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KEY CONCEPTS
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Allergic rhinitis is a common disease. Prevention measures and treatment are justified in most cases because of the potential for complications.
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Because an immune response to allergens results in release of inflammatory mediators that cause allergic rhinitis symptoms, patients must understand the rationale for proper timing and administration of prophylactic regimens.
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Avoidance of allergens is difficult and it may be impractical to expect full success.
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Antihistamines offer an effective option for treating both seasonal and persistent allergic rhinitis.
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Intranasal steroids are highly effective in patients who use them properly.
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While immunotherapy is the only disease-modifying treatment of allergic rhinitis, expense, potential risks, and the major time commitment required make patient selection critical.
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Patient Care Process* for Management of Allergic Rhinitis
Collect
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Primary complaint(s) (sneezing, clear rhinorrhea, postnasal drip, nasal congestion, ocular or otic symptoms, pruritic nose or palate)
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Patient characteristics (eg, age, race, sex, pregnant)
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Past medical history, allergy testing, medications
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Patient family, social history—dietary habits; presence of pets, mold, or wall-to-wall carpeting; times of year, situations, or locations (indoor or outdoor) when symptoms are worse
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Current over-the-counter (OTC) products, prescription medications, dietary supplements; past medications or interventions used for treating rhinitis symptoms
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Past or current use of environmental controls of potential allergens (eg, removal of carpeting or pets, air-filtration systems)
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Objective data
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Presence of allergic “shiners” (dark circles under eyes) or “salute” (crease across nose caused by constant rubbing)
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Labs when available (eg, IgE, serum eosinophil count)
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Other diagnostic tests when available (eg, allergy testing)
Assess
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Presence of concomitant atopic disorders (eg, asthma, atopic dermatitis)
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Presence of complications of allergic rhinitis (eg, acute otitis media, middle ear effusion, sinusitis, epistaxis)
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Timing of symptoms—seasonal or persistent (see Table e13-2)
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Usefulness for environmental controls of allergens (primarily for persistent cases)
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Which symptoms to control (eg, nasal congestion, clear rhinorrhea, sneezing, pruritus, ocular conjunctivitis)
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Current or past medications and patient response to those
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Appropriateness and effectiveness of current regimen
Plan*
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Nonpharmacologic interventions (eg, allergen avoidance, nasal rinses, nasal strips; see Table e13-3)
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Drug therapy regimen including specific agent(s), dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Table e13-2 and Fig. e13-2)
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Patient education (eg, purpose of treatment, allergen avoidance, nonpharmacologic interventions, drug therapy, and the potential need for referral to physician or allergist for prescription or immunologic treatment).
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Self-monitoring of symptoms and adverse effects—where and how to record results
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Referrals to other providers when appropriate (eg, physician, allergist)
Implement*
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Provide patient education regarding all elements of treatment plan
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Use motivational interviewing and coaching strategies to maximize adherence
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Schedule follow-up if needed
Follow-up: Monitor and Evaluate
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Monitoring parameters including efficacy (eg, bothersome symptoms), safety (eg, drowsiness, anticholinergic effects, effects on blood pressure; medication-specific adverse effects [see Table e13-8])
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Patient perception of control of bothersome symptoms
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Presence of adverse effects
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Continued presence of physical signs of nasal and ocular pruritus
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Patient adherence to treatment plan using multiple sources of information
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Referrals to other ...