Chapter e13: Allergic Rhinitis

KEY CONCEPTS

• Allergic rhinitis is a common disease. Prevention measures and treatment are justified in most cases because of the potential for complications.

• 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.

• Avoidance of allergens is difficult and it may be impractical to expect full success.

• Antihistamines offer an effective option for treating both seasonal and persistent allergic rhinitis.

• Intranasal steroids are highly effective in patients who use them properly.

• While immunotherapy is the only disease-modifying treatment of allergic rhinitis, expense, potential risks, and the major time commitment required make patient selection critical.

Patient Care Process for Management of Allergic Rhinitis

Collect

• Primary complaint(s) (sneezing, clear rhinorrhea, postnasal drip, nasal congestion, ocular or otic symptoms, pruritic nose or palate)

• Patient characteristics (eg, age, race, sex, pregnant)

• Past medical history, allergy testing, medications

• 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

• Current over-the-counter (OTC) products, prescription medications, dietary supplements; past medications or interventions used for treating rhinitis symptoms

• Past or current use of environmental controls of potential allergens (eg, removal of carpeting or pets, air-filtration systems)

• Objective data

  • Presence of allergic “shiners” (dark circles under eyes) or “salute” (crease across nose caused by constant rubbing)

  • Labs when available (eg, IgE, serum eosinophil count)

  • Other diagnostic tests when available (eg, allergy testing)

Assess

• Presence of concomitant atopic disorders (eg, asthma, atopic dermatitis)

• Presence of complications of allergic rhinitis (eg, acute otitis media, middle ear effusion, sinusitis, epistaxis)

• Timing of symptoms—seasonal or persistent (see Table e13-2)

• Usefulness for environmental controls of allergens (primarily for persistent cases)

• Which symptoms to control (eg, nasal congestion, clear rhinorrhea, sneezing, pruritus, ocular conjunctivitis)

• Current or past medications and patient response to those

• Appropriateness and effectiveness of current regimen

Plan^*

• Nonpharmacologic interventions (eg, allergen avoidance, nasal rinses, nasal strips; see Table e13-3)

• 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)

• 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).

• Self-monitoring of symptoms and adverse effects—where and how to record results

• Referrals to other providers when appropriate (eg, physician, allergist)

Implement^*

• Provide patient education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up if needed

Follow-up: Monitor and Evaluate

• 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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