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Rhinitis, not a condition to be trivialized, can have a significant impact on a patient’s quality of life and has a significant burden on the healthcare system.1 Symptoms like 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. Distinguishing between allergic and non-allergic rhinitis is critical, as management between the two groups differs in strategy. This can lead to incomplete or incorrect administration of therapies, patient dissatisfaction, and increased economic burden.4,5
It is important to use testing for allergen sensitization to help you distinguish 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 reduce avoidable antihistamine use.4,7,8
The Impact of Rhinitis
Approximately 600 million people globally are thought to be affected by rhinitis and there is evidence showing that those numbers are on the rise.2,6
Other symptoms of rhinitis can include: 5
Rhinitis usually presents as a blocked or runny nose, symptoms which arise from the sinuses, middle ear, nasopharynx, and lower airways.
Up to 80% of allergic patients are sensitized to more than one allergen.8 The effect is cumulative: An individual patient may have a number of triggers, which combined may lead to symptoms.9,11 The allergen symptom threshold is the point at which the cumulative allergen load leads to symptoms.9
Each patient has a different level of IgE antibodies at which he or she will show symptoms. Until the symptom threshold is reached, the patient will not show symptoms. However, when these allergens add up they have a cumulative effect, pushing the patient over his or her symptom threshold.9 By reducing exposure to certain triggers, symptoms can be avoided.9
Identifying the relevant sensitizing allergens will help you outline a comprehensive exposure reduction plan to keep your patient below their symptom threshold.
Learn more about managing rhinitis >
Before exposure reduction
After exposure reduction
Fortunately, guidelines provide a foundation for the process of diagnosing allergic rhinitis, which starts with a physical examination and an allergy-focused patient history.1,7
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 and specific IgE measurements can help you rule in or rule out allergen sensitization, which may give you the ability to correctly diagnose and improve clinical management.16,17 The patient medical history should be supplemented by allergen testing for accurate results.18
Coexistence of asthma and rhinitis1,6
Patients with asthma who also have rhinitis
Rhinitis often coexists with other diseases. Patients with eczema, conjunctivitis, sinusitis, polyposis, upper respiratory tract infections, and children with learning and attention impairments often also have rhinitis1,5.
The presence of rhinitis has been associated with numerous comorbidities like chronic otitis media5 and sleep disorders.1,5 What’s more, both allergic rhinitis and non-allergic rhinitis are risk factors for the development of asthma.1,5 More than 80% of people with asthma also suffer from rhinitis,1,5 suggesting the concept of ‘one airway one disease.’1 The presence of allergic rhinitis commonly exacerbates asthma, increasing the risk of asthma attacks, emergency visits and hospitalizations for asthma.1,18-21 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.22
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)
If your patient suffers from allergic rhinitis triggered by pollen and has an allergic reaction that typically occurs upon ingestion of certain foods, they may be experiencing Pollen Food Allergy Syndrome, also known as oral allergy syndrome.7
p<0.006% of patients hospitalized annually
0.45% Patients with asthma (n=22,692)
0.76% Patients with asthma + allergic rhinitis (n=4611)
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
Quillen DM, Feller DB. Diagnosing rhinitis: allergic vs. nonallergic. Am Fam Physician 2006;73:1583–1590.
Tran NP, Vickery J, Blaiss MS. Management of Rhinitis: Allergic and Non-Allergic. Allergy, Asthma & Immunology Research. 2011;3(3):148-156. doi:10.4168/aair.2011.3.3.148.
Pawankar R, Holgate S, Canonica G, at el. 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
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.
Pearce L. Managing allergic rhinitis. Nursing Times. 2012;108(17):20-22.
Ciprandi G, Alesina R, Ariano R, et al. Characteristics of patients with allergic polysensitization: the POLISMAIL study. Eur Ann Allergy Clin Immunol. 2008;40(3):77-83
Wickman M. When allergies complicate allergies. Allergy 2005;60 (suppl 79):14-18..
Burbach GJ, Heinzerline LM, Edenharter G, et al. GA(2)LEN skin test study II. Clinical reference of inhalant allergen sensitizations in Europe. Allergy. 2009;64:1507-1515.
Eggleston PA. Control of environmental allergens as a therapeutic approach. lmmunol Allergy Clin North Am. 2003;23(3):533-547.
Baxi SN, Phipatanakul W. The role of allergen exposure and avoidance in asthma. Adolesc Med State Art Rev. 2010;21(1):57-71.
Wu F, Takaro TK. Childhood asthma and environmental interventions. Environ Health Perspect. 2007;115:971-975
Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;351(11):1068-1080.
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.
Bousquet J, Gaugris S, Kocevar VS. Clinical and Experimental Allergy: Journal of the British Society for Allergy and Clinical Immunology. Clin Exp Allergy. 2005;35(6):723-727.
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.
Crystal-Peters J, Neslusan C, Crown WH, 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.