management of rhinitis in patients with asthma michael schatz, md, ms chief, department of allergy...
TRANSCRIPT
Management of Rhinitis in Patients
with Asthma
Michael Schatz, MD, MSChief, Department of Allergy
Kaiser Permanente, San Diego, CA
• Rhinitis is a trivial illness.• All rhinitis is allergic.• All non-allergic rhinitis is
homogeneous.
Some Misconceptions About Rhinitis
Outline of Presentation
Practical classification of chronic rhinitis
Diagnostic approach in primary care Specific syndromes
Distinguishing features Treatment
Practical ClassificationPractical Classification
Allergic RhinitisAllergic Rhinitis Seasonal versus PerennialSeasonal versus Perennial FrequencyFrequency
Persistent (> 4 days/week for > 4 weeks/year)Persistent (> 4 days/week for > 4 weeks/year) Intermittent (less than above)Intermittent (less than above)
SeveritySeverity MildMild Moderate-severe (interference with sleep or Moderate-severe (interference with sleep or
daily activities or “troublesome symptoms”)daily activities or “troublesome symptoms”)
OtherOther
Practical Classification: Practical Classification: OtherOther
OtherOther Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis
Practical Classification: Practical Classification: Asthmatic PatientAsthmatic Patient
OtherOther Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis
1. History2. Physical Exam3. Tests
Chronic Rhinitis: Diagnostic Approach
Chronic Rhinitis: Diagnostic Chronic Rhinitis: Diagnostic TestsTests
Nasal smear (eosinophilic disease)Nasal smear (eosinophilic disease) Specific IgE (allergic versus non-allergic)Specific IgE (allergic versus non-allergic)
Skin testsSkin tests RAST (blood tests)RAST (blood tests)
Total IgE (AFS)Total IgE (AFS) Immunoglobulins G, A, M Immunoglobulins G, A, M
(hypogammaglobulinemia with chronic (hypogammaglobulinemia with chronic sinusitis)sinusitis)
Fungal precipitating antibodyFungal precipitating antibody Sinus radiologySinus radiology
Skin Tests versus Blood Skin Tests versus Blood TestsTests
Skin TestsSkin Tests Time-honored methodTime-honored method Results immediately availableResults immediately available More sensitive for some allergens or More sensitive for some allergens or
patientspatients Potential for systemic reactionsPotential for systemic reactions Antihistamines interfereAntihistamines interfere
Blood testsBlood tests Easier for patientEasier for patient May be more specificMay be more specific No interference by medications or potential No interference by medications or potential
for systemic reactionsfor systemic reactions
Outline of Presentation
Practical classification of chronic rhinitis
Diagnostic approach in primary care Specific syndromes
Distinguishing features Treatment
Allergic RhinitisAllergic Rhinitis Distinguishing FeaturesDistinguishing Features
Sneezing, itching, rhinorrhea prominentSneezing, itching, rhinorrhea prominent May be seasonalMay be seasonal Triggered by freshly cut grass, cleaning house, or Triggered by freshly cut grass, cleaning house, or
pet exposurepet exposure TreatmentTreatment
Indoor allergen avoidanceIndoor allergen avoidance Intermittent: Antihistamines, intranasal Intermittent: Antihistamines, intranasal
corticosteroids (INS) as neededcorticosteroids (INS) as needed Persistent: Regular INS; add antihistamines (oral Persistent: Regular INS; add antihistamines (oral
and/or intranasal) and montelukast if needed)and/or intranasal) and montelukast if needed) Consider immunotherapyConsider immunotherapy
ImmunotherapyImmunotherapy
Consider for patients with definite Consider for patients with definite allergic rhinitis not controlled by allergic rhinitis not controlled by other meansother means
Because of potentially life-Because of potentially life-threatening allergic reaction, it threatening allergic reaction, it should be carried out only by should be carried out only by specialists trained in its usespecialists trained in its use
Goal: symptom and/or medication Goal: symptom and/or medication reduction, not usually eradication or reduction, not usually eradication or cure cure
Immunotherapy 2Immunotherapy 2
Used less for rhinitis now than it Used less for rhinitis now than it used to be due to better medicationsused to be due to better medications
Less effectiveness data for mold and Less effectiveness data for mold and animal danderanimal dander
One year trialOne year trial If effective, continue for 3-5 years If effective, continue for 3-5 years
and then consider discontinuationand then consider discontinuation Sublingual immunotherapy (SLIT) Sublingual immunotherapy (SLIT)
now being studiednow being studied
Eosinophilic Non-Allergic Eosinophilic Non-Allergic RhinitisRhinitis
Distinguishing featuresDistinguishing features Prominent mucosal edemaProminent mucosal edema Nasal eosinophiliaNasal eosinophilia No relevant allergyNo relevant allergy
TreatmentTreatment Intranasal corticosteroidsIntranasal corticosteroids Oral antihistamine or antihistamine-Oral antihistamine or antihistamine-
decongestant combination if neededdecongestant combination if needed Oral prednisone for recalcitrant diseaseOral prednisone for recalcitrant disease
Nasal PolypsNasal Polyps Distinguishing FeaturesDistinguishing Features
Nasal obstructionNasal obstruction AnosmiaAnosmia Nasal polyps on examNasal polyps on exam
TreatmentTreatment Intranasal corticosteroidsIntranasal corticosteroids Course of doxycycline (20 days)Course of doxycycline (20 days) Oral corticosteroidsOral corticosteroids Treatment of complicating infectionTreatment of complicating infection Consider montelukastConsider montelukast Surgery (polyp, sinus)Surgery (polyp, sinus)
GERD Induced “Post Nasal GERD Induced “Post Nasal Drip”Drip”
Distinguishing featuresDistinguishing features Feeling of post-nasal drip or mucus in Feeling of post-nasal drip or mucus in
throat with minimal or no other nasal throat with minimal or no other nasal symptomssymptoms
May be associated with hoarseness, throat May be associated with hoarseness, throat clearing, cough, pyrosis, regurgitationclearing, cough, pyrosis, regurgitation
May be worse after eatingMay be worse after eating TreatmentTreatment
Reflux precautionsReflux precautions Protein pump inhibitorsProtein pump inhibitors
Practical Classification: Practical Classification: OtherOther OtherOther
Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis
Symptoms Suggestive of Symptoms Suggestive of Chronic SinusitisChronic Sinusitis
Nasal congestion Nasal congestion Pain or pressure around the Pain or pressure around the
forehead, nose, or eyesforehead, nose, or eyes Discolored nasal discharge or Discolored nasal discharge or
discolored mucus in the throatdiscolored mucus in the throat Reduced sense of smell Reduced sense of smell Symptoms for > 12 weeks by Symptoms for > 12 weeks by
definitiondefinitionTomassen P, et al. Allergy 2011; 66:556
Allergy and Chronic Allergy and Chronic SinusitisSinusitis
Conflicting data regarding increased Conflicting data regarding increased prevalence of chronic sinusitis in allergic prevalence of chronic sinusitis in allergic patientspatients
Data suggests chronic sinusitis may be Data suggests chronic sinusitis may be more severe in allergic patientsmore severe in allergic patients
Appropriate to aggressively treat allergic Appropriate to aggressively treat allergic rhinitis in patients with coexistent chronic rhinitis in patients with coexistent chronic sinusitissinusitis
Immunotherapy not convincingly shown Immunotherapy not convincingly shown to improve sinusitis in allergic patients to improve sinusitis in allergic patients
Medical Approach to Medical Approach to Chronic SinusitisChronic Sinusitis
Saline lavageSaline lavage Intranasal corticosteroidsIntranasal corticosteroids Treat acute infectionsTreat acute infections Treat coexistent allergic rhinitisTreat coexistent allergic rhinitis Rule out hypogammaglobulinemiaRule out hypogammaglobulinemia Medical treatment of hyperplastic Medical treatment of hyperplastic
eosinophilic sinusitiseosinophilic sinusitis Post operative treatment of Allergic Post operative treatment of Allergic
Fungal SinusitisFungal Sinusitis
Chronic Hyperplastic Chronic Hyperplastic Eosinophilic Sinusitis Eosinophilic Sinusitis
Eosinophilia does not indicate Eosinophilia does not indicate allergyallergy
Associated with nasal polyps, Associated with nasal polyps, asthma, aspirin sensitivityasthma, aspirin sensitivity
Poorer prognosis after surgeryPoorer prognosis after surgery Consider montelukastConsider montelukast Aspirin desensitization for patients Aspirin desensitization for patients
with aspirin sensitivitywith aspirin sensitivity
Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: Diagnostic CriteriaDiagnostic Criteria
Radiologic evidence of sinusitisRadiologic evidence of sinusitis Allergic mucin in the sinusAllergic mucin in the sinus Fungal hyphae in the mucin or Fungal hyphae in the mucin or
positive sinus fungal culturepositive sinus fungal culture Absence of diabetes, Absence of diabetes,
immunodeficiency, or immunodeficiency, or immunosuppressive therapyimmunosuppressive therapy
Absence of fungal invasionAbsence of fungal invasion
Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: Immunologic FindingsImmunologic Findings
Elevated total IgE level (67-74 %)Elevated total IgE level (67-74 %) May correlate with course of diseaseMay correlate with course of disease Increases ≥ 10 % provides high sensitivity Increases ≥ 10 % provides high sensitivity
for disease progression but lower specificityfor disease progression but lower specificity Atopy (76-100 %)Atopy (76-100 %) Specific IgE against fungus (58-100 % Specific IgE against fungus (58-100 %
positive skin tests)positive skin tests) Precipitating antibody against fungus (8-Precipitating antibody against fungus (8-
89 %)89 %)
Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: ManagementManagement
SurgerySurgery Post-operative prednisonePost-operative prednisone
0.5 mg/kg daily for 14 days0.5 mg/kg daily for 14 days 0.5 mg/kg every other day, tapered over 0.5 mg/kg every other day, tapered over
3 months to 5 mg every other day3 months to 5 mg every other day Continue 5 mg every other day for at Continue 5 mg every other day for at
least 12 months least 12 months Intranasal steroidsIntranasal steroids ? Antifungal agents? Antifungal agents
ConclusionsConclusions
Rhinitis is NOT a trivial illnessRhinitis is NOT a trivial illness All rhinitis is NOT allergicAll rhinitis is NOT allergic All non-allergic rhinitis is NOT All non-allergic rhinitis is NOT
homogeneoushomogeneous Appropriate diagnosis and management Appropriate diagnosis and management
(medical and surgical) can substantially (medical and surgical) can substantially improve the quality of life of patients improve the quality of life of patients with chronic rhinitis or sinusitis and with chronic rhinitis or sinusitis and improve asthma control as wellimprove asthma control as well