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CO
MANAGEMENT OF
ALLERGIC RHINITIS AND
ITS IMPACT ON ASTHMA
POCKET GUIDE
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Management that follows evidence-based practice guidelines yields better patient results. However, global
evidence-based practice guidelines are often complicated and recommend the use of resources often not
available in the primary care setting worldwide. The joint Wonca/GARD expert panel offers support to
primary care physicians worldwide by distilling the existing evidence based recommendations into this
brief reference guide. The guide lists diagnostic and therapeutic measures that can be carried out worldwide in the primary care environment and in this way provide the best possible care for patients with allergic
rhinitis. The material presented in sections 1-5 will assist you in diagnosing and treating allergic rhinitis.
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Allergic rhinitis is a growing primary care challenge since most patients consult primary care physicians.
General practitioners play a major role in the management of allergic rhinitis as they make the diagnosis,
start the treatment, give the relevant information, and monitor most of the patients. In some countries,
general practitioners perform skin prick tests. Studies in Holland and the UK found that common nasal allergies can be diagnosed with a high certainty using simple diagnostic criteria. Nurses may also play an
important role in the identification of allergic diseases including allergic rhinitis in the primary care of developing countries and in schools. In addition, many patients with allergic rhinitis have concomitent asthma and
this must be checked.
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Qu e s ti o n
No
Yes
No
Postnasal drip (down the back of your throat) with thick mucus and/or runny nose (see NOTE)
Yes
No
Yes
No
Recurrent nosebleeds
Yes
No
Yes
No
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2. Do you have any of the following symptoms for at least one hour on most days (or on most days
during the season if your symptoms are seasonal)?
Yes
No
Yes
No
Nasal obstruction
Yes
No
Yes
No
Yes
No
Nasal itching
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E v al u a t i o n :
The symptoms described in Question 1 are usually NOT found in allergic rhinitis. The presence of ANY ONE of them suggests
that alternative diagnoses should be investigated. Consider alternative diagnoses and/or referral to a specialist.
NOTE: Purulent discharge, postnasal drip, facial pain, and loss of smell are common symptoms of sinusitis. Because most
patients with sinusitis also have rhinitis (though not always allergic in origin), in this situation the clinician should also evaluate
the possibility of allergic rhinitis.
The presence of watery runny nose with ONE OR MORE of the other symptoms listed in Question 2 suggests allergic rhinitis,
and indicates that the patient should undergo further diagnostic assessment.
The presence of watery runny nose ALONE suggests that the patient MAY have allergic rhinitis. (Additionally, some patients
with allergic rhinitis have only nasal obstruction as a cardinal symptom.)
If the patient has sneezing, nasal itching, and/or conjunctivitis, but NOT watery runny nose, consider alternative diagnoses
and/or referral to a specialist.
In adults with late-onset rhinitis, consider and query occupational causes. Occupational rhinitis frequently precedes or
accompanies the development of occupational asthma. Patients in whom an occupational association is suspected should be
referred to a specialist for further objective testing and assessment.
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Di a gn osti c Too l
F i n d i ng s th a t S u p p o r t D i a g n os i s
Physical examination
1International
Symptoms suggestive
of allergic rhinitis
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u n i l a t e r a l s ym p t o m s
nasal obstruction without other symptoms
mu copu ru le nt rh i no rrhe a
p o s t e r i o r r h i n o r r h e a ( p o s t n a sa l d r i p )
w i t h t h i c k m u c o u s
a n d / o r n o a n t e r i o r r h i n o r r h e a
p a in
re curren t epi s tax is
a no s m ia
C l a s s i f y a n d a s s es s s e ve r i ty
( se e se c t io n 4 )
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NO
OR
Anterior rhinorrhea
Sneezing
Nasal obstruction
(and possibly other nasal or ocular symptoms)
M
Phadiatop or
Multi-allergen test
M
Positive
Refer the
patient to
specialist
M
Positive
+ correlated
with
symptoms
M
Allergic rhinitis
M
Rhinitis is unlikely
to be allergic
2Allergic
M
Skin prick test
M
Negative
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M
Negative
Specialist
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Primary care
M
Negative
M
Non allergic
rhinitis
If strong suggestion of
allergy: perform serum
allergen specific IgE
M
Positive
+ correlated
with
symptoms
M
Allergic rhinitis
Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
Persistent
symptoms
>4 days/week
and >4 consecutive weeks
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Mild
all of the following
normal sleep
no impairment of daily activities, sport, leisure
no impairment of work and school
symptoms present but not troublesome
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Moderate-Severe
one or more items
sleep disturbance
impairment of daily activities, sport, leisure
impairment of school or work
troublesome symptoms
Trea t men t G oa ls
,
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DO
Unimpaired sleep
Ability to undertake normal daily activities, including work and school attendance, without limitation or
impairment, and the ability to participate fully in sport and leisure activities
No troublesome symptoms
No or minimal side-effects of rhinitis treatment
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A RI A 2 0 0 7
a d u l ts
SAR
ch i l d re n
a du lt s
PAR
c h il dre n
A**
A**
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I n t e r v en t i o n
P ER
In t r a n a s a l C S
In t r a n a s a l c r o m o n e
LTR As
A ( > 6 y rs )
S u b c u t a n eo u s S I T
A**
A**
A l l e rg e n a v o id an c e
A*
B*
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O r a l H 1 A n ti h i s t a m i n e
A**
Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
Intermittent
symptoms
moderatesevere
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mild
Persistent
symptoms
moderate
severe
mild
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In preferred order
intranasal CS
H1-antihistamine or LTRA**
,
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improved
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if failure: step-up
if improved: continue
for 1 month
failure
review diagnosis
review compliance
query infections
or other causes
step-down
and continue
treatment
for 1 month
DO
in persistent rhinitis
review the patient
after 2-4 weeks
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increase
rhinorrhea
intranasal CS
add ipratropium
dose itch/sneeze
blockage
add H1 antihistamine
add
decongestant
or oral CS
(short-term)
failure
surgical referral
.
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add:
oral H1-antihistamine
or intraocular H1-antihistamine
or intraocular cromone
(or saline)
Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
4 s i m pl e qu e s t i o n s :
ha ve you h ad an a ttack or recurrent a ttacks of wheez ing ?
d o yo u ha ve a t ou ble so me c ou gh, e spe ci ally at ni ght ?
d o yo u c o u gh or w he e ze afte r e xe r ci se ?
d oe s yo u r c hest fe e l ti ght?
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M e c h a ni s m o f
a c t i on
Si de ef fe cts
C o m m e nt s
O r a l H1
a n ti h i s t a m i n e s
H 1- b l o c k e r s
2 n d g e ne r a ti o n
Cetirizine
Ebastine
Fexofenadine
Loratadine
Mizolastine
Acrivastine
Azelastine
Mequitazine
N ew p r o d u c t s
Desloratadine
Levocetirizine
Rupatadine
- blockage of H1
receptor
- some anti-allergic
activity
- new generation
drugs can be used
once daily
- no development of
tachyphylaxis
2 n d g e ne r a ti o n
- no sedation for
most drugs
- no anti-cholinergic
effect
- no cardiotoxicity
- acrivastine has
sedative effects
- oral azelastine
may induce
sedation and a
bitter taste
Lo c a l H1
a nt i hi s ta m i n e s
( i nt r a na s a l ,
i nt r a o c u l a r )
Azelastine
Levocabastine
Olopatadine
I nt ra n a sal
g l u c oc o r ti c o s t er o i d s
- potently reduce
Beclomethasone
nasal inflammation
dipropionate
- reduce nasal
Budesonide
hyperreactivity
Ciclesonide
Flunisolide
Fluticasone
propionate
Fluticasone furoate
Mometasone furoate
Triamcinolone
acetonide
OR
- blockage of H1
receptor
- some anti-allergic
activity for azelastine
Rapidly effective
(less than 30 min)
on nasal or ocular
symptoms
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2Allergic
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1International
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Na me an d
A l s o k no w n a s
Or a l / I M
g l u c o c or ti c os te r oi d s
- Potently reduce
nasal inflammation
Cromoglycate
Nedocromil
Naaga
- mechanism of
action poorly
known
- Reduce nasal
hyperreactivity
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L o c a l c r om o n e s
( i n tr a n a s a l ,
i n tr a o c u l a r )
Dexamethasone
Hydrocortisone
Methylpredisolone
Prednisolone
Prednisone
Triamcinolone
Betamethasone
Deflazacort
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Ephedrine
Phenylephrine
Phenylpropanolamine
Pseudoephedrine
Oxymethazoline
Others
Intraocular cromones
are very effective
- sympathomimetic
drug
- relieve symptoms
of nasal
congestion
Hypertension
Palpitations
Restlessness
Agitation
Tremor
Insomnia
Headache
Dry mucous
membranes
- Urinary retention
- Exacerbation of
glaucoma or
thyrotoxicosis
-
- sympathomimetic
drugs
- relieve symptoms
of nasal
congestion
Effective in allergic
and nonallergic
patients with
rhinorrhea
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I nt r a na s a l
d e c o n g e s ta n ts
However, a short
course of oral glucocorticosteroids may be
needed if moderate/
severe symptoms
Overall excellent
safety
DO
Oral H1antihistaminedecongestant
combination
When possible,
intranasal glucocorticosteroids should replace
oral or IM drugs
Intranasal cromones
are less effective
and their effect is
short lasting
,
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O ra l
d e c o ng e s ta n ts
- Systemic side
effects common in
particular for IM
drugs
- Depot injections
may cause local
tissue atrophy
Ipratropium
- anticholinergics block
almost
exclusively
rhinorrhea
C y sLT
a n ta g o ni s ts
A nt i l e u k ot r i e n e s
Montelukast
Pranlukast
Zafirlukast
- Block CysLT
receptor
OR
I n tr a na s a l
a nt i c h ol i n e r g i c s
Limit duration of
treatment to less than
10 days to avoid
rhinitis medicamentosa
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R ef er enc es : 1) International Primary Care Airways Group (IPAG) Handbook available at http://www.globalfamilydoctor.com.
2) Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
GINA materials have been used with permission from the Global Initiative for Asthma (www.ginasthma.org). Material from the IPAG
Handbook has been used with permission from the International Primary Care Airways Group.
Nycomed
Phadia
Sanofi Aventis
Schering-Plough
Stallergenes
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