Dr Imran Rafi and Dr Shuaib Nasser discuss the role of primary care in the identification and management of allergic, non-allergic, and infective rhinitis

The Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) has recently published a comprehensive guideline on the management of allergic and non-allergic rhinitis.1 The guideline is evidence-based with additional expert opinion and the recommendations were agreed by consultation between experts on the committee and members of BSACI. This article provides an overview for primary care physicians and practitioners.

The guideline is intended to highlight rhinitis as an important disorder. It will assist the practitioner by improving recognition and management of rhinitis in primary care.

Rhinitis, or inflammation of the lining of the nose, is characterised by itching, sneezing, nasal discharge, and blockage or congestion. It can be classified as allergic, non-allergic, and infective. Rhinitis should be taken seriously as it can have three potential outcomes that can be detrimental to the patient, particularly when the condition is undertreated. These are:

  • an adverse effect on the patient’s quality of life,2 which can affect both school performance3and work life4
  • the association of rhinitis with co-morbidities such as asthma, sinusitis, otitis media, and conjunctivitis1
  • rhinitis can become chronic, difficult to treat, and in some cases irreversible.

Allergic rhinitis

A startling statistic is that 1 in 5 Europeans may be affected5 and the prevalence of allergic rhinitis appears to be increasing; for example, in one Swedish study the prevalence of allergic rhinitis had doubled over a 12-year period, to a rate of around 30% in 7-year-old children.6 The strongest risk factor reported for the development of allergic rhinitis is a family history of atopy, with a major risk factor being sensitisation to indoor allergens in genetically susceptible individuals.7 In children, allergic rhinitis accounts for the majority of rhinitis cases, while in adults it accounts for one-third.1

Physiology

Allergic rhinitis is caused by a biphasic allergic response to an allergen: an early phase reaction causes IgE-mediated mast cell degranulation and release of chemical mediators such as histamine, leukotrienes, and prostaglandins; an eosinophilic response characterises the late-phase reaction. The common allergens responsible for this form of rhinitis include house dust mites and animals such as cats, dogs, and horses, leading to perennial symptoms; tree and grass pollens and fungi, including Alternaria spp., typically cause seasonal symptoms. Occupational exposure to flour, latex, and wood dust (allergens often associated with the subsequent development of asthma) can cause chronic irreversible rhinitis, while smoke, cold air, and solvents can aggravate pre-existing rhinitis.1

Presentation

Symptoms associated with allergic rhinitis may be intermittent or persistent:

  • intermittent—affecting an individual for less than 4 weeks and/or less than 4 days a week
  • persistent—occurring 4 days or more a week and/or lasting for more than 4 weeks.8

Symptoms are also classified as mild or moderate to severe:1

  • mild—do not affect sleep, daily activities, school or work
  • moderate to severe—exhibiting one or more of: sleep disturbance, interference with daily activities, disruption of school or work, troublesome symptoms.

When to suspect allergic rhinitis

A diagnosis of allergic rhinitis should be considered if there is:

  • a family history of atopy, asthma, or seasonal rhinitis
  • a personal history of asthma
  • seasonal variation in symptoms
  • work-related or animal-related trigger.

Symptoms and signs of allergic rhinitis

The most obvious symptoms and signs of allergic rhinitis are:1

  • itching of the palate and nose
  • clear or yellow-coloured rhinorrhoea
  • itching and/or excessive watering of the eyes
  • chemosis and periorbital oedema
  • examination of the nose may reveal a nasal crease across the dorsum of the nose.

Non-allergic rhinitis

Non-allergic rhinitis is an umbrella term for a number of types of rhinitis caused by a variety of conditions, with nasal blockage and rhinorrhoea being typical presentations. The symptoms can be more severe and difficult to treat than in allergic rhinitis. Non-allergic rhinitis is also associated with asthma, for example patients with aspirin-sensitive asthma usually present with nasal polyps and rhinosinusitis. Some possible causes and triggers of non-allergic rhinitis are listed in Box 1.

Table 2: Stepped approach to treatment

Signs/symptoms Type Example triggers
Nasal blockage Drugs ACE inhibitors
  Hormonal Pregnancy
Hypothyroidism
  Atrophic Trauma
Surgery
Radiation
Systemic/inflammatory Rheumatoid arthritis
Systemic lupus erythematosus
Malignancy Squamous cell
Melanoma
Structural Nasal septal deviation
Rhinorrhoea Drugs Cocaine
  Hormonal Contraceptive pill
  Food Alcohol

Infective causes of rhinitis

Thick, green nasal secretions associated with symptoms of rhinitis may indicate infection by agents such as cold viruses and bacteria such as Streptococcus and Haemophilus.1

Investigations

A detailed history together with examination findings should help to differentiate between allergic, non-allergic, and infective rhinitis, and help to identify potential triggers and co-morbidities. The findings will direct treatment in primary care, determine the requirement for further investigation, or indicate the need for onward referral to either an allergy clinic or the ear, nose and throat (ENT) department (see Figure 1).

The BSACI guideline recommends that skin prick tests are used routinely in all cases in secondary care to determine whether allergic or non-allergic rhinitis is the cause. In primary care, if skin prick tests are not possible, serum-specific IgE may be requested.1

Additional investigations that may aid diagnosis include:

  • full blood count and differential white cell count
  • C-reactive protein, if chronic infection is suspected
  • sputum culture
  • urine toxicology—recommended if cocaine abuse is suspected
  • peak expiratory flow measurements and spirometry should be considered for the many patients in whom co-morbid asthma is suspected.

Figure 1: Treatment of rhinitis

Treatment of rhinitis

*Check nasal inhalation technique and compliance

INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; www.eguidelines.co.uk/links/guidelines/summaries/eye_ear_nose_throat/bsaci_rhinitis.php

Referral

Referral to an ENT clinic should be made if certain signs are found on examination. These are:

  • evidence of nasal crusting or bleeding from the nostrils, which may be a sign of systemic disorders such as sarcoidosis or Wegner’s granulomatosis—for example, blood-stained discharge, crusting high in the nasal cavity, or nasal collapse
  • unilateral symptoms and signs, such as nasal obstruction (which may be due to new polyps or nasal tumours), nasal perforation, or ulceration—these warrant urgent ENT referral
  • the presence of thick, green nasal secretions, suggesting an acute or recurrent infective rhinitis or sinusitis in the presence of a periorbital cellulitis—this warrants urgent ENT referral.

Patients should be referred to an allergy clinic under the following circumstances:8

  • inadequate control of symptoms—if symptoms are classical of an infective rhinitis but standard therapy does not control symptoms (see below)
  • classical symptoms of allergic rhinitis (itching, associated conjunctivitis, exacerbation with a specific season or allergen), which fail to respond to therapy
  • recurrent nasal polyps
  • systemically unwell as a result of rhinitis
  • no obvious cause and need for allergen or trigger identification
  • inadequate response to standard treatment
  • need to consider desensitisation
  • presence of multisystem allergy (e.g. rhinitis with asthma, eczema, or food allergy)
  • occupational rhinitis.

Pharmacological treatment

Antihistamines

The principle of use for both oral and intranasal antihistamines is that they should be taken on a regular basis. If symptoms are mild, use non-sedating oral or topical intranasal antihistamines:

  • oral antihistamines include: cetirizine, fexofenadine, loratidine, desloratidine, or levoceterizine
  • topical antihistamines include azelastine
  • intranasal antihistamines are active against sneezing, rhinorrhoea, and nasal itch with a rapid onset of action but have no activity against eye symptoms.

Generally, antihistamines provide little benefit against nasal obstruction.

First generation antihistamines such as chlorphenamine can cause sedation and reduced work and school performance, while second-generation antihistamines, such as loratidine, fexofenadine, and cetirizine are less sedating with few major drug interactions. Adverse effects of azelastine, a topical nasal antihistamine, include local irritation and taste disturbance.

Topical corticosteroids

Topical corticosteroids include fluticasone propionate, mometasone furoate, budesonide, and beclomethasone diproprionate. Systemically bioavailable absorption is very low with mometasone and fluticasone, and modest for the others but systemic absorption is high for betamethasone and dexamethasone. Although these agents have a fast onset of action (within 6–8 hours), maximal improvement in symptoms may not occur for at least 2 weeks.

Topical corticosteroids may be used as follows:1

  • if symptoms are moderate or severe, or antihistamines (oral or topical) provide inadequate relief then topical nasal steroids are recommended
  • intranasal corticosteroids are beneficial for sneezing, rhinorrhoea, and nasal obstruction (with some activity against allergic conjunctivitis).

Hypothalamic-pituitary axis suppression may occur with long-term use of topical corticosteroids and the guideline advises monitoring of growth in children. More common side effects include nasal irritation, sore throat, and epistaxis. Some of these side effects can be reduced by judicious use of the spray, aiming the nozzle towards the lateral wall of the nostril when placed just inside the nose.

Combination therapy

If symptoms of rhinitis persist despite the use of antihistamines or topical intranasal corticosteroids, and maximal doses have been used with good nasal spray technique and compliance, combined treatment with both agents is recommended (see Figure 1).

Other treatment options

Other treatment options that can be used are:1

  • for nasal blockage, the short-term use (i.e. <10 days) of an intranasal decongestant (e.g. ephedrine, xylometazoline, or oxymetazoline) may be beneficial, although it should be borne in mind that regular use leads to tachyphylaxis and chronic nasal obstruction—oral decongestants are not recommended1
  • in patients with co-morbid asthma, oral anti-leukotrienes (montelukast and zafirlukast) have been used, although more evidence of benefit for rhinitis is required when these agents are used alone or in combination with antihistamines
  • topical anticholinergic preparations such as ipratropium bromide may be beneficial in reducing rhinorrhoea, particularly in the treatment of autonomic (previously called vasomotor) or allergic rhinitis
  • sodium cromoglicate has some effect on nasal obstruction
  • systemic corticosteroids should be used rarely but have a role in severe nasal obstruction as short-term rescue of symptoms, particularly for important life events. The guideline recommends a dose of 0.5 mg/kg orally for 5–10 days in combination with a topical nasal corticosteroid taken in the morning with food.

Treatment in pregnancy

Pregnancy-associated rhinitis is a self-limiting condition and treatment should only be initiated if the benefit of treatment outweighs the risk to the foetus. Saline nasal douching may be beneficial, although the potential sodium load requires blood pressure monitoring. Intranasal corticosteroids such as beclometasone, fluticasone, and budesonide have been used by pregnant women, as have antihistamines such as chlorphenamine, loratidine and cetirizine. The guideline advises against the use of decongestants in pregnancy because of the potential for teratogenic effects, for example with pseudoephedrine.

Treatment in children

Therapy for children includes the use of long-acting antihistamines and nasal corticosteroids. Growth monitoring may be required if the child remains on long-term treatment with nasal corticosteroids and in these circumstances the child should be switched to a preparation with the lowest systemic bioavailability and at the lowest possible dose.

Treatment failure should prompt a check for compliance and, if necessary, referral to either an allergy clinic or ENT department as discussed above.

Education and prevention

The BSACI guideline emphasises the importance of allergy education, particularly with regard to the (negative) effect rhinitis may have on quality of life. The patient should be provided with information about the potential complications of rhinitis. A review of drug therapy should be carried out to assess efficacy of and compliance with treatment, and this should also include an assessment of technique in the use of nasal therapy.

The guideline also makes recommendations on allergen avoidance, both within the home and at work. For example, there is lack of evidence to recommend the use of mite-proof bed covers as a single intervention in sensitised patients. However the guideline recommends that multiple measures to reduce house dust mite exposure, including the use of mite-proof bed covers, hot washing bed linen, removing soft toys, and so on, are most likely to be successful. In individuals who have sensitivity to domestic pets such as cats, measures to reduce allergen exposure include shampooing carpets, washing the cat on a weekly basis and replacing carpets with hardwood floors.

A number of pollen avoidance measures such as using nasal filters, wearing wraparound glasses, and minimising early morning outdoor activity when the greatest pollen is emitted, are sensible although not always practical. Occupational rhinitis is considered a risk factor for occupational asthma and usually predates the onset of asthma. Of particular relevance to the workplace is primary prevention, particularly through the use of non-powdered or non-latex gloves, and avoidance of other occupational allergens known to cause allergic sensitisation.9

Co-morbidities

Over 80% of patients with asthma may have co-existing rhinitis, and rhinitis is also a risk factor for development of asthma.9 Asthma tends to be more severe in patients with perennial rhinitis, and bronchial hyperreactivity can be reduced by using nasal corticosteroids. Patients with asthma whose rhinitis is well treated have been shown to have fewer emergency visits to hospital.10

Implications for primary care

The BSACI guideline emphasises the importance of skin prick testing to differentiate between allergic and non-allergic rhinitis. With training and education it is possible for primary care to offer skin prick testing to aeroallergens in the community. The importance of close collaboration between primary care and allergy specialists is important, particularly in the interpretation of skin prick testing.

Local referral pathways are important in dealing with patients where treatment has not worked or where co-morbidities complicate management.

In a study of a general practice population of patients with moderate-to-severe rhinitis, more than 80% of patients reported impaired activities, as opposed to only 40% with mild rhinitis.11 A randomised controlled trial to evaluate the effectiveness of standardised allergy training for healthcare professionals in patients suffering from perennial rhinitis showed modest improvements in disease-specific quality of life.12

Summary

Rhinitis can be subdivided into allergic, non-allergic, or infective subtypes and recognition of the subtype can be particularly important in patients whose rhinitis has proved refractory to standard therapy. Rhinitis often remains unrecognised, particularly when symptoms accompany co-morbid conditions such as asthma or sinusitis.

Primary care has an important role in the identification and management of this condition, and practice-based commissioning may allow development of speedy referral pathways, particularly to allergy and ENT services, for the management of rhinitis.

  • Rhinitis is a common condition affecting up to 20% of the UK population
  • Skin prick testing is necessary to make an accurate diagnosis
  • The House of Lords Science and Technology Committee 2007 report on allergy recommends the establishment of at least one specialist allergy centre per SHAa
  • Tariff pricesb (2008/09 outpatient indicative tariff):
      • Allergy clinic = £178 (new), £94 (follow up)—includes skin prick testing where required
      • ENT = £121 (new), £63 (follow up) for adults and £130 (new), £72 for children
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  2. Canonica G, Bousquet J, Mullol J et al. A survey of the burden of allergic rhinitis in Europe. Allergy 2007; 62 (Suppl 85): 17–25.
  3. Walker S, Khan-Wasti S, Fletcher M et al. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol 2007; 120 (2): 381–387.
  4. Blaiss M. Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc 2000; 21 (1): 7–13.
  5. Maurer M, and Zuberbier T. Undertreatment of rhinitis symptoms in Europe: findings from a cross-sectional questionnaire survey. Allergy 2007; 62 (9): 1057–1063.
  6. Aberg N, Hesselmar B, Aberg B, Eriksson B. Increase of asthma, allergic rhinitis and eczema in Swedish schoolchildren between 1979 and 1991. Clin Exp Allergy 1995; 25 (9): 815–819.
  7. Kaiser H. Risk factors in allergy/asthma. Allergy Asthma Proc 2004; 25 (1): 7–10.
  8. Standards of Care Committee, The British Society for Allergy and Clinical Immunology. Rhinitis management guidelines. In: Foord-Kelcey G, editor. Guidelines – summarising clinical guidelines for primary care. 34th ed. Berkhamsted: MGP Ltd; February 2008, pp 371–376.
  9. Bousquet J, Khaltaev N, Cruz A et al; World Health Organization; GA2(2)LEN;AllerGen. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008; 63 (Suppl 86): 8–160.
  10. Corren J, Manning B, Thompson S et al. Rhinitis therapy and the prevention of hospital care for asthma: a case-control study. J Allergy Clin Immunol 2004; 113 (3): 415–419.
  11. Bousquet J, Neukirch F, Bousquet P et al. Severity and impairment of allergic rhinitis in patients consulting in primary care. J Allergy Clin Immunol 2006; 117 (1): 158–162.
  12. Sheikh A, Khan-Wasti S, Price D. Standardized training for healthcare professionals and its impact on patients with perennial rhinitis: a multi-centre randomized controlled trial. Clin Exp Allergy 2007; 37 (1): 90–99.G