Allergic Rhinitis (AR)

1. Allergic Rhinitis (AR) Lindsay Kurtz, RN, FNP-S

2. Integrated Literature Review • Problem: • Increase in prevalence and multiple associated co-morbidities • Impacts quality of life • Inadequate treatment related to lack of insight on seriousness of condition (Meltzer, Gross, Kafial, & Storms, 2012; Burns, 2012; Holmes & Scullion, 2012; Hadley, Derebery, & Marple, 2012) • Literature Search: • Databases (CINAHL, Health Source, medscape, ebscoHost, MEDLINE), google search engine • Data Evaluation: • Meta-analysis, cochrane reviews, RCTs, and empirical • Synthesis: • Similarities- atopic triad/atopic march, history taking, method of diagnosis, treatment plan • Differences- impact on quality of life and severity of diagnosis • Gap- research on efficacy of allergen avoidance

3. Definition • Chronic atopic (allergic) condition where expression has hereditary tendency (Boston-Cox, 2012; Burns, 2012; Fitzsimmons, Swan, & Roberts, 2012) • Rhinitis: diagnosis that affects the lining of the nasal cavity, mucous membranes (Henochowicz & Zieve, 2012) • Multiple symptoms all involving mucous membranes of the eyes, nose, ears, and throat after exposure to an allergen (Rafiq, 2013) • Classifications: • Seasonal- outdoor allergens= pollen, flowers, grasses, weeds, molds, trees • Perennial- indoor allergens= dust mites, mold, mildew, animal dander, environmental toxins • Intermittent • Persistent • Occupational- only impacted at workplace (Boston-Cox, 2012; Burns, 2012; Fitzsimmons, Swan, & Roberts, 2012; Rafiq, 2013)

4. Pathophysiology • IgE mediated response after exposure to an extrinsic protein causing inflammation of nasal mucosa • IgE mediated response occurs when individual produces IgE antibodies in response to an allergen(Holmes & Scullion, 2012) • Aeroallergen-driven inflammation of mucous membranes due to the infiltration of and resident inflammatory cells, vasoactive and pro-inflammatory mediators (Rafiq, 2013) • Histamines and leukotrienes are released (Boston-Cox, 2012) • Allergic or hypersensitive immunologic response generally occurs in two phases • Early- within minutes of exposure, high histamine release • Later- 4-6 hours after, mediated by eosinophils = inflammation • adfa Adapted from “Recognizing and managing allergic disease in the community,” by B. Boston-Cox, 2012, British Journal of Community Nursing, 12(7), p.302-308. (Ahmadifisher, Taghiloo, Esmalizadeh, & Falakaflaki, 2012)

5. Incidence and Prevalence • Difficult to pinpoint exact numbers related to ability to self-treat (Burns, 2012) • Common medical condition impacting at least 40 million people in US (Meltzer, Gross, Kafial, & Storms, 2012) • Average age of onset = 8-11 years and 80% of cases established by age 20 • Onset usually in first two decades of life, usually not prior to six months and tends to decline with climbing age • 10-25% of US adults, equal men and women • 9-24% of US children, equal boys and girls • 44-87% of individuals with AR have mixed allergic and non-allergic rather than a pure form (Rafiq, 2013)

6. Risk Factors • History of other atopic conditions: asthma, eczema, allergic conjunctivitis • Family history of atopic diseases (especially if in both parents) • Pediatrics: chronic nasal obstructions= facial deformities, dental malocclusions • Pregnancy: physiologic changes may aggravate all types of rhinitis especially in 2nd trimester • Higher socioeconomic status • Tobacco smoke exposure • Conditions of environment/home (Meltzer, Gross, Kafial, & Storms, 2012; Burns, 2012; Holmes & Scullion, 2012; Hadley, Derebery, & Marple, 2012; Rafiq, 2013)

7. Clinical Presentation (Holmes & Scullion, 2012; Rafiq, 2013; Meltzer, Gross, Kafial, & Storms, 2012; “Is it allergic,” 2012) • Nasal: • Rhinorrhea, congestion, sneezing, pruritis, allergic crease • Sinus: • pressure or congestion • Conjunctiva: • Watery eyes, redness, pruritis, allergic shiners • Ears: • Pressure, pain, inflamed/pale TM, check for fluid line • Mouth: • Pruritic palate, dry mucous membranes (mouth breathers) • Airway: • Inflammed, erythematous, wheeze Adapted from “Reducing impact of allergic rhinitis,” by R. Fitzsimons, K. Swan, G. Roberts, 2012, British Journal of School of Nursing, 7(5), p. 231-236.

8. Diagnosis • Made primary through history and physical (“Allergic rhinitis,” 2007, Rafiq, 2013) • Symptom diary • Medication trial • Allergy testing • Critical component of diagnosis is clinical history (Holmes & Scullion, 2012) • Important not to dismiss or minimize symptoms (Hadley, Derebey, & Marple, 2012) • ICD-9: • Allergic rhinitis due to pollen 477.0 • Allergic rhinitis due to other allergen 477.8 • Allergic rhinitis, cause unspecified 477.9

9. History • Nature, duration, and time course of symptoms • Any history of “clinical findings” key systems = integumentary, eyes, ears, nose, throat, lymph, respiratory • Symptoms proximity to triggers • Seasonality, exposures • Family history of atopic diagnosis • Individual history of asthma, eczema, allergic conjunctivitis • Individual history of other allergies to foods, medications  hypersensitive immune system ( Sicherer & Sher, 2011; Sussman, Sussman, & Sussman, 2010; Rafiq, 2013)

10. Physical Exam • Look test: • Allergic salute • Allergic shiners • Allergic crease • Suggestive, but not specific • Rhinorrhea with clear mucous • Pale, boggy nasal mucosa/turbinates • Post-nasal drip • Bilateral rather than unilateral nasal obstruction (Holmes & Scullion, 2012, Rafiq, 2013) http://healthyhappychildren.blogspot.com/2010/04/seasonal-allergies-allergic-salute.html http://www.drbunn.com/archives/1228 http://www.peds.ufl.edu/peds2/research/debusk/pages/page6_78.html

11. Differential Diagnosis Types of Rhinitis Non-rhinitis Skier’s nose- temperature exposure Septal abnormality Nasal polyps/tumor Pharyngitis Sinusitis Otitis Media Bacterial Conjunctivitis Viral URI Head trauma- CSF rhinorrhea • Non-allergic • Infectious • Occupational • Drug-induced (OCP, ACE, Viagra) • Hormonal • Vasomotor (idiopathic) ( Burns, 2012; Boston-Cox, 2012; “Is it allergies,” 2012; Holmes & Scullion, 2012, Rafiq, 2013)

12. Diagnostics • Labs done prior to referral for skin testing • Imaging: not routine due to cost, radiation exposure, and other tests available (Sicherer & Sher, 2011; Rafiq, 2013) • Eosinophils = principle effector cells related to the pathophysiology of allergic inflammation • Nasal smears with eosinophilic test = moderately sensitive but highly specific for diagnosis of AR • easy, non-invasive, inexpensive (Ahmadfisher, Taghiloo, Esmailzadeh, & Falakaflaki, 2012)

13. Red Flags • Presence of other allergic conditions • Sleep disturbance or apnea  life threatening? (Hadley, Derebery, Marple, 2012) • Interference with quality of life?  impacting school, work, or role performance (Holmes & Scullion, 2012) • Severe anaphylaxis  history of this type of allergic reaction, if so to what • If not know the signs and symptoms

14. Complications • Poorly controlled or untreated AR= huge impact on quality of life • Nasal Allergy Survey Assessing Limitations (NASAL): first national survey to look at the burden of disease of AR in adults in the US • Decrease sleep, impaired learning, impaired cognitive functioning, day-time fatigue, and long-term decrease in productivity (Meltzer, Gross, Kafial, & Storms, 2012) • Uncontrolled can trigger exacerbations of co-morbid conditions: asthma, rhinosinusitis, oropharyngeallympoid hypertrophy with secondary obstructive sleep apnea, chronic otitis media (Hadley, Derebery, & Marple, 2012) • Secondary infections: otitis media, sinusitis • Airway hyperreactivity with exposure • Facial changes: especially with mouth breathers (Rafiq, 2013)

15. Management Plan • 3 steps: • 1. Allergen avoidance • 2. Medication **if no impact or uncontrolled = refer to an Allergist** • 3. Allergy immunotherapy • If indicated after further testing • Based on failure of medications, severity of allergies, associated co-morbidities, any severe allergic reactions • Education • Follow-up • Support (“Allergic rhinitis, “2007; Boston-Cox, 2012; Fitzsimons, Swan, & Roberts, 2012; Holmes & Scullion, 2012; Rafiq, 2013)

16. Non-Pharmacological Treatment • Limit allergen exposure • Controversial r/t lack of evidence of efficacy • Most benefit if allergen is domestic pet or occupational • To limit exposure, is there a negative effect of quality of life? • Nasal Saline Rinses • Clears airway of secretions and allows for allergen removal ( Burns, 2012; Boston-Cox, 2012; Henochowicz & Zieve, 2012; Holmes & Scullion, 2012, Rafiq, 2013)

17. Pharmacological ( Burns, 2012; Boston-Cox, 2012Holmes & Scullion, 2012, Rafiq, 2013)

18. Patient Education • Inform about use of symptom diary • Inform of possible necessary environmental adaptation related to symptom triggers and allergen exposure avoidance • Shower before bed to remove allergens from hair and skin • Stay inside on dry windy days • Keep windows and doors shut • Remove carpeting if possible • Clean frequently to rid of dust mites and molds • Decrease humidity in home with dehumidifier • Educate about medication selection, dosing, and usage • Review signs and symptoms of anaphylaxis • Encourage to write down questions/concerns to bring to next visit to help establish a supportive relationship ( “Allergies: controlling,” 2011; Burns, 2012; Boston-Cox, 2012; Holmes & Scullion, 2012; “Is it allergic,” 2012; Rafiq, 2013)

19. Follow-Up • Non-specific restrictions • Avoid allergen exposure and activities where exposure more likely • Return for evaluation of management/treatment plan goals, symptom reduction, compliance with medication, improved quality of life (Burns, 2012; Rafiq, 2013)

20. Key Points • Atopic triad and atopic march • Allergic shiners, salute, and/or crease • HISTORY and physical fundamental to diagnosis • Avoidance of known allergens • Intranasal corticosteroids = most effective treatment of sx in AR • What is the impact on quality of life?

21. Questions?

22. References Ahmadifisher, A., Taghiloo, D., Esmailzadeh, A., & Falakaflaki, B. (2012). Nasal eosinophilia as a marker for allergic rhinitis: a controlled study of 50 patients. ENT: Ear, Nose, & Throat Journal, 91(3), p.122-124. Allergies: controlling your symptoms. (2011). American Family Physician, 83(5), p. 620. Allergic rhinitis. (2007). University of Michigan Health Systems. Retrieved from: http://guidelines.gove/content.aspx?id=11684 Boston-Cox, B. (2012). Recognizing and managing allergic disease in the community. British Journal of Community Nursing, 12(7), p. 302-308. Burns, D. (2012). Management of patients with asthma and allergic rhinitis. Nursing Standard, 26(32), P. 41-46. Fitzsimons, R., Swan, K., & Roberts, G. (2012). Reducing impact of allergic rhinitis. British Journal of School of Nursing, 7(5), p. 231-236. Hadley, J., Derebery, M., & Marple, B. (2012). Comorbidities and allergic rhinitis: not just a runny nose. Journal of Family Practice, 61(2 suppl), p. S11-5. Henochowicz, S. & Zieve, D. (Eds.). (2012). Allergic rhinitis: hay fever; nasal allergies. US National Library of Medicine (PubMed Health). Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001816

23. Holmes, S., & Scullion, J. (2012). Allergic rhinitis: assessment and treatment. Nurse Prescribing, 10(5), p. 222. Is it allergies or sinus infection?. (2012). Consumer Reports on Health, 24(6), p. 8-9. Meltzer, E., Gross, G., Kafial, R., & Storms, W. (2012). Allergic rhinitis substantially impacts patient quality of life: findings from the Nasal Allergy Survey Assessing Limitations. Journal of Family Practice, 61(2 suppl), p. S5-10. Parle-Peche, S., Powers, L., & St. Anna, L. (2012). Clinical inquiry: intranasal steroids vs. antihistamines: which is better for seasonal allergies and conjunctivitis?. Journal of Family Practice, 61(6), p. 429-448. Rafiq, N. (2013). Allergic rhinitis. In F. Domino, et al (Eds.). The 5 Minute Clinical Consult 2013, (p. 1146-1147). Philadelphia: WoltersKluwer/ Lippincott Williams and Wilkins. Sichere, S. & Sher, L. (2011). Diagnosing allergic diseases. Contemporary Pediatrics, 28(8), p. 34-36. Sussman, G., Sussman, D., & Sussman, A. (2010). Intermittent allergic rhinitis. CMAJ: Canadian Medical Association Journal, 182(9), p. 935-937. Woody, J., Wise, S., Koepp, S., & Schloseer, K. (2011). Clinical improvement after escalation of sublingual immunotherapy (SLIT). ENT: Nose, & Throat Journal, 90(9), p. E16-22.