Upon completion of the chapter, the reader will be able to:
Describe the basic pathophysiology of allergic rhinitis (AR).
Define mild versus moderate/severe AR, persistent versus episodic, and differentiate between seasonal, perennial, and episodic AR.
Differentiate the categories of pharmacotherapy choices for treatment of AR based on mechanism, efficacy on symptom type (eg, ocular, nasal congestion), and side effect profile.
Identify situations in which a referral to an allergy specialist is needed.
Describe an approach for treatment and monitoring for treatment of mild and moderate–severe AR based on patient specific factors.
Identify the differences in approach to the treatment of AR for children, pregnant women, and the elderly compared with the routine approach in adults.
Rhinitis is inflammation of the lining of the nose and contiguous parts of the upper respiratory tract.1–4 Allergy is only one of numerous causes of rhinitis.1–5 The most common causes of nonallergic rhinitis (NAR) are shown in Table 63–1.1-5 Some patients suffer concurrently from both allergic rhinitis (AR) and one or more types of NAR. This is sometimes called mixed rhinitis (MR).1,3 AR will be emphasized in this chapter, but some mention will be made of NAR. Because ocular symptoms (eg, itching and/or redness of eyes, tearing) frequently occur in association with AR, some sources use the term allergic rhinoconjunctivitis. This acknowledges involvement of the bulbar and palpebral conjunctivae in the allergic process.
Table 63–1Types of Rhinitis |Favorite Table|Download (.pdf) Table 63–1Types of Rhinitis
|Allergic (see Table 63–2 for details) |
|Vasomotor (also known as perennial nonallergic, idiopathic, and autonomic rhinitis) (triggered by irritants, cold air, exercise/running, or unidentified factors) |
|Food/meal related (gustatory) |
|NARES (nonallergic rhinitis with eosinophilia syndrome) |
|Occupational (caused by protein allergens [IgE-mediated] or by irritants [probably non–IgE-mediated]) |
|Hormonally related (hypothyroidism, pregnancy, menstrual cycle related, and some drugs [see below]) |
| Angiotensin-converting enzyme inhibitors (ACEIs) |
| α1-blockers (used for treatment of BPH and HTN) |
| Phosphodiesterase-5 inhibitors (used for treatment of ED) |
| Aspirin and other NSAIDs (as an isolated side effect of AERD) |
Oral contraceptives and hormone replacement therapy
Miscellaneous agents have been implicated (calcium channel blockers, some diuretics, centrally acting alpha-2 agonists, risperidone, gabapentin)
|Atrophic rhinitis |
|Rhinitis associated with inflammatory or immunologic diseases (eg, granulomatous infections, SLE, Wegener granulomatosis, sarcoidosis, Churg–Strauss syndrome) |
|Combination of allergic and nonallergic manifestations |
AR is an allergen-induced, immunoglobulin E (IgE)-mediated inflammatory condition of the lining of the nose and upper respiratory tract.1,6–9 This pathophysiologic feature differentiates AR from NAR. AR has traditionally been categorized as either seasonal or perennial.7,8 Seasonal allergic rhinitis (SAR) is attributed to inhaled allergens (aeroallergens) ...