Figure 1: An algorithm to enable the detection and treatment of rhinitis in patients with asthma Identifying and managing allergic rhinitis in the asthma population. In: Hatton S, editor. Guidelines—summarising clinical guidelines for primary care. Chesham: MGP Ltd, Available at: www. References 1. Scadding G et al. Prim Care Respir J ; 21 2 : — Bousquet J et al. J Allergy Clin Immunol ; 2 : — CKS: Allergic rhinitis.
NICE, Scadding GK et al. Clin Exp Allergy ; 47 7 : — Brozek J et al. J Allergy Clin Immunol ; 4 : — Del Cuvillo A. Rhinology ; 55 1 : 34— The algorithm recommends that at asthma review a few more questions are asked. First, are there any problems with your nose? Second, more detailed questions about blockage, snoring, and smell impairment to identify patients with persistent rhinitis or rhinosinusitis.
Finally, there are three questions relating to seasonal rhinitis: hay fever, nasal running, itching, sneezing, and eye involvement. Persistent colds are included here as sometimes AR is misdiagnosed by the patient.
Nasal pain, unilateral symptoms, or heavy nasal bleeding are red flags that should prompt urgent referral to ENT. Snoring that is severe enough to cause sleep apnoea also warrants referral to a sleep clinic with advice in the meantime on weight loss for those who are overweight or obese , avoiding alcohol, sleeping pills, and tobacco smoke, sleeping on their side, and not eating after If the answers to all the questions are negative, the patient does not have rhinitis or rhinosinusitis.
If the answers are all positive, further questions involve timing, current treatment, and nasal symptom severity scoring using a simple visual analogue scale VAS from 0 to 10, with 0 indicating no current symptoms and 10 the worst possible. All patients with rhinitis should be advised to avoid relevant allergens, tobacco smoke, and other pollutants, and of the benefits of saline nasal douching.
For patients scoring less than 5 on a VAS, a level indicating control, 11 current medication should be continued unless it is a sedating antihistamine, in which case a switch to a non-sedating antihistamine or an intranasal corticosteroid INS spray is necessary.
Sedating antihistamines worsen the psychomotor retardation of rhinitis and decrease work and school performance and driving ability, as well as having more potential for cardiac arrhythmias. Reproduced with permission. It is important to show patients the correct use of a nasal spray see Figure 3 , to explain that regular prophylactic use is needed, and that benefit from INS is not immediate and can take 2 weeks.
Patients should be warned about possible side-effects such as epistaxis with INS, or a bitter taste with azelastine. Learn how to manage it. Learn more about vaccine availability. Advertising Policy.
You have successfully subscribed to our newsletter. Related Articles. Trending Topics. What Parents Need to Know. Coughing, Sneezing, Wheezing? Cetirizine, an antihistamine, has shown effectiveness in relieving upper- and lower-airway symptoms in patients suffering from concomitant allergic rhinitis and asthma [ 45 ].
Cetirizine was found to be protective against late bronchial hyperresponsiveness that follows nasal allergen challenge in patients with allergic rhinitis [ 46 ]. Combined therapy with montelukast and cetirizine for asthmatic patients with seasonal allergic rhinitis lessens the need for a rescue inhaler and improves lung function and asthma symptom score to the same extent as does inhaled budesonide combined with intranasal budesonide [ 47 ].
Greiff and colleagues treated nonasthmatic allergic rhinitis patients with inhaled corticosteroids during pollen season. They found an inhibition of the increase of eosinophils in blood and nasal tissues that is usually observed in pollen season [ 48 ].
The patients who received inhaled budesonide had significantly milder nasal symptoms. In a study comparing treatment with montelukast alone to treatment with inhaled and intranasal corticosteroids in patients with allergic rhinitis and in patients with asthma, only the group treated with corticosteroids showed a significant reduction in nasal nitric oxide and in nasal peak flow, whereas both treatments were efficient in decreasing rhinitis symptoms [ 50 ].
Immunotherapy is reserved for patients with moderately severe allergic rhinitis. Immunotherapy reduces inflammatory-cell recruitment and activation as well as the secretion of mediators [ 2 ]. In a group of allergic rhinitis patients with asthma, immunotherapy improved methacholine hyperreactivity and quality of life and reduced seasonal asthma symptoms [ 51 ].
Reducing the allergen sensitivity not only leads to relief of rhinitis but also helps control asthma although less effectively. It is important to carefully assess the upper airways in asthmatic patients and the lower airways in patients with allergic rhinitis. Allergic rhinitis is an important risk factor for developing asthma and is also an important cause of nonoptimal control of asthma.
Links between upper- and lower-airway diseases exist through inflammatory mediators, but other mechanisms, such as mouth breathing and postnasal drip, can contribute.
Many therapeutic options are currently available although corticosteroids remain the most effective anti-inflammatory drugs. Antileukotrienes have beneficial effects on rhinitis and asthma because they work through a systemic effect.
Our common approach to the treatment of asthma and rhinitis needs to be revised to prevent the expression of the asthma phenotype in individuals who have rhinitis and to achieve better control of asthma in patients who already have both rhinitis and asthma. Pediatr Allergy Immunol. J Allergy Clin Immunol. Togias AG: Systemic immunologic and inflammatory aspects of allergic rhinitis.
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