allergic rhinoconjunctivitis (hayfever)
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Etiology
- IgE-mediated hypersensitivity to nasally-inhaled allergens
- seasonal allergens
- perennial allergens
- see 'allergens causing allergic rhinitis'
Pathology
- irritation & inflammation of mucous membranes of eyes & upper respiratory tract
- generally requires about 3 seasonal exposures for a patient to develop clinically significant symptoms to a new aeroallergen
- nasal polyps may cause refractory nasal obstruction
Genetics
- implicated genes SDAD1
Clinical manifestations
- sneezing
- rhinorrhea (thin, clear nasal discharge)
- postnasal drip
- nasal congestion
- pale, swollen nasal mucosa
- turbinate edema
- may lead to loss of taste &/or smell
- may lead to sinusitis, acute or chronic
- conjunctivitis
- ocular itching
- lacrimation, clear watery discharge (tears)
- conjunctival injection
- cough
- frequent nose rubbing (allergic salute)
- dry mouth
- halitosis
- fatigue
- sleep disturbances
- dark circles under the eyes (allergic shiners)
Laboratory
- nasal cytology (smears) may show eosinophils
- skin testing for allergen-specific IgE
- radioallergosorbent [RAST] testing
Radiology
Complications
- bronchitis
- asthma (coexisting asthma not uncommon)
Differential diagnosis
- infectious agents
- non-infectious
- vasomotor rhinitis
- smoke
- air pollution
- perfumes
- detergents & soaps
- solvents or fumes
- changes in temperature, light, or atmospheric pressure
- emotion
- rhinitis medicamentosa
- sympathomimetic nasal drops or sprays
- cocaine
- antihypertensives
- oral contraceptives
- antidepressants
- nasal obstruction
- systemic disorders
- cerebrospinal fluid leak (CSF rhinorrhea)
- atrophy of nasal mucosa
- vasomotor rhinitis
Management
- topical nasal steroids (most effective agents)
- also reduces ocular symptoms of allergic conjunctivitis[12]
- intranasal glucocorticoids
- beclomethasone (Beconase, Vancenase)
- flunisolide (Nasalide) - 2 sprays (50 ug) BID
- triamcinolone (Nasocort) - 2 sprays (110 ug) QD
- budesonide[3]
- antihistamines
- chlorpheniramine 4 mg PO TID/QID
- loratadine (Claritin) 10 mg PO QD
- astemizole (Hismanal) 10 mg PO QD
- fexofenadine (Allegra) 60 mg PO BID
- azelastine (Astelin) 2 sprays/nostril BID (nasal spray)
- azelastine (Optivar) ophthalmic 1 drop BID
- decongestants
- effective but associated with rebound congestion (rhinitis medicamentosa)
- pseudoephedrine (Sudafed) 30-60 mg QID
- oxymetazoline (Afrin) intranasal enhances effectiveness of intranasal glucorticoids without rebound congestion
- montelukast (Singulair) 10 mg PO QD (adults) is NOT more effective than antihistamines or decongestants
- prednisone 40 mg PO QD for 5 days for very severe symptoms
- nasal chromolyn (Nasalchrom)
- one spray (5.2 mg) TID/QID
- prophylactic dosing
- variable response
- tolerance induction (immunotherapy)
- injection of allergen defined by RAST or skin testing
- best response with seasonal allergies
- patients with severe rhinitis not well controlled with intranasal glucocorticoids, antihistamines, decongestants[10]
- contraindicated with beta blocker therapy
- systemic or ocular
- increases likelihood of adverse systemic reaction
- diminished response to epinephrine rescue
- subcutaneous immunotherapy (SCIT) or 'allergy shots' may someday be replaced by daily sublingual-dissolving tablets that contain allergens[11][14]
- pregnancy
- oxymetazoline nasal spray for 5 days
- pseudoephedrine
- intranasal cromolyn
- intranasal beclomethasone
- chlorpheniramine if unresponsive to cromolyn
- treat sinusitis
- patient education
- dust mites
- mold
- keep humidity < 50%
- vent bathrooms & clean with fungicidal agent
- remove books & plants from the bedroom
- install air filters
- animal dander
- remove pets from house
- bathe pets frequently (at least every week)
- shampoo carpets
- pollen
- avoid outdoors during pollen season
- keep windows closed (use air conditioning)
- install air filter units for air conditioning
- Refer to allergist if response to treatment is poor & diagnosis of allergic rhinitis seems probable
- Refer to ENT specialist if response to treatment is poor & diagnosis of allergic rhinitis is questionable.
More general terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 84-86
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
- ↑ 3.0 3.1 Journal Watch 22(9):70, 2002 Rinne et al, Clin Immunol 109:426, 2002
- ↑ Singulair (Montelukast) for Seasonal Allergic Rhinitis Prescriber's Letter 10(2):9 2003 Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=190210&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Meltzer EO. Evaluation of the optimal oral antihistamine for patients with allergic rhinitis. Mayo Clin Proc. 2005 Sep;80(9):1170-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16178497
- ↑ Prescriber's Letter 13(4): 2006 Drug Treatments for Allergic Rhinitis Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=220414&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Prescriber's Letter 14(1): 2007 Ophthalmic Medications for Allergic Conjunctivitis Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230106&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Wahn U et al Efficacy and safety of 5-grass-pollen sublingual immunotherapy tablets in pediatric allergic rhinoconjunctivitis. J Allergy Clin Immunol 2009 Jan; 123:160 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19046761
Bufe A et al Safety and efficacy in children of an SQ-standardized grass allergen table for sublingual immunotherapy. J Allergy Clin Immunol 2009 Jan; 123:167. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19130937
Frew AJ. Sublingual immunotherapy. N Engl J Med. 2008 May 22;358(21):2259-64. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18499568 - ↑ Prescriber's Letter 16(8): 2009 COMMENTARY: Neuropsychiatric Adverse Effects with Leukotriene Modifiers GUIDELINES: NAEPP Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007 GUIDELINES: The Diagnosis and Management of Rhinitis: An Updated Practice Parameter Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=250805&pb=PRL
- ↑ 10.0 10.1 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, American College of Physicians, Philadelphia 2006, 2009
- ↑ 11.0 11.1 Durham SR et al. Long-term clinical efficacy in grass pollen-induced rhinoconjunctivitis after treatment with SQ-standardized grass allergy immunotherapy tablet. J Allergy Clin Immunol 2010 Jan; 125:131 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20109743
- ↑ 12.0 12.1 Prenner BM et al. Mometasone furoate nasal spray reduces the ocular symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol 2010 Jun; 125:1247 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20434199 <Internet> http://dx.doi.org/10.1016/j.jaci.2010.03.004
- ↑ Baroody FM et al. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol 2011 Apr; 127:927. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21377716
- ↑ 14.0 14.1 Didier A et al. Sustained 3-year efficacy of pre- and coseasonal 5-grass- pollen sublingual immunotherapy tablets in patients with grass pollen-induced rhinoconjunctivitis. J Allergy Clin Immunol 2011 Sep; 128:559 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21802126