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Allergic Rhinitis: Overview, Diagnosis, and Treatment
About Allergic Rhinitis
Seasonal allergies, often called rhinitis or hay fever, can have a significant impact on a patient’s quality of life and has a significant burden on the healthcare system.1,3 Symptoms such as sleep disturbance and daily fatigue, along with inappropriate use of antihistamines, can result in impaired performance at school and work.1-3
Rhinitis is generally divided into two groups: allergic and non-allergic. Differentiating between allergic and non-allergic rhinitis is critical, as half of patients prescribed antihistamines for their reported allergic rhinitis have symptoms that are not due to allergy.4
It is important to use testing for allergen sensitization to help you decipher allergic from non-allergic rhinitis. These results, along with a physical exam and medical history, can ensure that patients receive appropriate treatment sooner, as well as helping to reduce avoidable antihistamine use.5,6
600 million people
Approximately 600 million people are thought to be affected by rhinitis and there is evidence showing that those numbers are on the rise.2,7
Allergic rhinitis usually presents as a blocked or runny nose, symptoms that arise from the sinuses, middle ear, nasopharynx, and lower airways.
Common symptoms of rhinitis can include:7
- Post nasal drip
- Red, itching eyes
- Watering eyes
- Repeated sneezing
- Headache
- Nasal itching
- Facial pain
- Ear pain
- Tiredness
As allergic rhinitis and non-allergic rhinitis have such similar symptoms, but different management, it is imperative to correctly diagnose the cause and target the correct management.9
Allergic rhinitis: Refining differential diagnosis through testing
Approximately 65 percent of patients diagnosed as having allergic rhinitis and prescribed a non-sedating antihistamine are not allergic.7,8 As allergic rhinitis and non-allergic rhinitis have such similar symptoms, but different management, it is imperative to correctly diagnose the cause and select the correct management.9
Fortunately, guidelines provide a foundation for the process of diagnosing allergic rhinitis, which starts with a physical examination and an allergy-focused patient history.1,5
Guided by the findings of an allergy-focused patient history, you can continue to work through the most appropriate next steps, which may include specific IgE tests. Skin-prick testing (SPT) and specific IgE blood testing can help you determine allergen sensitization, which may give you the ability to correctly diagnose and improve clinical management.10,11 The patient medical history should be supplemented by allergen testing for accurate results.12
Who should be tested?
It is important to consider allergic rhinitis in patients with asthma, atopic dermatitis (eczema), conjunctivitis, sinusitis, polyposis, upper respiratory tract infections, otitis media, sleeping disorders, and in children with learning and attention impairments.
More than 80 percent of people with asthma also suffer from rhinitis,7 suggesting the concept of “one airway, one disease.”13,14 The presence of allergic rhinitis commonly exacerbates asthma, increasing the risk of asthma attacks, emergency visits, and hospitalizations for asthma. It is not clear whether allergic rhinitis represents an earlier clinical manifestation of allergic disease in atopic patients who will later develop asthma or whether rhinitis itself is causative for asthma.14-17
If your patient suffers from allergic rhinitis triggered by pollen and has an allergic reaction that typically occurs upon ingestion of certain foods, he or she may be experiencing pollen food allergy syndrome (PFAS), also known as oral allergy syndrome (OAS).5
In a UK general practice survey of adults with asthma and comorbid allergic rhinitis (n=4,611), versus patients with asthma alone (n=22,692), the presence of concomitant allergic rhinitis with asthma increases the following:20
- Annual number of GP visits (P<0.0001)
- Likelihood of hospitalizations (P<0.01)
- Increased asthma drug costs (P<0.0001
Allergic rhinitis and quality of life
Rhinitis significantly reduces quality of life and results in substantial healthcare costs.5,18,19 As such, there are several valid reasons to consider a specific IgE serological test, including:
- Receiving objective, reproducible results
- Optimizing medication plan
- Avoiding unnecessary or inefficient medication
- Identifying all relevant allergy triggers so a relevant exposure reduction plan can be developed
Common allergens
These symptoms are often triggered by seasonal and perennial allergies, including:5
- Pollen
- Molds
- Dust mites
- Animal dander
Testing Increases Diagnostic Confidence
Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv
i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238
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Management and care of patients with allergic rhinitis
Guidelines suggest that one of the first steps in managing and caring for patients with allergic rhinitis (AR) is to classify their disease, based on symptom duration and severity. AR is a major chronic respiratory disease due to its prevalence, impact on quality of life, and relationship to asthma. AR affects physical and psychological well-being by reducing sleep quality that in turn negatively impacts work performance and productivity, school attendance and concentration, and the patient’s social life.18,21
The management of AR consists of three major categories of treatment:
1. Allergen avoidance and environmental control measures
2. Pharmacological management
3. Immunotherapy
Practice parameters have been developed to classify and manage treatment of AR and guideline-directed management has been shown to improve disease control.18,21
Symptoms are classified as intermittent or persistent, and mild or moderate to severe. Optimal treatment includes allergen avoidance and pharmacotherapy. Immunotherapy and asthma evaluation should be considered when appropriate. AR is worth treating effectively, as when it is poorly controlled, it can impact daily activities, quality of life, and other areas of the respiratory tract, such as ears, sinuses, throat, and lungs.18,21
Practice parameters and guidelines
for allergic rhinitis:
- Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38:19-42.
- Bousquet, J., Vignola, A. M. and Demoly, P. (2003), Links between rhinitis and asthma. Allergy. 58: 691–706. doi:10.1034/j.1398-9995.2003.00105.x
- Roberts, G, Xatzipsalti, M, Borrego, LM, Custovic, A, Halken, S, Hellings, PW, Papadopoulos, NG, Rotiroti, G, Scadding, G, Timmermans, F, Valovirta, E. Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy. 2013; 68: 1102– 1116.
- European Academy of Allergy and Clinical Immunology; Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis, 2015. http://www.eaaci.org/globalatlas/ENT_Atlas_web.pdf. Accessed December 2017.
- House of Lords, Science and Technology sixth report- the extent and burden of allergy in the United Kingdom. http://www.bsaci.org/pdf/HoL_science_report_vol.1.pdf. Accessed December 2017. Immunology. Allergy. 2013;68:1102-1116.
- Pearce L. Managing allergic rhinitis. Nursing Times. 2012;108(17):20-22.
- Pawankar R, Holgate S, Canonica G, et al. World Allergy Organization. White Book on Allergy (WAO). 2011. http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf. Accessed December 2017
- Szeinbach SL, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004;10(3):234-238.
- Smith P. Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis. 2015. http://www.eaaci.org/globalatlas/ENT_Atlas_web.pdf. Accessed December 2017.
- Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl 78):35-41.
- Niggemann B, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by invitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
- Smith HE, Hogger C, Lallemant C, et al. Is structured allergy history sufficient when assessing patients with asthma and rhinitis in general practice? J Allergy Clin Immunol. 2009;123:646-650.
- Grossman J. One Airway, One Disease. CHEST. 1997:111:2:11S - 16S
- Bousquet J, et al. Allergic Rhinitis and Its Impact on Asthma. J Allergy Clin Immunol. 2001;108(suppl 5):S147–S334.
- Thomas M, et al. Asthma-Related Health Care Resource Use Among Asthmatic Children With and Without Concomitant Allergic Rhinitis. Pediatrics. 2005;15:129-134.
- Crystal-Peters J, et al. Treating allergic rhinitis in patients with comorbid asthma: The risk of asthma related hospitalizations and emergency department visits. J Allergy Clin Immunol. 2002;109(1):57-62.
- Valovirta E. Managing Co-Morbid Asthma With Allergic Rhinitis: Targeting the One-Airway With Leukotriene Receptor Antagonists. World Allergy Organ J. 2012;5:S210-S211.
- Scadding GK. Optimal management of allergic rhinitis. Arch Dis Child. 2015 Jun; 100(6): 576-582.
- Bousquet, J., et al. Important research questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper. Allergy. 2008;63: 842–853.
- Price D, Zhang Q, Kocevar VS, et al. Effect of a concomitant diagnosis of allergic rhinitis on asthma-related health care use by adults. Clin Exp Allergy. 2005;35:282-287.
- Seidman MD, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015 Feb;152(2):197-206.
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