Transcript Rhinitis.AsthmaticPatients_WAO_12.11_2

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.
Outline of Presentation
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Practical classification of chronic rhinitis
Diagnostic approach in primary care
Specific syndromes
Distinguishing features
 Treatment
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Practical Classification
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Allergic Rhinitis
Seasonal versus Perennial
 Frequency
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Persistent (> 4 days/week for > 4 weeks/year)
 Intermittent (less than above)
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Severity
Mild
 Moderate-severe (interference with sleep or daily activities
or “troublesome symptoms”)
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Other
Practical Classification: Other
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Other
Rhinitis medicamentosa
 Septal deviation
 Eosinophilic non-allergic rhinitis
 Nasal polyps
 Cholinergic rhinitis
 Vasomotor rhinitis
 GERD induced “post nasal drip”
 Turbinate hypertrophy
 Chronic sinusitis
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Practical Classification: Asthmatic
Patient
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Other
Rhinitis medicamentosa
 Septal deviation
 Eosinophilic non-allergic rhinitis
 Nasal polyps
 Cholinergic rhinitis
 Vasomotor rhinitis
 GERD induced “post nasal drip”
 Turbinate hypertrophy
 Chronic sinusitis
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Chronic Rhinitis: Diagnostic Approach
1.History
2.Physical Exam
3.Tests
Chronic Rhinitis: Diagnostic Tests
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Nasal smear (eosinophilic disease)
Specific IgE (allergic versus non-allergic)
Skin tests
 RAST (blood tests)
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Total IgE (AFS)
Immunoglobulins G, A, M
(hypogammaglobulinemia with chronic sinusitis)
Fungal precipitating antibody
Sinus radiology
Skin Tests versus Blood Tests
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Skin Tests
Time-honored method
 Results immediately available
 More sensitive for some allergens or patients
 Potential for systemic reactions
 Antihistamines interfere
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Blood tests
Easier for patient
 May be more specific
 No interference by medications or potential for systemic
reactions
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Outline of Presentation
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Practical classification of chronic rhinitis
Diagnostic approach in primary care
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Specific syndromes
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Distinguishing features
 Treatment
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Allergic Rhinitis
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Distinguishing Features
Sneezing, itching, rhinorrhea prominent
 May be seasonal
 Triggered by freshly cut grass, cleaning house, or pet
exposure
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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
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Immunotherapy
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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
Immunotherapy 2
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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
Eosinophilic Non-Allergic Rhinitis
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Distinguishing features
Prominent mucosal edema
 Nasal eosinophilia
 No relevant allergy
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Treatment
Intranasal corticosteroids
 Oral antihistamine or antihistamine-decongestant
combination if needed
 Oral prednisone for recalcitrant disease
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Nasal Polyps
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Distinguishing Features
Nasal obstruction
 Anosmia
 Nasal polyps on exam
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Treatment
Intranasal corticosteroids
 Course of doxycycline (20 days)
 Oral corticosteroids
 Treatment of complicating infection
 Consider montelukast
 Surgery (polyp, sinus)
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GERD Induced “Post Nasal Drip”
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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
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Treatment
Reflux precautions
 Protein pump inhibitors
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Practical Classification: Other
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Other
Rhinitis medicamentosa
 Septal deviation
 Eosinophilic non-allergic rhinitis
 Nasal polyps
 Cholinergic rhinitis
 Vasomotor rhinitis
 GERD induced “post nasal drip”
 Turbinate hypertrophy
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 Chronic
sinusitis
Symptoms Suggestive of Chronic
Sinusitis
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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
Allergy and Chronic Sinusitis
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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
Medical Approach to Chronic
Sinusitis
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Saline lavage
Intranasal corticosteroids
Treat acute infections
Treat coexistent allergic rhinitis
Rule out hypogammaglobulinemia
Medical treatment of hyperplastic eosinophilic
sinusitis
Post operative treatment of Allergic Fungal
Sinusitis
Chronic Hyperplastic Eosinophilic
Sinusitis
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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
Allergic Fungal Sinusitis: Diagnostic
Criteria
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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
Allergic Fungal Sinusitis:
Immunologic Findings
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Elevated total IgE level (67-74 %)
May correlate with course of disease
 Increases ≥ 10 % provides high sensitivity for
disease progression but lower specificity
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Atopy (76-100 %)
Specific IgE against fungus (58-100 % positive
skin tests)
Precipitating antibody against fungus (8-89 %)
Allergic Fungal Sinusitis:
Management
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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
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Intranasal steroids
? Antifungal agents
Conclusions
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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