Rhinitis (allergic)
Rhinitis (allergic)
What is allergic rhinitis?
The word “rhinitis” is defined as inflammation of the nasal passages. It is a common disorder that can affect up to 40% of the population, with 10-20% of these patients having allergic rhinitis.1 It can lead to annoying symptoms, such as sneezing, itching, nasal congestion, runny nose and post-nasal drip (sensation of mucus going down the back of the throat). For many people, allergic rhinitis is a lifelong condition, but fortunately, the symptoms can be controlled by various methods, such as environmental measures, medications and immunotherapy (allergy shots).2
What causes allergic rhinitis?
This type of rhinitis is caused by small airborne particles called allergens, and sometimes, these particles can also cause asthma and allergic conjunctivitis (itchy, watery, red eyes). Allergic rhinitis can be seasonal (occurring during certain times of the year) or perennial (occurring year-round):
1. Seasonal allergic rhinitis: caused by pollens from trees, grasses and weeds
2. Perennial allergic rhinitis: caused by dust mites, cockroaches, animal dander, fungi or molds.
What are the common signs and symptoms?
1. Nose – watery nasal discharge, nasal congestion, sneezing, nasal itching, postnasal drip, loss of taste, facial pressure or pain
2. Eyes – itchy, redness, grittiness of the eyes, swelling and dark areas under the eyes (“allergic shiners”)
3. Throat and eyes – sore throat, hoarse voice, itching of the ears or throat
4. Sleep – mouth breathing, frequent awakening, daytime fatigue, disturbance of normal activities
How is allergic rhinitis diagnosed?
Your doctor will review your medical history, symptoms and complete a physical examination to diagnose allergic rhinitis. It is possible to identify the causes and triggers by:
Thinking about where you were or what you were doing before your symptoms started
Noting the time of year when your symptoms are the worst
Identifying any triggers at home, work or school
Your allergist may suggest skin testing to identify what may be causing your symptoms.
How can allergic rhinitis be treated?
1. Avoiding triggers
Dust mites
o Use allergen-impermeable covers for bedding
o Keep humidity in the home below 50%
Pollen
o Keep windows closed
o Use window screen filters
o Use air conditioner
o Limiting time outside during high pollen seasons
Animal dander
o Remove animal from home – symptoms will reduce within 4-6 months
o High-efficiency particular air (HEPA) filters
o Restrict animal from bedroom
Mould
o Cleaning with fungicides
o Dehumidification to less than 50%
o Fix water damage
o HEPA filtration
2. Antihistamines
Second-general oral antihistamines are first-line medications for allergic rhinitis:
o Desloratadine (Aerius)
o Fexofenadine (Allegra)
o Loratadine (Claritin)
o Cetirizine (Reactine)
New, prescription-only, non-sedating antihistamines
o Bilastine (Blexten)
o Rupatadine (Rupall)
Although older, sedating antihistamines (such as Benadryl) are effective in relieving symptoms, there has been evidence to show that they may affect your memory and neurological functioning, so they are not recommended
3. Intranasal corticosteroids
Also considered first line therapy, and when used regularly and effectively, can reduce inflammation in the nasal passages
The following nasal sprays are available in Canada:
o Fluticasone furoate (Avamys)
o Beclomethasone (Beconase)
o Fluticasone propionate (Flonase)
o Triamcinolone acetonide (Nasacort)
o Mometasone furoate (Nasonex)
o Ciclesonide (Omnaris)
o Budesonide (Rhinocort)
How to use a nasal spray
o Hold head straight
o Point spray away from the nasal septum
o After spraying, sniff gently to pull the spray to the higher areas of the nose
o Don’t sniff too hard, as the medicine could go down the back of the throat
4. Combination intranasal corticosteroid and antihistamine nasal spray
Dymista (fluticasone proprionate/azelastine hydrochloride)
o May be more effective than intranasal steroids for some patients
5. Leukotriene receptor antagonists (Montelukast)
Not as effective as intranasal steroids
o Only considered when all the medications above have been tried and are not effective
6. Allergy shots
Also known as “allergen immunotherapy”
Can be given subcutaneously (a shot in the arm just under the skin) or sublingually (under the tongue)
Increasing quantities of the patient’s relevant allergens are given until an effective dose is reached that controls the allergy symptoms
Allergy shots are available for common allergens, like pollens (tree, grass and ragweed), cat and dog dander, dust mites and moulds
Subcutaneous
o Shots are given on a weekly basis for 6-8 months, followed by maintenance shots every month for 3-5 years
Sublingual
o Available for grass, ragweed and now, tree pollen
o Benefits include avoiding injections, taking the tablets at home, and increased safety
Angeliki Barlas, MD
Clinical Immunology and Allergy Fellow
References:
1. Small P, et al. Rhinitis: a practical and comprehensive approach to assessment and therapy. J Ototlaryngol. 2007;36(Suppl 1):S5-27
2. Wallace DV, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1