Allergic Rhinitis

Background

• Allergic rhinitis is a common Type I hypersensitivity response of the upper respiratory tract to seasonal and perennial aeroallergens, usually resulting in recurrent nasal congestion, rhinorrhea, sneezing, and mucosal itching of the nose, eyes, ears, and palate.
• Associated conditions include asthma, atopic dermatitis and allergic conjunctivitis, nasal polyps, sinusitis, and sleep apnea.

Evaluation

• Presentation often includes:
  • sneezing, congestion, and rhinorrhea which may follow a seasonal pattern or be triggered by exposure to animals, dust, or other environmental factors
  • enlarged, pale or bluish boggy nasal mucosa, nasal polyps, allergic shiners (dark areas under eyes from venous congestion), and cobblestoning of the posterior oropharynx from postnasal drip
• Diagnosis is usually made clinically based on history, physical, and exposure to aeroallergens.
• Perform testing to identify specific triggers when considering immunotherapy (Strong recommendation), or if the diagnosis is uncertain. Testing options include skin testing (preferred) or serum IgE allergen testing (Weak recommendation).
• Nasal smears for eosinophils are not routinely necessary but may be considered if the history, physical exam, and IgE studies are not clearly diagnostic (Weak recommendation).

Management

• Offer intranasal corticosteroids as the most effective treatment for allergic rhinitis. Intranasal corticosteroids are most effective when given continuously but can be used on an as-needed basis (Strong recommendation).
• Offer intranasal antihistamines (such as azelastine 0.1% 1-2 sprays per nostril twice daily in patients > 5 years old) as an alternative or an additional first-line therapy for allergic rhinitis (Strong recommendation).
• Consider a combination of intranasal corticosteroids and intranasal antihistamines for moderate-to-severe nasal symptoms of seasonal allergic rhinitis (Weak recommendation).
• Consider oral antihistamines for symptom relief (Weak recommendation).
  • Oral antihistamines reduce rhinitis, itching, and sneezing but have a minimal effect on nasal congestion.
  • Second-generation antihistamines, such as cetirizine, loratadine, and fexofenadine, are preferred over more sedating first-generation antihistamines such as diphenhydramine.
• Consider oral decongestants, such as pseudoephedrine, which are effective but due to adverse effects use with caution or avoid in patients with comorbidities (Weak recommendation).
• Consider intranasal decongestants such as oxymetazoline or phenylephrine for intermittent use, but do not use continuously due to the risk of rebound rhinitis (rhinitis medicamentosa) (Weak recommendation).
• Consider leukotriene receptor antagonists (alone or in combination with antihistamines) but they are less effective than intranasal steroids (Weak recommendation).
  • Montelukast has a black box warning for serious behavior- and mood-related changes (including suicide) and restricted use for allergic rhinitis is advised.
• Consider immunotherapy when specific causative allergens can be identified by skin or IgE testing (Weak recommendation).
• Consider nasal saline irrigation to improve symptoms, especially for patients with a preference for not using medication (Weak recommendation).
• Consider allergen avoidance (environmental control) if it is feasible for perennial allergic rhinitis (Weak recommendation).
  • Animal avoidance is effective for sensitivity to animal dander (but may take 4-6 months to clear home of allergens).
  • Effective dust mite avoidance includes combination approaches with dust mite covers for bedding, humidity control, high-efficiency particulate air (HEPA) filters (for vacuuming of carpeting), and acaricides.