)
Other Nasal Sprays Atrovent (ipratropium) nasal spray: Excellent for rhinorrhea Contraindicated with glaucoma Patanase (olapatadine): 6+ yrs, 1-2 sprays BID Astelin/Astepro (azelastine) Approved for allergic and nonallergic rhinitis Approximately as effective as nasal steroids Main issue bitter taste and large volume of spray Approved for ages 5y and up. Dymista: Fluticasone + Azelastine 1 spray BID, 12+yrs
Leukotriene Receptor Blockers Montelukast Similar in efficacy to loratadine, but decreased efficacy versus nasal steroids Montelukast + antihistamine Greater efficacy than when used alone In some studies = nasal steroids AR + Asthma montelukast vs. placebo improvements in both AR and asthma
Eye Drops Add eye drops if oral antihistamines not helping. Most OTC eye drops - decongestant + antihistamine Antihistamine eye drops: Optivar (azelastine) and Elestat (epinastine) NSAID eye drops: Acular (ketorolac) less effective for itching Mast cell stabilizer + antihistamine Zaditor (ketotifen): OTC; 1 drop each eye BID Patanol/Pataday (olapatadine): 1 drop each eye daily
When do we start Immunotherapy? Environmental changes not fully effective Medications ineffective/ have adverse effects Adherence/ compliance Patient preference Possible prevention of asthma in patients with allergic rhinitis
Who is eligible? Minimum age: 5y or older Pt likely to be compliant, and willing to tolerate injections Allergens are not avoidable Stable asthma Pt understands the following: IT is a 3-5 year treatment course Benefits may not be seen for at least one year Injections are given weekly for several mos., then spaced out to every two weeks, and then to once a month Pt needs to wait in the doctor s office for thirty minutes after getting injections every time Pt understands they should not get an injection if they have fever, cough, wheeze or SOB Pt must not be on a beta blocker
Oral Immunotherapy Tablets Grastek Timothy grass pollen allergen extract (Merck) Approved for 5y and up Oralair Multiple grass pollens (Stallergene) Approved for 10y and up Ragwitek ragweed pollen (Merck) Approved for 18y and up Initial dose given in office, 30 minute wait Start 12 weeks prior to season onset Require EpiPen
Acknowledgements Riley Hospital for Children Division of Pulmonary, Allergy and Sleep Medicine Frederick Leickly, MD, MPH IU North Girish Vitalpur, MD Downtown and Bloomington Kirsten Kloepfer, MD, MS Downtown On call 24 hours a day for questions from outside providers 317-274-7208 kloepfer@iu.edu