Allergic Rhinitis

Question 1

What is allergic rhinitis?

Answer 1

Very prevalent allergic disorder, all age groups (Except asthma children), strong genetic basis

High prevalence highest between 25 and 44 years, ACT, WA

Lowest Rates QLD, NSW

Question 2

What is the Atopic Triad?

Answer 2

Atopic dermatitis, atopic asthma, allergic rhinitis

Question 3

What factors should be considered in someone presenting with allergic rhinitis?

Answer 3

Age of the patient (les likely in young and old)

Atopy family history

Timing of the year, exposure to triggers

Freq/severity of symptoms, recurrent symptoms?, signs of infection?, potential cold?

Risk of complications, impacts of quality of life

Comorbidities, smoking status

Question 4

What are common triggers and duration of intermittent allergic rhinitis?

Answer 4

Pollen, fungal spores

<4x/week or <4 consecutive weeks

Question 5

What are common triggers and duration of persistent allergic rhinitis?

Answer 5

Dust mites, mould, animals

> 4x/week or >4 consecutive weeks

Question 6

What are the symptoms of early phase reaction in rhinitis?

Answer 6

Nasal itch, rhinorrhoea, sneezing, nasal congestion

Question 7

What are the symptoms of late phase reaction in rhinitis?

Answer 7

nasal congestions (main symptoms)

Question 8

What are the general nasal symptoms of allergic rhinitis?

Answer 8

itchy nose, sneezing, runny/blocked nose, post-nasal drainage

Question 9

What are the general eyes and other symptoms of allergic rhinitis?

Answer 9

itchy eyes, watery discharge, itchy mouth, puffy red eyes, headache, cough, poor smell/taste, tiredness, nsorking

Question 10

What is the classification of mild symptoms in allergic rhinitis?

Answer 10

All of the following:

symptoms present but not troublesome

No sleep disturbances

no impairment of daily activities, leisure, or sport

No impairment of school or work performance

Question 11

What are the classifications of moderate to severe symptoms in allergic rhinitis?

Answer 11

One or more of the following:

Troublesome symptoms

sleep disturbances

impaired daily activities, leisure, or sport

Impairment of school or work performance

Question 12

What are some sever allergic rhinitis symptoms?

Answer 12

worsening snoring, poor sleep, inability to concentrate, exacerbated asthma, chronic sinusitis

Question 13

What are the consequences of improper treatment of allergic rhinitis?

Answer 13

Poorer quality of sleep = fatigue, impaired learning, worsening snoring, inc sleep apnoea risk

More prone to sinus, ear infection, eye infection

Asthma is difficult to control, abnormal development of mouth and teeth (from mouth breathing)

Question 14

When should you refer someone with allergic rhinitis?

Answer 14

Symptoms unresponsive to treatment, medicine induced rhinitis, symptoms of uncontrolled asthma/undiagnosed

Nasal obstruction (not clearing), unilateral discharge (esp. children), severe impact on quality of sleep

impaired sense of smell

First episode <12 y/o

Infectious symptoms = purulent discharge, facial pain, severe headache, fever, earache, hearing loss

Question 15

Key history questions to ask for allergic rhinitis

Answer 15

Describe symptoms? how start? how long? any other symptoms?

When do symptoms arise? what are triggers? how is your exposure to triggers

When are symptoms worse? any fam history of allergies?

what have you done to manage this so far?

Any other health conditions? pregnancy?

Question 16

What do we aim to do in allergic rhinitis treatment?

Answer 16

Relieve symptoms, improve QoL, Improve daily function, allergen avoidance

Question 17

How is allergic rhinitis commonly treated?

Answer 17

Intranasal corticosteroids, oral antihistamines

other potential = intranasal saline, anti-allergy eye drops, ipratropium bromide

Allergen avoidance

Question 18

List the intranasal corticosteroids used to treated allergic rhinitis

Answer 18

beclomethasone (beconase 12 hr), mometasone (nasonez allergy), fluticasone (beconase 24 hours)

Budesonide (rhinocort hayfever), traimcinolone (telnase)

Question 19

What are some differential diagnoses for allergic rhinitis?

Answer 19

Common cold = sore throat, nasal congestion, potential cough

Acute rhinosinusitis = facial pain/pressure, loss of smell, congested nose, upper airway cough, mild localised pain initially

Nasal blockage = no nasal itch, sneezing, rhinorrhoea, progressive and accompanied by loss of smell

Question 20

What role do INCS have in treatment of hayfever/allergic rhinitis?

Answer 20

Work locally on nasal mucosa, dec capillary permeability and mucous production

Relieves nasal symptoms = congestion, may reduce ocular symptoms

Onset of action: 3-7 hours (for congestion & rhinorrhoea), optimal effect several days w/ reg use

Local ADR = stinging, itching, sore throat, dry mouth, taste

Question 21

List the oral antihistamines used to treated allergic rhinitis

Answer 21

2nd generation preferred due to less sedation

Fexofenadine (telfast), cetirizine (Zyrtec), loratadine (Claratyn), desloratadine (Claramax), levocetirizine (Xyzal)

Question 22

What role do oral antihistamines have in the treatment of hayfever/allergic rhinitis?

Answer 22

Reduce nasal itching, sneezing, rhinorrhoea, eye symptoms

Less effective on nasal congestion, symptoms reduce and prevention

Question 23

List the intranasal antihistamine used to treated allergic rhinitis

Answer 23

Azelastine (Azep) = bitter taste in mouth
Levocabastine (Livostin)

Question 24

What role do intranasal antihistamines have in the treatment of allergic rhinitis?

Answer 24

Rapid onset % long lasting (up to 12 hours)

Not recommended in persistent allergic rhinitis

Can be used with nasal decongestant or INCS

Less effective than INCS alone

Question 25

What is the role on intranasal ipratroium bromide in allergic rhinitis?

Answer 25

Effective to treat Rhinorrhoea, indicated for persistent AR

Rapid onset of action, prolonged effect (4-12 hours)

Used with INCS or antihistamine

ADS = nasal dryness, nosebleed, taste disturbances, dry mouth

Question 26

What is the role of intranasal cromoglycate in the treatment of allergic rhinits?

Answer 26

Mast cell stabiliser = prevent histamine release

Prophylactic use only, efficacy determined with at least 4-6 weeks of use

Less effective INCS or antihistamines for mild-moderate AR

Preferred as first line in children

Disadv = req freq use 4-6x/day

Question 27

What is the role of intranasal saline in the treatment of allergic rhinits?

Answer 27

Nasal wetting agent –> moistens mucosa

Counteracts drying from INCS

Clears nasal passage by washing out allergens, sticky mucus, reduce congestion and irritation

Question 28

When to refer a patient with allergic rhinitis

Answer 28

Symptoms unresponsive to treatment, medicine induced

Nasal obstruction not clearing, unilateral discharge (Esp in kids), impaired sense of smell

Quality of life severely impacted, symptoms of uncontrolled asthma/undiagnosed

First episode in child <12 y/o

symptoms of infection = purulent discharge, facial pain, severe headache, fever, earache, hearing loss

Question 29

Tips on avoiding pollen

Answer 29

stay inside when count is high, avoid outdoor activities when trees/grass/related triggers are present

Shower after being outside (Remove pollen), close doors/windows of house/car to limit pollen

Question 30

Tips on avoiding mould

Answer 30

Keep house ventilated, use air-conditioner to limit humidity

clean anti-mould cleaners

Question 31

Tips on avoiding dust mites

Answer 31

wash bedding weekly (hot water), vacuum weekly with heap filter in vacuum cleaner

use mattress covers, limit dust collecting furniture