What Are the New Management Guidelines for Classifying Allergic Rhinitis?

Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Disclosures

April 15, 2004

Question

What are the ARIA guidelines for the management of a patient with allergic rhinitis?

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

The recently published guidelines issued by the World Health Organization, known as Allergic Rhinitis and its Impact on Asthma (ARIA),[1] have been explained in a previous "Ask the Expert" article, "What Are the New Guidelines for Classifying Allergic Rhinitis?[2]" The focus of this article is on specific management guidelines for patients diagnosed with allergic rhinitis.

Because the mucosa of the nose and bronchial tree has many similarities, the management of allergic rhinitis includes interrelated strategies:

  • Allergen avoidance/environmental control;

  • Pharmacologic treatment;

  • Immunotherapy considerations; and

  • Patient education.

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

As soon as patients are diagnosed with allergic rhinitis, they should be instructed to avoid a specific allergen whenever possible. Often this is simple, but it may be extremely complex in many instances. It may be easy for patients to avoid a particular allergen, such as a tree, grass, or weed, particularly if only 1-2 allergens have been identified and if the sensitivity is mild. However, most patients suffer from a combination of allergen sensitivities. This presents a challenge, as patients may be unable to avoid mold in a house or workplace, dust mites in living quarters, or the family pet.[3]

If a specific trigger cannot be avoided (dust and mold are good examples), management of the environment must be considered. Controls need to be established and the nurse practitioner must consider the home, auto, school, day-care, and workplace environments. Some effective measures include[4]:

  • Encasing all mattresses, pillows, and box springs in allergen-impermeable covers;

  • Washing all bedding in hot water;

  • Removing animals (pets and stuffed) and carpets from bedrooms;

  • Minimizing upholstered furniture;

  • Using air-conditioning;

  • Using HEPA (high-efficiency particulate air) filters in bedroom; and

  • Drying clothes in vented dryers -- not outside.

In addition, a careful assessment of the workplace is essential. The use of chemicals and paints as well as the presence of tobacco smoke can be instrumental in increasing the patient's sensitivity and impairing effective treatment. The patient may even have to be moved from a specific work area. The Allergy Report

[5]

provides easy access to more information on setting up an environmental control program in all settings.



Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Many patients will need medication in addition to allergen avoidance and environmental control methods. Medications used in the treatment of allergic rhinitis are most commonly administered either intranasally or orally. These medications, with the exception of oral corticosteroids, have no long-lasting effects and must be maintained on a daily basis.

The list of specific medications known to be effective is lengthy and can be found in the ARIA guidelines.[1] Classifications of these medications include the following:

  • Antihistamines

    There are 2 generations of available antihistamines. The first-generation agents are usually available over-the-counter and are often used before a healthcare provider is consulted. Most cause sedation and have sometimes been included in sleep aids. However, they remain highly effective in symptomatic treatment, and some new products have recently been released (prescription only) that provide new delivery systems that decrease drowsiness.[6]

    The second-generation antihistamines are favored by ARIA for their efficacy/safety ratio and rapid onset of relief from sneezing, pruritus, and watery rhinorrhea. These antihistamines are not very effective against nasal congestion. Local antihistamine nasal spray and various ocular antihistamines are also effective in less than 30 minutes.

  • Intranasal Corticosteroids

    Intranasal corticosteroids are the most effective agents for the management of allergic rhinitis because of their direct reduction of nasal inflammation and their ability to reduce nasal hyperreactivity. All agents are safe and effective and will improve the patient's quality of life if the patient uses them on a daily basis. As a healthcare provider, it is essential to help the patient understand the important role of these agents and to demonstrate how to administer them correctly.

    Many patients do not like the odor or taste associated with specific agents, and 1-2 different medications may need to be tried before the most tolerable agent can be found for an individual.

    Intranasal corticosteroids can be used with asthmatic patients and with those who have comorbid nasal polyposis.

  • Oral Corticosteroids

    These powerful drugs reduce nasal inflammation and hyperreactivity but have potentially serious side effects when used over a long period. A short course of tapered corticosteroids is advisable only for moderate-to-serious exacerbations of allergic rhinitis.

  • Mast Cell Stabilizers

    These agents are particularly effective in patients with intermittent allergies, especially when determined to be prevalent in only 1 season of the year. They are usually available over-the-counter and should be started 3-4 weeks before a peak allergy season occurs. Their effect on the nose is short-acting and makes compliance more difficult as several doses are needed per day. Intraocular agents are also very effective.

  • Oral Decongestants

    These common drugs, widely available without prescription, are very effective in treating nasal congestion. They are, however, contraindicated in large populations of patients, including those with hypertension, mitral valve prolapse, cardiac palpitations, urinary retention, and glaucoma. They also have many side effects that can limit their use.

  • Intranasal Decongestants

    Commonly misused, these nasal sprays are rapidly effective but are limited because of the possibility of developing rebound congestion, a condition known as rhinitis medicamentosa.

  • Intranasal Anticholinergics

    These drugs are often used by patients with gustatory rhinitis, as they prevent rhinorrhea in social situations. They are effective against nasal discharge only and have no anti-inflammatory effects.

  • Antileukotrienes

    Recently approved for use in the treatment of allergic rhinitis, these agents have been successfully used for patients with asthma. At this time, ARIA recommends antileukotriene use in combination with other therapies, especially when nasal congestion is not ameliorated by other modalities.

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Immunotherapy is indicated in patients who present with any of the following characteristics:

  • Insufficient control by pharmacotherapy;

  • Insufficient control of symptoms;

  • A desire not to take medication;

  • Medication produces undesirable side effects; and

  • A desire to avoid long-term pharmacotherapy.

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

A comprehensive and individualized educational program is essential to the treatment of allergic rhinitis. Education should include, but not be limited, to[4]:

  • Learning about specific triggers and mechanisms for avoidance and control;

  • Understanding all the reasons and options for treatment;

  • Learning how to manage health problems at home and at work; and

  • Having an emergency-action plan available to family members and significant others.

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Once the patient's symptoms are under control, ARIA recommends that maintenance be based on a minimum quantity of medication so that exacerbations can be easily managed.[1] This stepped approach is similar to the approach used in asthma management and facilitates patient understanding when there is comorbidity present.

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

The ARIA guidelines create an important tool for the successful treatment of allergic rhinitis. The conclusions drawn from the panel have important implications for decreasing the severity of asthmatic symptoms. It has recently been proposed that the prevention or early treatment of allergic rhinitis may actually help to prevent the occurrence of asthma, but more data are needed. Nurses in advanced practice are in a position to develop and oversee comprehensive allergic rhinitis treatment plans for their patients that will help to clarify this issue.

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