Allergic

Rhinitis
 1 Tips about allergic rhinitis

Definition:
Allergic rhinitis is an inflammatory disease that mediated by Immunoglobulin-E.
Symptoms:
Allergic rhinitis characterized by nasal congestion, rhinorrhea (almost thin and watery
transparent nasal drainage), sneezing, and/or nasal itching, red watery eyes,
accompanied by dry cough in some cases.

Some causes of allergic rhinitis:

1- Pollens and outdoor molds.
2- Dust mites.
3- Pets and animals.
4- Smoking.
5- Perfumes.
6- Occupational allergens (ex. Cement factories..)

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 How to diagnose?

It is preferred to ask patient about previous history and if he/she suffered from such
case (allergic rhinitis) before or not. Then to focus in questions about the following:

• Listen to Sypmtoms from

Symptoms patient first
• Then ask your questions

• If duration less than 4

Duration and frequency days/week or more
of symptoms • less than 4 weeks per
time or more

• Ask about any factor

that cause symptoms to
Suspected exposures or appear (illusterated
exacerbating factors and before)
seasonality • Ask if symptoms
associated with specific
seasons

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 Allergic rhinitis classification:

Allergic rhinitis classified according 2 parameters:

1 Allergic rhinitis severity can be classified as:

A- Mild when symptoms are present but are not interfering with quality of life.

B- Moderate/severe when symptoms are bad enough to interfere with quality of life
(interfere with daily activity like sleeping, go to work and so on).

2 Symptoms duration:

A- Intermittent: if symptoms present for less than 4 days per week or less than 4 weeks
per time.

B- Persistent: if symptoms present more or equal 4 days per week or more or equal 4
weeks per time.

So Allergic rhinitis cases may be:

1- Mild and intermittent
2- Mild and persistent.
3- Moderate/severe and intermittent.
4- Moderate/severe and persistent.

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 Differentiation from rhino sinusitis:

Symptoms of allergic rhinitis are common and similar to other respiratory

disorders like rhino sinusitis and common cold, so it is a critical point to differentiate
between these disorders. So, make sure to ask patient about some differential
symptoms as follow:
Patient with rhino sinusitis suffers from :
1) Pain over cheek radiating to teeth and this pain increases with bending
down.)‫ألم بالخد (الوجه) يؤدي ألآلم باألسنان ويزداد مع اإلنحناء (وضع الركوع والسجود‬
2) Facial pain (pain at vertex ‫قمة الرأس‬, temple ‫الصدغ‬, or occiput ‫)القافية‬.
3) Nasal discharges (mainly purulent, yellow/green color).
So, if patient suffers from some of allergic rhinitis symptoms plus one of these
symptoms above, in this case conclude that patient suffers from rhino sinusitis
not allergic rhinitis

Management:

1 Non pharmacologic:
1) Keeping the windows and doors of the house and car closed as much as
possible during the pollen season (with air conditioning, if necessary, on
recirculating mode).
2) Taking a shower after outdoor exposure can be helpful by removing pollen
that is stuck to the hair and skin.
3) For protection from dust mites covering the mattress and pillows with
impermeable covers helps reduce exposure to dust mites, in addition bed
linens should be washed every 2 weeks in hot (at least 130°F) water to kill
any mites present.
4) Dust mites thrive when indoor humidity is above 50%, so dehumidification,
air conditioning, or both is helpful.
5) For animal allergy, complete avoidance is the best option, but for patients
who cannot, or who do not want to, completely avoid an animal or pet,
confinement of the animal to a non-carpeted room and keeping it entirely
out of the bedroom can be of some benefit.
6) Cat allergen levels in the home can be reduced with filters and by bathing
the cat every week.
7) Use facial mask if allergens are in the place of work (occupational
allergens).
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 2 Pharmacologic with patient education:

SEE Guidelines part.

2 Why we should care about allergic rhinitis patients?

Allergic rhinitis if not managed and treated well may cause more complicated
disorders, so in order to protect our patients from such cases we should professionally
do our role of care. Complications of allergic rhinitis are listed in the following part:

Complications of allergic rhinitis:

1- Acute or chronic sinusitis.
2- Otitis media.
3- Many studies have demonstrated AR to be an independent risk factor for asthma,
especially in patients diagnosed with AR during infancy.
4- Eustachian tube dysfunction commonly manifests in patients with AR and presents
as ear fullness, otalgia, and ear-popping.
5- Sleep disturbance or apnea.

3 Guidelines to treat allergic rhinitis:

The tow medications that consist the backbone in treating allergic rhinitis are:

1 Intranasal corticosteroids:

 Can treat all symptoms of allergic rhinitis.

 Effective after 10 to 12 hours but need time to reach its maximum effect (1 week
to 2 weeks)
Important Note: Intranasal corticosteroids are safe to be used for long duration
according patient case (i.e. safe for chronic use).

2 Oral antihistamines (2nd generation are preferred):

 Can treat all allergic rhinitis symptoms except nasal congestion.

 Duration of using oral antihistamines for allergic rhinitis (used as needed or till
symptoms resolves then stopped).

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 3 Other agent that are used according case are:

A- Intranasal antihistamines (Livostin spray (levocabastine)).

Used in case of patient using intranasal corticosteroids for sufficient period but
not get full response so it is preferred to add intranasal antihistamines not to add oral
antihistamines.
B- Oral decongestant (pseudoephedrine). Used for short course duration 3-5 days due
to its side effects.
C- Nasal decongestant (ex. Xylometazoline). Not to exceed 3-5 days.
D- Intranasal saline.
Choosing suitable agent is determined according severity and duration of
symptoms as follow:

1 Intranasal corticosteroids:

Are first choice in case of:

 Persistent symptoms.
 Moderate/severe symptoms. Keep in mind that moderate/severe symptoms means
when symptoms are bad enough to interfere with quality of life (interfere with
daily activity like sleeping, go to work and so on).

2 Oral antihistamines (H1 antagonists):

Examples (loratadine, desloratadine, fexofenadine and cetirizine) are first choice in

case of:
 Intermittent symptoms (symptoms less than 4 days /week or less than 4
weeks/episode).
 Mild symptoms (symptoms not interfere or affect quality of life of patient).

NOTE: Oral antihistamines do not treat nasal congestion so in case of patient

suffer from mild/ intermittent symptoms and will prescribed oral antihistamines, it is
recommended to add saline spray, nasal decongestant or oral pseudoephedrine if
patient suffers from nasal congestion.

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 3 Combination therapy:
A combination of intranasal corticosteroids + oral antihistamines should be used
in patient not responds to monotherapy.

4 Montelukast: is not used as primary therapy in allergic rhinitis but can be used
only in patient with allergic rhinitis who suffers from asthma.

5 Immunotherapy and surgery: Are preserved for patients with severe and not
respond to pharmacological therapy.

4 Protocol (brand name examples)

A- Examples of available intranasal corticosteroids:

1 NASONEX spray (mometasone)

2 FLIXONASE spray (fluticasone)

3 BUDINID spray (budesonide): The only one approved for pregnant women.

B- Examples of available oral antihistamines:

1 TELFAST, FEXODINE (fexofenadine).

2 LORINE, CLARITINE (loratadine). Evidences show that loratadine is safe in

pregnant women.
3 ZYRTIC, ARTIZ (cetirizine). safe to be used during lactation.

4 AERIUS, NEORIN (desloratadine).

5 Combined oral antihistamines/pseudoephedrine (CLARINASE & LORINASE-D)

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 5 When to refer patient?

 Patient less than 2 years old.

 Severe symptoms.
 Poor or not response to therapy.
 If quality of life is excessively impaired (examples. no sleep, lead to absence from
work and so on).
 If detecting specific causative allergen is needed to target suitable therapy.

References:
American academy of otolaryngology-Head and Neck Surgery

[Link]

[Link]

[Link]

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 Intermittent

if symptoms present for less than 4 days per week or less than 4 weeks per time.

Persistent
if symptoms present more or equal 4 days per week or more or equal 4 weeks per
time.

Mild

when symptoms are present but are not interfering with quality of life.

Moderate
/Severe
when symptoms are bad enough to interfere with quality of life (interfere with
daily activity like sleeping, go to work and so on).

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 Allergic Rhinitis Treatment

NB
Add Montelukast to any patient suffers allergic rhinitis and Asthma.

NB
Oral antihistamines do not treat nasal congestion so in case of patient suffer
from mild/ intermittent symptoms and will prescribed oral antihistamines, it is
recommended to add saline spray, nasal decongestant or oral pseudoephedrine if
patient suffers from nasal congestion.

NB
Budesonide is the FDA approved corticosteroids for pregnant women.
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 Pharmacological Treatment products

Intranasal Corticosteroids

FDA approved for pregnant women

Intranasal Antihistamine

Intranasal Decongestant

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 Pharmacological Treatment products

Oral Antihistamine

Oral Antihistamine + Decongestant

NB
Add Montelukast to any patient suffers allergic rhinitis and Asthma.

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 Non-Pharmacological Treatment

Humidifier

NB
Dry sinuses, bloody noses and cracked lips — humidifiers can help soothe
these familiar problems caused by dry indoor air. And cool-mist humidifiers also
may help ease symptoms of a cold or other respiratory condition.

Intranasal saline spray and wash kit

Avoid exposure to

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 Allergic Rhinitis patient
• For protection & decrease severity of symptoms &
frequency

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 Intranasal corticosteroid

• Should add …. Gargle ( dentu – chlorohex ) …

normal sale nasal spray or nasal wash

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 Allergic Rhinitis symptoms relief

• Red watery eye

• Headache ….. ( pain killer – paracetamol )

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 Supportive treatment for patient with Allergic
Rhinitis
1- Nasal Allergy prophylaxis

Adult formula: for patient 12 years and above.

Kids formula: for children from 6 to 12 years.
Give its action after 3 seconds only.
It is a gel that transformed to liquid after shaking. So, it is important to shake it
before using. After applying inside the nose, it will transformed again to a micro-
gel form that trap any pollens and other allergens so protect patient from
suspected allergy.
Doses: 1 to 2 sprays into each nostril, 2 to 3 times a day (it works up to 6 hours).

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 Instructions on how to apply

Contraindication: Contraindicated for patient with sesame

allergy.

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 2- Nasal Moisturizers

Vivo spray:
Suitable from 6 years old and above.
Doses: 1 to 3 times per day.
Contain sesame oil & aloe oil.
Act as nasal moisturizer in patients suffer dry nasal mucosa.
Preserve and prevent water loss.

Vivo plus:
 Same information for Vivo spray in addition it contains more
natural oils that give a pleasant odor.
 Contain bergamot oil & marjoram oils that give a pleasant
odor.

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 Salinose gel

 Suitable for adult.

 Contain sodium chloride in a gel formula that act as
moisturizer to nasal mucosa.
Doses: 1 to 2 times daily.

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 3-Throat soothing lozenges

Septolete lozenges

 Contain cetylpyridinium chloride which act as antiseptic for

mouth and throat.
 Not suitable for age 4 years or less.
 Doses: 1 tablet every 2-3 hours with maximum 8 tablet /day
for adult.

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 Septofort lozenges

 Contain chlorhexidine which act as antiseptic for mouth and

throat.
 Suitable for diabetic patients
Doses: 1 tablet 3 times daily.

Strepsisls lozenge

 Strepsils lemon only from strepsilis family is suitable for

diabetic patients.
Strepsils Extra contain hexylresorcinol that has antiseptic and local
anesthetic action, so it gives fast soothing action

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 Gargles

 Betadine mouthwash/gargle contain iodine that act as

antiseptic for oral cavity and sore.
 Betadine gargle can be used 2 to 3 times daily.

 Dento & Avohex mouth wash contain chlorhexidine that has

antiseptic properties.
 Dento & Avohex is suitable for patient for whom iodine
gargles is not suitable.
 Dento & Avohex can be used 2 to 3 times daily.

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 Eye drops

 Patients with allergic rhinitis may suffer from itchy and

irritating eyes, in such case it is recommended to prescribe
eye drops to alleviate these bothering symptoms.
• Used twice daily to alleviate eye inflammation and watery
eyes.

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