Seasonal Allergic Rhinitis: Guideline Updates Applied to Clinical Cases

Marine Demirjian, MD FACAAIAssociate Clinical Instructor, David Geffen School of Medicine at UCLA

Allergy & Asthma Treatment Center, Glendale CA

Disclosures

• None

Objectives

• Definition and characterization of allergic rhinitis

• Selection of pharmacologic therapy for treatment of symptoms using evidence based guidelines

What Is Rhinitis

• Characterized by one of more of the following symptoms:

• Congestion

• Sneezing

• Rhinorrhea (anterior and posterior)

• Nasal Itching

• Associated symptoms: Itchy, watery, red swollen eyes

Prevalence of Rhinitis

• In adults, 6th most common prevalent chronic condition, effects 10-30% of adults

• In children, most common prevalent chronic condition, effects about 40% of children

Major Categories of Rhinitis

• Allergic Rhinitis

• Non Allergic Rhinitis

• Mixed

Comorbidities

• Appropriate treatment of rhinitis is important and can effect overall treatment of other comorbidities including

• Asthma (US surveys report that 38% of patients with AR have asthma and up to 78% of asthma patients have AR)

• Sleep Apnea

• Sinusitis

Allergic Rhinitis

• IgE Mediated

• Common allergic triggers including• Pollen (Tree, Grass, Weed ) Seasonal

• Fungi (Indoor/Outdoor)

• Indoor Allergens (Dust Mites, Pets, Rats/Mice, Cockroaches)

Types of Allergic Rhinitis

• FDA Classification

– Seasonal

– Perennial

• Episodic Environmental Exposures

• Rhinitis is Intermittent vs. Persistent

ICD 10 Rhinitis Codes

• J30.1 Allergic rhinitis due to pollen

• J30.2 Other Season allergic rhinitis

• J30.5 Allergic rhinitis due to food

• J30.81 Allergic rhinitis due to animal hair and dander (cat, dog)

• J30.89 Other allergic rhinitis

• J30.9 Allergic rhinitis, unspecified

Case 1

• 37 yo F history of summer time allergies while living in New York now has symptoms year round consisting of sneezing, rhinorrhea, itchy/watery eyes. Feels is tired throughout the day and is “sick and tired of feeling sick and tired”. She is otherwise healthy with a complete negative ROS. Has 3 siblings also with “hay fever”.

– Not a fan of medications

– Wants to know exactly what she has

Categories of Allergic Rhinitis

• Allergic Rhinitis Can be Classified By1. Temporal Pattern

Seasonal, Perennial, Episodic Environment2. Frequency of symptoms

Intermittent (<4days/week or <4 weeks/year)Persistent (>4days/week and >4 weeks/year

3. Severity Mild vs. more severe (where symptoms

interfere with QOL such as sleep, impairment of activities, school and work)

History

• What are your most bothersome symptoms– Rhinorrhea

– Congestion

– Sneezing

– Itching (less common in non-allergic rhinitis)

Associated eye symptoms

- itchy, watery, red, swollen, eyes (more common in allergic rhinitis from pollen than dust mites)

History

• Environmental effects?

– Home vs. work

– Outdoor vs. indoor

– Acute symptoms with house dust mites, mold, cutting grass, pets

– Better on vacations (away from pets?)

• Drugs: ASA/NSAIDS, ACE -I

• Food: gustatory rhinitis

History

• Nasal congestion: Shifting (consistent with nasal cycling) vs. unilateral (anatomic cause)

• Assess previous response to medications, compliance/adherence

• Sinusitis? Acute onset with persistent symptoms after URI? Headache and purulent drainage non specific

• Presence of coexisting conditions (asthma, OSA, GERD)

• Family history of atopy

Physical Exam

Physical Exam

• Nose

– Septum (deviation, mucosal ulcers)

– Can nasal sprays be delivered successfully?

• Need for short term nasal decongestant spray or oral steroids

– Characterize mucosa, is mucous (purulence)

– Nasal polyps

• Eyes, ears, oropharynx

• Lungs (high prevalence of concomitant asthma)

Specific IgE determination

• Immediate Skin testing or in vitro tests to determine allergen specific IgE can support or exclude an allergic basis for symptoms

– Assist in selection of pharmacotherapeutic options, some of which are of no value for non-allergic rhinitis

– Identifies specific allergens responsible for symptoms

• Direct focused allergen avoidance measures

• When appropriate, proceeding to allergen immunotherapy

Allergy Skin Testing

Skin prick test results

+ Timothy Grass, Bermuda Grass and Johnson Grass

Treatment of Allergic rhinitis• Avoidance

– Environmental Control

• Pharmacologic Therapy

• Allergen Immunotherapy

Pollen Count

HEPA Air Purifier

Categories of pharmacologic therapies

• Pharmacologic therapy includes • antihistamines (intranasal and oral)

• decongestants (intranasal and oral)

• corticosteroids (intranasal and oral)

• intranasal cromolyn

• intranasal anticholinergics

• oral leukotriene receptor antagonists (LTRAs).

Cornucopia of Nasal Sprays

Evidence Based Treatment Recommendations

Medication General Guidelines

• ORAL antihistamines, oral leukotrienes and nasal cromolyn generally are effective only in AR

Intranasal Corticosteroids

• Most effective monotheray for SAR/PAR

• Effective for all symptoms of SAR/PAR including nasal congestion

• More effective than combination of oral antihistamines and LTRA for SAR and PAR

• Similar effectiveness of oral antihistamines for associated ocular symptoms of AR

Medication Use General Guidelines

• Patients receiving intranasal sprays

– Instruct to avoid spraying medially towards the septum

– Offer “nose to toes” technique to avoid “drainage” and perception of adverse taste

Septal Perforation

Periodic septal examination for presence of mucosal erosions that may evolve to frank ulcers and nasal septal perforation

Side Effects of Intranasal Corticosteroids

• Local side effects minimal• Nasal irritation, bleeding,

• Systemic side effects• Adults – none significant; generally reassuring data

about cataracts and increased IOP

• Children – no HPA axis suppression, but growth concerns ( data mostly reassuring but…)

• OTC class labeling:…when using, the “growth rate of some children might be slightly slower, if a child needs to use the spray for longer than two months a year, the parent should talk to the child’s doctor.”

Selection of Agent Keeping In Mind Onset of Action

Oral Antihistamines

• Continuous use most effective for SAR and PAR, but appropriate for PRN use in intermittent or episodic AR because of relative rapid onset of action

• Avoid 1st generation “sedating agents”– Performance impairment may not be perceived

– Driving impairment may be equivalent to ETOH inebriation

– Disturbed sleep architecture

– Anticholinergic effects (dry mouth, urinary retention)

– Fall risk in seniors

– Risk for dementia from anticholinergics in seniors?

Oral Antihistamines

• 2nd generation OAH preferred

– Cetirizine

– Fexofenadine

– Levocetirizine

– Loratidine

– Desloratidine

Oral Decongestants

• Oral Agents:

– Hypertension, insomnia, anxiety

– Evidence of effectiveness greater for pseudoephedrine (BTC) than phenylephedrine (OTC)

– Associated with increased risk of gastroschesis in first trimester of pregnancy

Intranasal Antihistamines

• Less effective than intranasal steroids for nasal symptoms

• Clinically significant effect on nasal congestion

• Nasal azelastine: FDA indication for vasomotor rhinitis

• Have clinically significant rapid onset of acting, making them appropriate for PRN use in episodic AR

• Adverse effects: sedation and dysgeusia

Leukotriene Receptor Antagonists

• Montelukast is FDA approved LTRA for SAR treatment

• Good safety profile for patients 6 months and older

• Potential adverse effects include URI and headache

• Post marketing reports of rare drug-induced neuropsychiatric events including aggression, depression and suicidal thinking and behavior have been reported

Case 2

• 26 yo F w/ AR and asthma– Symptoms present throughout the year but worse

in late spring

– Symptoms controlled on nasal steroid, inhaled steroids, albuterol need on most days with prn anti-inflammatory eye drops

– Wondering whether there is something that can make her less dependent on “all of this medicine”

– Lives in older home with some water damage

– Worsening of symptoms since getting a cat

Skin testing

• + Timothy grass, june grass, orchard grass

• + Cat hair and dander

• +Dermatophagoides pteronyssinus

• +Penicillium notatum

Clinical Vignette Continued

• Patient is relatively young and unlikely to spontaneously improve in her allergies for several decades

• She is on multiple medications throughout the year and not even obtaining complete control of symptoms

• Immunotherapy may not only improve her symptoms but allow for decrease in amount of medication she needs

• Offers likelihood of benefit persisting for years after immunotherapy is stopped

• Disadvantages include inconvenience of weekly and later monthly visits, discomfort of local reactions and the risk of systemic reactions

Allergen Immunotherapy

• Subcutaneous immunotherapy – controlling symptoms of allergic rhinitis

– favorably modifies long-term course of disease

• Patient with allergic rhinitis should be considered candidates for immunotherapy – severity of their symptoms

– failure or unacceptability of other treatment modalities

– presence of comorbid conditions and possibly as means of preventing worsening of the condition or the development of co morbid conditions (asthma and sinusitis)

– Immunotherapy for allergic rhinitis can reduce the development of asthma in children and possibly adults

Allergen Immunotherapy

• Approximately 80% of patient will experience symptomatic improvement of symptoms after 1-2 years of subcutaneous immunotherapy

• Guidelines recommend treatment continue for a total of 4-5 years

• Benefits in many patients persist for years after injections are stopped

Allergen Immunotherapy

Sublingual Immunotherapy

• SLIT• Method of allergy treatment that uses

a dissolvable allergen tablet given under the tongue.

• Treatment for allergic respiratory diseases with demonstrated efficacy and safety

• Several formulations available worldwide for AR

• Grass tablets • Ragweed tablets• House dust mite tablets

Sublingual Immunotherapy

• SLIT-tablet therapy is initiated with a full dose or a short escalation in dose, with the first dose given under medical supervision, and then administration continues once daily and is self-administered by the patient or caregiver at home

• Most adverse events are local

• Patients should have Epi-pen

Sublingual Immunotherapy

• Clinical trials of grass or ragweed tablets have shown that treatment effect is optimized with initiation of treatment 12 to 16 weeks prior to the onset of pollen season.

• Environmental chamber study design with house dust mite SLIT demonstrated an early onset of action at eight weeks

Case 3

• 52 yo male with severe congestion, feels he can’t breathe from his nose bilaterally. He notes he has tried “EVERYTHING” available over the counter, has also gone to urgent care and received several prescriptions (can’t recall names) but NOTHING is working for him.

Cornucopia of Nasal Sprays

Structural/Mechanical factors that mimic rhinitis

• Deviated septum/septal wall anomalies

• Hypertrophic turbinates (inferior)

• Adenoidal hypertrophy (in kids)

• Foreign Bodies

• Nasal tumors; benign, malignant, choanal atresia

Medication Related Rhinitis

• Rhinitis Medicamentosa (topical decongestants, cocaine)

• Aspirin/NSAIDs

• ACE inhibitors (need not have cough!)

• Beta blockers and other anti-hypertensives

– Symptoms temporally correlate with initiation of medication

• OCP

GE Reflux

• Common cause of rhinitis

Inflammatory/immunologic conditions

• Nasal Polyposis• Wegners granulomatosis• Midline granulmoa• Sacroid• SLE• Sjogren’s syndrome• CSF rhinorrhea

• Often unilateral• Posttraumatic or spontaneous• Check discharge of beta-2 transferrin level (not present in

usual nasal secretions), glucose levels

Hormonal-induced rhinitis

• Oral contraceptives

• Hypothyroidism

• Pregnancy

• Menstrual cycle related

Nasal Decongestants

• More effective than oral agents and lack many of the cardiovascular and CNS side effects

• Unfortunately, associated with tolerance and rebound rhinitis medicamentosa

• Some studies show that concomitant nasal steroid and nasal decongestants reduces risk

Rhinitis Medicamentosa

• Down regulation of alpha-adrenergic receptors

• Treat with intranasal corticosteroids

• Discontinue topical decongestant as soon as symptoms abate’ may require short course of oral steroid (e.g., prednisone 30mg daily for 5-7 days in adults)

• Evaluate, treat underlying acute/chronic rhinitis

The End

• Questions?