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Management of Rhinitis in Patients with Asthma

Management of Rhinitis in Patients with Asthma. Michael Schatz, MD, MS Chief, Department of Allergy Kaiser Permanente, San Diego, CA. Some Misconceptions About Rhinitis. Rhinitis is a trivial illness. All rhinitis is allergic. All non-allergic rhinitis is homogeneous .

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Management of Rhinitis in Patients with Asthma

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  1. Management of Rhinitis in Patients with Asthma Michael Schatz, MD, MS Chief, Department of Allergy Kaiser Permanente, San Diego, CA

  2. Some Misconceptions About Rhinitis • Rhinitis is a trivial illness. • All rhinitis is allergic. • All non-allergic rhinitis is homogeneous.

  3. Outline of Presentation • Practical classification of chronic rhinitis • Diagnostic approach in primary care • Specific syndromes • Distinguishing features • Treatment

  4. Practical Classification • Allergic Rhinitis • Seasonal versus Perennial • Frequency • Persistent (> 4 days/week for > 4 weeks/year) • Intermittent (less than above) • Severity • Mild • Moderate-severe (interference with sleep or daily activities or “troublesome symptoms”) • Other

  5. Practical Classification: Other • Other • Rhinitis medicamentosa • Septal deviation • Eosinophilic non-allergic rhinitis • Nasal polyps • Cholinergic rhinitis • Vasomotor rhinitis • GERD induced “post nasal drip” • Turbinate hypertrophy • Chronic sinusitis

  6. Practical Classification: Asthmatic Patient • Other • Rhinitis medicamentosa • Septal deviation • Eosinophilic non-allergic rhinitis • Nasal polyps • Cholinergic rhinitis • Vasomotor rhinitis • GERD induced “post nasal drip” • Turbinate hypertrophy • Chronic sinusitis

  7. Chronic Rhinitis: Diagnostic Approach 1. History 2. Physical Exam 3. Tests

  8. Chronic Rhinitis: Diagnostic Tests • Nasal smear (eosinophilic disease) • Specific IgE (allergic versus non-allergic) • Skin tests • RAST (blood tests) • Total IgE (AFS) • Immunoglobulins G, A, M (hypogammaglobulinemia with chronic sinusitis) • Fungal precipitating antibody • Sinus radiology

  9. Skin Tests versus Blood Tests • Skin Tests • Time-honored method • Results immediately available • More sensitive for some allergens or patients • Potential for systemic reactions • Antihistamines interfere • Blood tests • Easier for patient • May be more specific • No interference by medications or potential for systemic reactions

  10. Outline of Presentation • Practical classification of chronic rhinitis • Diagnostic approach in primary care • Specific syndromes • Distinguishing features • Treatment

  11. Allergic Rhinitis • Distinguishing Features • Sneezing, itching, rhinorrhea prominent • May be seasonal • Triggered by freshly cut grass, cleaning house, or pet exposure • Treatment • Indoor allergen avoidance • Intermittent: Antihistamines, intranasal corticosteroids (INS) as needed • Persistent: Regular INS; add antihistamines (oral and/or intranasal) and montelukast if needed) • Consider immunotherapy

  12. Immunotherapy • Consider for patients with definite allergic rhinitis not controlled by other means • Because of potentially life-threatening allergic reaction, it should be carried out only by specialists trained in its use • Goal: symptom and/or medication reduction, not usually eradication or cure

  13. Immunotherapy 2 • Used less for rhinitis now than it used to be due to better medications • Less effectiveness data for mold and animal dander • One year trial • If effective, continue for 3-5 years and then consider discontinuation • Sublingual immunotherapy (SLIT) now being studied

  14. Eosinophilic Non-Allergic Rhinitis • Distinguishing features • Prominent mucosal edema • Nasal eosinophilia • No relevant allergy • Treatment • Intranasal corticosteroids • Oral antihistamine or antihistamine-decongestant combination if needed • Oral prednisone for recalcitrant disease

  15. Nasal Polyps • Distinguishing Features • Nasal obstruction • Anosmia • Nasal polyps on exam • Treatment • Intranasal corticosteroids • Course of doxycycline (20 days) • Oral corticosteroids • Treatment of complicating infection • Consider montelukast • Surgery (polyp, sinus)

  16. GERD Induced “Post Nasal Drip” • Distinguishing features • Feeling of post-nasal drip or mucus in throat with minimal or no other nasal symptoms • May be associated with hoarseness, throat clearing, cough, pyrosis, regurgitation • May be worse after eating • Treatment • Reflux precautions • Protein pump inhibitors

  17. Practical Classification: Other • Other • Rhinitis medicamentosa • Septal deviation • Eosinophilic non-allergic rhinitis • Nasal polyps • Cholinergic rhinitis • Vasomotor rhinitis • GERD induced “post nasal drip” • Turbinate hypertrophy • Chronic sinusitis

  18. Symptoms Suggestive of Chronic Sinusitis Nasal congestion Pain or pressure around the forehead, nose, or eyes Discolored nasal discharge or discolored mucus in the throat Reduced sense of smell Symptoms for > 12 weeks by definition Tomassen P, et al. Allergy 2011; 66:556

  19. Allergy and Chronic Sinusitis Conflicting data regarding increased prevalence of chronic sinusitis in allergic patients Data suggests chronic sinusitis may be more severe in allergic patients Appropriate to aggressively treat allergic rhinitis in patients with coexistent chronic sinusitis Immunotherapy not convincingly shown to improve sinusitis in allergic patients

  20. Medical Approach to Chronic Sinusitis Saline lavage Intranasal corticosteroids Treat acute infections Treat coexistent allergic rhinitis Rule out hypogammaglobulinemia Medical treatment of hyperplasticeosinophilic sinusitis Post operative treatment of Allergic Fungal Sinusitis

  21. Chronic Hyperplastic Eosinophilic Sinusitis Eosinophilia does not indicate allergy Associated with nasal polyps, asthma, aspirin sensitivity Poorer prognosis after surgery Consider montelukast Aspirin desensitization for patients with aspirin sensitivity

  22. Allergic Fungal Sinusitis: Diagnostic Criteria Radiologic evidence of sinusitis Allergic mucin in the sinus Fungal hyphae in the mucin or positive sinus fungal culture Absence of diabetes, immunodeficiency, or immunosuppressive therapy Absence of fungal invasion

  23. Allergic Fungal Sinusitis: Immunologic Findings • Elevated total IgE level (67-74 %) • May correlate with course of disease • Increases ≥ 10 % provides high sensitivity for disease progression but lower specificity • Atopy (76-100 %) • Specific IgE against fungus (58-100 % positive skin tests) • Precipitating antibody against fungus (8-89 %)

  24. Allergic Fungal Sinusitis: Management • Surgery • Post-operative prednisone • 0.5 mg/kg daily for 14 days • 0.5 mg/kg every other day, tapered over 3 months to 5 mg every other day • Continue 5 mg every other day for at least 12 months • Intranasal steroids • ? Antifungal agents

  25. Conclusions Rhinitis is NOT a trivial illness All rhinitis is NOT allergic All non-allergic rhinitis is NOT homogeneous Appropriate diagnosis and management (medical and surgical) can substantially improve the quality of life of patients with chronic rhinitis or sinusitis and improve asthma control as well

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