How do I begin an effective treatment regimen for a patient with newly diagnosed allergic rhinitis?
Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP
Allergic rhinitis is neither an uncommon nor a minor complaint. It is self-reported by 14% of the US population. Recent prevalence studies show that it may occur in as many as 31.5% of all adults. In addition, 79.5 million Americans, although undiagnosed, report rhinitis symptoms. Finally, allergic rhinitis annually affects between 10% and 30% of American adolescents and children, and is considered the most common chronic medical condition of childhood.
The importance of the above prevalence data cannot be underestimated. These data translate into annual direct costs of $3.4 billion and an additional $1.93 billion in indirect costs (lost work productivity, missed school days, and over-the-counter medication purchases). The possibility of comorbid conditions such as otitis media, chronic rhinosinusitis, gastroesophageal reflux disease, and asthma add additional costs, as do the effects that allergic rhinitis have on quality of life and daily functions.
Because of its prevalent nature, it is essential for all health providers to have an understanding of the relevant pathophysiology of allergic rhinitis. Appropriate treatment can only be effectively started after a rigorous history and physical examination confirm the correct diagnosis. This is absolutely necessary in a managed care environment, where medications are increasingly controlled by insurance mandates and patients are often frustrated by prior ineffective regimens.
Allergy affects the paranasal sinuses in the following ways:
There is a direct effect from an IgE-mediated allergic event that results in the release of histamine and other inflammatory agents, mucus secretors such as leukotrienes, and cellular attractants like neutrophils. This results in mucosal edema and increased mucus secretion with accompanying vasodilation. Increased mucus becomes trapped in the sinuses. This results in stagnation and obstruction of the osteomeatal complex (intranasal spaces found between nasal turbinates along lateral wall).
There is a simultaneous altered responsiveness in pollen-allergic patients that results in an increased amount of nasal congestion and discharge with exposure to the same amount of allergen. For example, a patient who is sensitive to ragweed will have more allergy symptoms at the end of the ragweed season than at the season's beginning, even though the exposure to the allergen remains constant.
Nasal polyp formation, while not conclusively found to be a causal agent of allergic rhinitis, is an important marker for allergy comorbidity. In these patients, appropriate allergy management will lessen the likelihood of polyp recurrence.
Most patients with allergic rhinitis complain of nasal congestion. However, this is also true in common chronic rhinosinusitis. An important distinguishing characteristic of allergic rhinitis is an associated clear rhinorrhea and frequent sneezing. The presence of ocular irritation or burning is also found almost exclusively in allergic rhinitis. Physical examination will commonly reveal the appearance of conjunctival irritation, allergic "shiners" (bluish discoloration of the infraorbital skin), and a horizontal crease on the surface of the external nose caused by constant rubbing. In addition, a careful internal nasal assessment will reveal a large amount of clear watery discharge and edematous, pale, and boggy turbinates. The presence of mucoid postnasal discharge in the posterior pharynx is also indicative of allergic rhinitis.
There are many forms of testing available to confirm a suspicion of inhalant environmental allergies. The most sensitive are the common skin-prick and intradermal tests done by allergy specialists. Another commonly used test is the radioallergosorbent test (RAST), a simple blood test. This method is valuable in the patient who cannot be skin tested because of comorbid dermatologic disease (eczema). Nasal smears for the presence of eosinophils may be helpful. All skin testing must be done in a specialist environment, while other outlined testing can easily be done in the primary care setting.
Once the diagnosis of allergic rhinitis has been confirmed and the results correlated with the individual patient's history and physical examination, an appropriate and specific treatment plan can be started.
Topical nasal steroid preparations are the most effective and the most underused pharmacologic agents for control of allergic rhinitis. These agents are highly effective in relieving all nasal allergy symptoms (congestion and discharge) by re-establishing intranasal patency. These preparations have been extensively studied and are safe for all age groups above 3-6 years (dependent on the individual product). Topical nasal steroid preparations should be used as first-line agents for all patients who complain only of nasal symptoms. However, patients must be taught proper administration procedures.
Agents must be used daily until maintenance dosing is reached (usually about 2 weeks). It is then safe to use a maintenance dose lower than initially prescribed. All preparations have equal anti-inflammatory results on nasal mucosa, although aqueous preparations tend to be less drying and irritating. Side effects may include nasal crusting and excoriation with mild epistaxis and dryness of nasal membranes. Pointing the spray bottle away from the nasal septum can alleviate these effects. One agent may be substituted safely for another if there is no improvement after 4 weeks. A complete table of these agents is readily available.
If the above treatment regimen does not result in a substantial reduction in nasal symptoms, a long-acting, nonsedating antihistamine may be added to the regimen. These agents are particularly effective against severe rhinorrhea, sneezing, and pruritus, and may also be used alone as first-line agents when there are diffuse allergy symptoms including ocular irritation and pruritus. This medication class consists of cetirizine (Zyrtec), fexofenadine (Allegra), and loratadine (Claritin). Desloratadine (Clarinex) has just been released for use and is expected to replace Claritin. All medications are safe, equally effective, and are dosed once daily. Cetirizine may have a mild sedative effect in some patients. It is wise to give this particular agent at bedtime. These medications may also be combined with decongestants such as pseudoephedrine (Sudafed) for severe nasal congestion. They should be used with caution in patients with hypertension and heart disease and only for short periods. Patients may develop tolerance to the systemic decongestant and experience rebound congestion. Combination agents may also cause sleep disturbances in some patients.
A newer class of drugs, the leukotriene antagonists, such as zafirlukast (Accolate) and montelukast (Singulair), are currently reserved for patients with comorbid asthma or for patients unresponsive to conservative treatment measures. A first-generation antihistamine, azelastine (Astelin), may also be used as a nasal spray. Frequent side effects of bitter taste and somnolence may limit long-term use. Mast-cell stabilizers such as cromolyn sodium (Nasalcrom) may help to decrease ocular pruritus and nasal inflammation. There are minimal side effects but dosing is 4 times daily, a fact that may decrease patient compliance. Use of systemic steroids should be reserved only for patients with intractable symptoms and/or nasal polyposis, and must be limited to a week's duration with a rapid dose taper.
In addition to pharmacologic treatment, there must be a high degree of patient involvement in altering home and work environments. In perennial allergies (dust and mold), this is the cornerstone of treatment. Once an allergen has been identified, efforts must be rigorous to reduce patient exposure. It is essential to spend time exploring the individual patient's needs, and a journal of symptoms correlated with environmental exposures to offensive agents can be helpful while awaiting test results. Patients with seasonal allergies (trees, weeds, etc.) will have a difficult time avoiding these common allergens during certain times each year. Beginning the treatment regimen by a month before the onset of a budding season will often reduce symptoms.
When there is failure of medical therapy or when the patient seeks long-term symptom relief, immunotherapy must be considered. This involves the injection of increased doses of specific allergens over time to sensitize the patient to a specific allergen. This is a long-term investment and should be carefully explored before referral, as some insurance companies do not cover costs of these programs and others require a weekly copayment over a period of years. It is not wise to keep patients on long-term medical therapy with any class of described medication without a complete specialist evaluation. Also, if an anatomic abnormality or nasal polyposis is observed, referral to an allergist is indicated. Patients often return to their original health provider for maintenance shots after the initial period of immunotherapy is completed.
Medscape Nurses. 2002;4(1) © 2002
Cite this: What Are the Considerations for a Newly Diagnosed Allergic Rhinitis Patient? - Medscape - Apr 02, 2002.