Rhinitis

What is rhinitis?
Rhinitis is a reaction that
occurs in the eyes, nose and
throat when airborne irritants
(allergens) trigger the release
of histamine. Histamine
causes inflammation and fluid
production in the fragile
linings of nasal passages,
sinuses, and eyelids.
What are the different types
of rhinitis?
The two categories of rhinitis
are:
 allergic rhinitis

There are two types of allergic rhinitis:

o seasonal - occurs particularly during pollen

seasons
o perennial - occurs throughout the year

The most-common causes of allergic rhinitis are:

o pollen
o dust mites
o mold
o animal dander

Reactions from allergic rhinitis include:

o sneezing
o congestion
o runny nose
 o itchy nose, throat, eyes, and ears

Preventive measures for avoiding allergic rhinitis include:

o environmental controls, such as air

conditioning, during pollen season

o avoiding areas where there is heavy dust,

mites, molds

o avoiding pets

Treatments for allergic rhinitis, as determined by your

physician and based on your condition, may include:

o oral medications
o inhaled medications
o immunotherapy
o allergy injections

 nonallergic rhinitis

Types of nonallergic rhinitis are:

o vasomotor rhinitis (irritant rhinitis)

o eosinophilic

o rhinitis medicamentosa

o neutrophilic rhinosinusitis

o structural rhinitis

o nasal polyps

o primary vasomotor instability

Causes of nonallergic rhinitis include:

o fumes
o odors
o temperature
o atmospheric changes
o smoke
 o other irritants

Reactions from nonallergic rhinitis include:

o sneezing
o congestion
o runny nose
o itchy nose, throat, eyes, and ears

The preventive measure for avoiding nonallergic rhinitis is

avoiding the primary cause.

Treatments for nonallergic rhinitis, as determined by your

physician and based on your condition, may include:

o oral medications
o inhaled medications
o immunotherapy
o allergy injections
o surgery for some conditions

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In this section
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Rhinosinusitis

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Fact Sheet: Allergic
Rhinitis, Sinusitis, and
Rhinosinusitis

Inflammation of the nasal mucous

membrane is called rhinitis. The
symptoms include sneezing and
runny and/or itchy nose, caused by
irritation and congestion in the
nose. There are two types: allergic
rhinitis and non-allergic rhinitis.

Allergic Rhinitis: This condition

occurs when the body’s immune
system over-responds to specific,
non-infectious particles such as
plant pollens, molds, dust mites,
animal hair, industrial chemicals
(including tobacco smoke), foods,
medicines, and insect venom.
During an allergic attack,
antibodies, primarily immunoglobin
E (IgE), attach to mast cells (cells
that release histamine) in the
lungs, skin, and mucous
membranes. Once IgE connects
with the mast cells, a number of
chemicals are released. One of the
chemicals, histamine, opens the
blood vessels and causes skin
redness and swollen membranes.
When this occurs in the nose,
sneezing and congestion are the
result.

Seasonal allergic rhinitis or

hayfever occurs in late summer or
spring. Hypersensitivity to
ragweed, not hay, is the primary
cause of seasonal allergic rhinitis in
75 percent of all Americans who
suffer from this seasonal disorder.
People with sensitivity to tree
pollen have symptoms in late
March or early April; an allergic
reaction to mold spores occurs in
October and November as a
consequence of falling leaves.
 American Academy of Otolaryngology−Head and Neck Surgery
One Prince St., Alexandria, VA 22314-3357, 1-703-836-4444

© 2006 AAO-HNS/AAO-HNSF

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Allergic and Non-Allergic Rhinitis

Do you suffer from a runny or stuffy nose much of the
time? In the U.S., about 40 million people do. This
problem is known as rhinitis. Approximately 40 million
people in the U.S. have rhinitis. There are several types
of rhinitis.

What Are the Types of Rhinitis?

Allergic Rhinitis
If you sneeze and have a runny or stuffy nose during the spring, summer or fall allergy
seasons, you may have seasonal allergic rhinitis or hay fever. Hay fever is the most
common type of allergy problem. It mainly affects the eyes and nose. Hay fever
symptoms include sneezing, itching, runny or stuffy nose and red, watery eyes.

Rhinitis can be a problem all year or only some of the year. It can be a problem when
inside or when outside. Allergy symptoms are caused when someone has a problem when
around a certain substance. These substances are called allergens. They can be inside,
such as cats or dust. They can be outside such as tree and grass pollen in the spring and
weed pollen and molds in the summer and fall. Hay fever is mainly an allergy caused by
outdoor allergens.

Non-Allergic Rhinitis
This type of rhinitis is not as well understood. Although not triggered by allergy, the
symptoms are often the same as seen with allergic rhinitis. Although the symptoms are
similar, allergy skin test results are negative. Nasal polyps may also be seen with this type
of rhinitis.

Vasomotor Rhinitis
Common symptoms of vasomotor rhinitis are often nasal congestion and postnasal drip.
A person with this type of rhinitis may have symptoms when exposed to temperature and
humidity changes. Symptoms may also occur with exposure to smoke, odors and
emotional upsets. Allergy skin test results are negative.

Infectious Rhinitis
This can occur as a cold, which may clear rapidly or continue with symptoms longer than
a week. Some people may also develop an acute or chronic bacterial sinus infection.
Symptoms include an increased amount of colored (yellow-green) and thickened nasal
discharge and nasal congestion.

Rhinitis Medicamentosa
This type of rhinitis is seen with long-term use of decongestant nasal sprays or
recreational use of cocaine. Symptoms may include nasal congestion and postnasal drip.
Decongestant nasal sprays are intended for short-term use only. Over-use can cause
rebound nasal congestion. It is very important for a person with rebound congestion to
work closely with a doctor to gradually decrease the nasal spray.

Mechanical Obstruction
This is most often seen with a deviated septum or enlarged adenoids. Symptoms often
include nasal obstruction, that may be one sided.

Hormonal
This type of rhinitis is often seen with changes in the hormones. This often occurs during
pregnancy, puberty, menses or hypothyroidism.

How is Rhinitis Diagnosed?

Often a person may have more than one types of rhinitis. In making the diagnosis, an
evaluation by your doctor may include:

 History
The.

 .
How Can You Manage Symptoms?
The goal of treatment is to reduce symptoms. This often includes:

 .
What Makes Your Symptoms Worse?
Pollen and mold countscan vary throughout the day. Peak times are:

House Dust Mites

If you are allergic to house dust mites and live in a humid area:

Animals
Dander, urine and saliva from feathered or furry animals is a major year-round allergen.
Cats, dogs, birds, hamsters, gerbils and horses are common pets. If you are allergic to an
animal:

Many substances can irritate the nose, throat or airways. Common irritants include smoke
such as tobacco smoke from wood-burning stoves, or kerosene stoves and fireplaces,
aerosol sprays, strong odors, dust and air pollution. Reducing exposure to irritants can be
very helpful.

Anti-inflammatory medicines control inflammation in the body. This inflammation

causes redness and swelling (congestion).

Cromolyn and nedocromilare anti-inflammatory medicines that are not steroids. They
may help prevent nasal and eye symptoms.

Nasal steroid sprayswork well to reduce nasal symptoms of sneezing, itching, runny and
stuffy nose. Nasal steroids may also improve eye symptoms. A steroid nasal spray may
work after several hours or take several days to work. Nasal steroids work best if you
take them daily.

Nasal Wash
A nasal wash with salt water may help clean out your nose. When done routinely, this can
also lessen post-nasal drip. If you do a nasal wash, do this before using other nasal
medicine.

Click here for more information on nasal wash treatment.

Antihistamine Medicine
Antihistamines can help decrease allergy symptoms. They may be used daily during
allergy season or when allergy symptoms occur. There are many different antihistamines.
If one doesn’t work, another can be tried. Some can make you sleepy and some do not.

Common antihistamines that do not make you sleepy:

Some over the counter antihistamines can make you feel sleepy. They may also affect
thinking and your reflexes. If you take one of these, use caution when driving or using
any kind of machine.

Astelin® (azelastine) is an antihistamine nasal spray. It usually does not make you sleepy.

Decongestant Medicine
Decongestants help when your nose is stuffy (congestion). They are available as pills,
liquids or nasal sprays. Many are available over the counter. A common over the counter
decongestant is Sudafed (pseudoephedrine). Use caution when taking a decongestant
nasal spray. Using one longer than 4 days can have a rebound effect. This causes you to
have more nasal congestion.

Atrovent® (ipatroprium bromide) is a nasal spray. Atrovent may be helpful for decreasing
symptoms of a runny nose. This nasal spray may be helpful for vasomotor rhinitis.

Immunotherapy (Allergy Shots)

Allergy shots may be helpful for specific allergies that aren’t controlled with medicine. At
National Jewish, we recommend that you see a board certified allergist for allergy testing
or allergy shots.

Rhinitis can be managed so you can have an active, fun life. Talk with your doctor if you
think you have rhinitis. Your doctor is your partner in your healthcare.

Click here for more information on immunotherapy.

This information has been approved by Dr. Rafeul Alam (January 2005).

Note: This information is provided to you as an educational service of National Jewish. It is not meant to be a
substitute for consulting with your own physician.

© Copyright 2006 National Jewish Medical and Research Center

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Rhinitis
Rhinorrhea Rhinitis

Rhinitis is an inflammation of the nasal mucosa (the mucous membrane that lines the nose
and the sinus ), often due to an allergic reaction to pollen , dust or other airborne
substances ( allergens ). Although the pathophysiology of many types of rhinitis is
 unknown, an accurate diagnosis is necessary, since not all types of rhinitis will respond to
the same treatment measures. A heterogeneous disorder.

Classification of chronic rhinitis:

 Atopic Rhinitis
 Seasonal Allergic Rhinitis (also known as hay fever )
 Perennial Rhinitis (year-round) with Allergic Triggers
 Perennial Rhinitis with Non-Allergic Triggers
 Idiopathic Non-Allergic Rhinitis
 Infectious Rhinitis
 Rhinitis Medicamentosa
 Mechanical Obstruction
 Hormonal
 Other types

Allergic (seasonal and perennial) rhinitis

Characterised by an inflammation of the nasal mucous membranes due to an allergic

response. The most common of all atopic diseases in the United States, affecting up to
10% of the adult population. While no one dies directly as a result of allergic rhinitis, the
economic impact is substantial. Over $600 million is spent in the USA annually in the
management of this disease. This does not include the costs of the 2 million lost
workdays, 3 million lost school days and 28 million days of decreased productivity from
the symptoms of the disease and/or side effects of the medications used to treat them.
Clinically, information is gained from a nasal examination which may reveal pale, boggy
turbinate as well as clear to greenish rhinorrhea. When colored nasal secretions are
stained and examined, they typically reveal large numbers of eosinophils as the main
inflammatory cell. In many instances (particularly in children) complications such as
chronic otitis media, rhinosinusitis and conjunctivitis can be traced to chronic obstruction
from allergic rhinitis.
Concerning the treatment of allergic rhinitis, corticosteroid nasal sprays are very effective
agents, especially for symptoms of congestion, sneezing, and runny nose.
The main cause of seasonal allergic rhinitis are tree , grass or weed pollens . For
information on the main pollens and their pollination periods in all the world's regions, go
to the HON Pollen Calendar .

Vasomotor Rhinitis
PATRICIA W. WHEELER, M.D., and STEPHEN F. WHEELER, M.D. Email This Link
UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE, LOUISVILLE, KENTUCKY PDF Available
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Browse by Topic
A PDF version of this document is available. Download PDF now (6 pages /148 KB).
MEDLINE:
Vasomotor rhinitis affects millions of Americans and results in significant symptomatology. Characterized • Citation
by a combination of symptoms that includes nasal obstruction and rhinorrhea, vasomotor rhinitis is a • Related Articles
diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in
select cases, testing the patient with known allergens. According to a 2002 evidence report published by MORE IN AFP:
• Adrenal Cortex
the Agency for Healthcare Research and Quality (AHRQ), there is insufficient evidence to reliably
Hormones (5)
differentiate between allergic and nonallergic rhinitis based on signs and symptoms alone. The minimum • Rhinitis (9)
level of diagnostic testing needed to differentiate between the two types of rhinitis also has not been
established. An algorithm is presented that is based on a targeted history and physical examination and a MORE BY:
stepwise approach to management that reflects the AHRQ evidence report and U.S. Food and Drug • Wheeler PW
Administration approvals. Specific approaches to the management of rhinitis in children, athletes, AFP MEDLINE
pregnant women, and older adults are discussed. (Am Fam Physician 2005;72:1057-62. Copyright © 2005 • Wheeler SF
American Academy of Family Physicians.) AFP MEDLINE

The classification of rhinitis has long been debated in the literature. Rhinitis is categorized as allergic
or nonallergic, with vasomotor rhinitis in the nonallergic family. The symptoms of allergic and
1

nonallergic rhinitis overlap significantly, but the causes appear to be entirely different. The major
2

manifestations of allergic rhinitis are triggered by exposure to allergens and include nasal pruritus, clear
rhinorrhea, postnasal drip, and nasal obstruction caused by inflammation of the nasal mucous
membranes. Nonallergic rhinitis, a diagnosis of exclusion, can be sporadic or perennial. It includes a
3 1

highly diverse group of rhinitis syndromes united by their pervasive symptoms of clear rhinorrhea or
congestion with less prominent sneezing, nasal pruritus, and conjunctival irritation (Table 1). 1

Vasomotor rhinitis is characterized by prominent symptoms of nasal obstruction, rhinorrhea, and

TABLE 1
Types of Nonallergic Rhinitis
Drug induced
Gustatory
Hormonal
Infectious
Nonallergic rhinitis with eosinophilia syndrome
Occupational
Vasomotor

Information from reference 1.

congestion. These symptoms are excessive at times and are exacerbated by certain odors (e.g.,
perfumes, cigarette smoke, paint fumes, inks); alcohol; spicy foods; emotions; and environmental
factors such as temperature, barometric pressure changes, and bright lights. Patients with vasomotor
2

rhinitis are further divided into two subgroups: "runners," who demonstrate "wet" rhinorrhea; and "dry"
patients, who exhibit nasal obstruction and airflow resistance with minimal rhinorrhea. Many studies
1

have attempted to clarify the pathogenic mechanisms for these subgroups. Current theories include
increased cholinergic glandular secretory activity (for runners), and nociceptive neurons with
heightened sensitivity to usually innocent stimuli (for dry patients). These theories have not been
1

adequately proven. The vasomotor nasal effects of emotion and sexual arousal also may be caused by
autonomic stimulation. In one small study, researchers concluded that autonomic system dysfunction is
4

significant in patients with vasomotor rhinitis (P < .005). Possible compounding factors included
previous nasal trauma and extraesophageal manifestations of gastroesophageal reflux disease. 4
Whatever their causal mechanisms, the various rhinitis syndromes result in significant morbidity in the
United States. The National Rhinitis Classification Task Force concluded that 17 million Americans
have nonallergic rhinitis. An evidence report from the Agency for Healthcare Research and Quality
5 6

(AHRQ) estimated that 20 to 40 million Americans have allergic rhinitis, making it the sixth most
prevalent chronic illness. Treatment costs are at least $1.8 billion annually for physician visits and
medications, or nearly 4 percent of the $47 billion annual direct cost for treatment of respiratory
illnesses in the United States. The total annual cost of allergic rhinitis in the mid-1990s, including lost
6

productivity to employers and society, was $5.6 billion. 6

The AHRQ found no prospective studies in the literature that explicitly differentiated allergic from
nonallergic rhinitis. Making a specific diagnosis is most important if treatments vary between the
conditions. Because of the crossover in treatments, differentiation is primarily significant when
considering environmental control and institution of oral antihistamines and immunotherapy, which
have proven benefit only in the treatment of allergic rhinitis. Because asthma and sinusitis are
3

associated with allergic rhinitis, and a growing body of literature shows the increased effectiveness of
intranasal steroids over oral antihistamines in the management of allergic rhinitis, it may be useful to
establish a more specific diagnosis through diagnostic testing. 3,6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References
Topical anticholinergics should be used for rhinorrhea caused by A 6, 13
vasomotor rhinitis.
Azelastine (Astelin) may be used for vasomotor rhinitis associated with B 6
rhinorrhea, sneezing, postnasal drip, and nasal congestion.
Topical corticosteroids may be used for vasomotor rhinitis associated with B 6, 11
nasal obstruction and congestion.
Cromolyn sodium (Intal) may be used for vasomotor rhinitis associated B 6
with sneezing and congestion in patients older than two years.
A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C =
consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT
evidence rating system, see page 983 or http://www.aafp.org/afpsort.xml.

Laboratory Testing
No specific test is available to diagnose vasomotor rhinitis. In studies and in practice, allergic rhinitis is
excluded or implicated as the cause of symptoms by using conventional skin testing or by evaluation
for specific IgE antibodies to known allergens. According to the AHRQ, the results of "only one small
7 6

recent study suggest that total serum IgE may be as useful as specific allergy skin prick tests, which, in
turn, are more useful than radioallergosorbent testing in confirming a diagnosis of allergic rhinitis." The 8

lack of sensitivity and specificity of nasal cytology, total serum IgE, and peripheral blood eosinophil
counts, which have been favored in the past for differentiating among rhinitis syndromes, makes their
clinical use problematic. The minimum level of testing needed to confirm or exclude a diagnosis of
1

vasomotor rhinitis has not been established in the literature. 6

Suggested Approach to the Pharmacologic Management of Vasomotor Rhinitis

Figure 1. Algorithm for the pharmacologic management of vasomotor rhinitis.

Management
Figure 1 outlines an algorithm for effective pharmacologic management of vasomotor rhinitis. Table 2 6,9-13

displays stepwise recommendations for treatment based on the AHRQ Evidence Report and on
additional treatments empirically employed but not discussed by the AHRQ.

TABLE 2
Treatment Recommendations for Vasomotor Rhinitis: A Stepwise Approach
Medication class Product Effect Side effects
Topical Azelastine (Astelin) Improvement in No serious or
antihistamines 6,9,10
rhinorrhea, sneezing, unexpected
postnasal drip, and adverse events;
nasal congestion 9
bitter taste 9

Topical Mometasone furoate Improvement in nasal Epistaxis, nasal

corticosteroids 11
(Nasonex) obstruction and irritation
11

congestion scores 11

Topical Budesonide (Rhinocort), Improvement in nasal Epistaxis,

corticosteroids 6
beclomethasone (Beclovent), obstruction and headache, nasal
triamcinolone acetonide congestion scores 6,12
congestion
(Kenalog)
Topical Cromolyn sodium (Intal) Decrease in sneezing Nasal irritation,
cromoglycate 6
and congestion headache, nasal
scores 6
congestion 6

Topical Ipratropium (Atrovent) Reduced rhinorrhea Minor adverse

anticholinergics 6,13
only6,13
effects; nasal
dryness and
irritation
13

Other agents not recommended by AHRQ

Oral Sedating and nonsedating AHRQ outcome not Somnolence,
antihistamines identified dizziness, dry
mouth, headache
Oral Only phenylpropanolamine Withdrawn from the
sympathomimetic (not available in the United market; no
s States) was studied. other oral
decongestant was
identified or
specifically studied.
Leukotriene Not identified in any trial on
modifiers nonallergic rhinitis
Other agents not discussed by AHRQ: evidence for use lacking, empiric use possible
Topical Oxymetazoline (Nezeril, Afrin, Improvement in
decongestants Dristan) congestion
Oral Pseudoephedrine Improvement in
decongestants congestion

AHRQ = Agency for Healthcare Research and Quality.

note: Use of topical antihistamines and corticosteroids is approved by the U.S. Food and Drug Administration.
Information from references 6 and 9 through 13.

Once a working diagnosis of vasomotor rhinitis has been made, the patient can be empowered to avoid
known environmental triggers as much as possible. These may include odors (e.g., cigarette smoke,
perfumes, bleach, formaldehyde, newspaper or other inks); auto emission fumes; light stimuli;
temperature changes; and hot or spicy foods. A stepwise pharmacologic approach may then be
employed, choosing the initial intervention based on the patient's predominant symptoms. If the
presenting symptom is solely rhinorrhea, a topical anticholinergic is the logical first step. With nasal
6,14

congestion and obstruction only, topical corticosteroids would be a wise starting point for therapy. If
6

the patient presents with the full range of symptoms including rhinorrhea with sneezing, postnasal drip,
and congestion, a topical antihistamine may be initiated. After an adequate trial period, changes and
6,9,10

additions may be made if the response is inadequate. Figure 1 describes a possible approach.

Traditional oral antihistamines and newer less-sedating antihistamines have no established

benefit for the treatment of vasomotor rhinitis.

Exercise, beneficial for overall health, may be a useful treatment addition because it produces
decreased airway resistance and assists natural nasal decongestion by I-adrenergic-mediated
mechanisms. The effect of exercise on nasal decongestion is short-lived, but it has numerous other
2

benefits and can be repeated.

Traditional oral antihistamines have no established beneficial effect in patients with vasomotor rhinitis
and may be associated with sedation. Newer, less-sedating antihistamines also have no proven
effectiveness for vasomotor rhinitis, and their administration delays proper treatment while incurring
significant cost and burden to the health care system. According to the AHRQ report, there has been
3 6

only one study regarding the use of oral antihistamines, and that study used an antihistamine-
decongestant combination product, so the benefit of individual components could not be determined. 15

The empiric use of the topical decongestant ephedrine on a chronic basis has resulted in tolerance and
development of rhinitis medicamentosa. The inclusion of benzalkonium chloride as a preservative has
been speculated to contribute to the development of these problems. In a small study of 35 patients,
16

investigators examined the use of a newer agent, oxymetazoline, both with benzalkonium chloride
preservative (Nezeril, Afrin No Drip 12 Hour, 4-Way 12-Hour, Dristan 12 Hour) and without. Results
of this study demonstrated the short-term safety of the newer agent and the avoidance of rhinitis
16

medicamentosa, with or without preservative, during use up to three times daily for 10 days.

Special Populations
CHILDREN
Preventive and nonpharmacologic approaches should be tried before beginning medication in children.
Approved for use in patients six years and older, nasal anticholinergics such as ipratropium (Atrovent)
often reduce rhinorrhea without the undesirable side effects of sedation and fatigue sometimes
associated with oral antihistamine use. However, anticholinergics have no effect on the other
2,6

symptoms of vasomotor rhinitis. Investigators conducted a multicenter, double-blind, placebo-

controlled, parallel-group trial in 204 children (six to 12 years of age) and adolescents (13 to 18 years
13

of age) with allergic or nonallergic perennial rhinitis. Patients with nonallergic perennial rhinitis who
used ipratropium had a 41 percent mean decrease in severity and a 37 percent decrease in duration of
rhinitis with excellent tolerability, compared with decreases of 15 and 17 percent in severity and
duration, respectively, in the placebo group.13

Certain nasal corticosteroids, such as mometasone furoate (Nasonex), are approved by the U.S. Food
and Drug Administration (FDA) for children older than two years and improve the symptoms of
congestion and nasal obstruction. Investigators conducted a randomized, double-blind, placebo-
controlled, 12-month study to monitor growth in children during treatment with mometasone furoate. A
11

total of 82 patients, three to nine years of age, completed the study. There was no evidence of growth
retardation or hypothalamic-pituitary-adrenal axis suppression. Although short-term use studies
11

purporting safety are quoted in the literature, budesonide (Rhinocort), beclomethasone (Beclovent), and
triamcinolone acetonide (Kenalog) are not recommended for children younger than six years because of
continued concern over possible long-term growth suppression by these older agents. Cromolyn
12,17

sodium (Intal) can be used to manage symptoms of sneezing and congestion in children older than two
years.6

As in adults, traditional oral antihistamines and newer less-sedating antihistamines have no established
beneficial effects on vasomotor rhinitis in children. Prolonged use of topical nasal decongestants can
cause irritation and rhinitis medicamentosa without proven benefit. If a therapeutic trial of one of these
agents is attempted because of treatment failures with recommended agents, judicious and time-limited
use should be considered.

ATHLETES
Topical antihistamines, topical corticosteroids, and topical anticholinergics are treatments permitted by
the U.S. Olympic Committee and the International Olympic Committee. As of January 1, 2005, the
World Anti-Doping Code no longer bans the use of pseudoephedrine, but systemic decongestants are
included in the 2005 monitoring program. The code does not prohibit the use of topical decongestants.
18

The stepwise approach to manage athletes should be the same as that used with other populations. A
topical antihistamine (e.g., azelastine [Astelin]), topical corticosteroids (e.g., budesonide), and topical
anticholinergics (e.g., ipratropium) may be tried. The 2005 World Anti-Doping Code requires an
Abbreviated Therapeutic Use Exemption form to notify relevant agencies about the use of topical
corticosteroids. Empiric short-term treatment with topical decongestants may be considered if these
19

agents fail.

PREGNANT WOMEN
Symptoms of rhinitis can increase during pregnancy. This increase is thought to be caused by
progesterone- and estrogen-induced glandular secretion, augmented by nasal vascular pooling from
vasodilation and increased blood volume. Vasomotor rhinitis in pregnancy responds well to intranasal
20

saline instillation. Potential risks versus benefits should be considered in the use of FDA-approved
20

topical anticholinergics (pregnancy category B), topical antihistamines (pregnancy category C), and
topical corticosteroids (pregnancy category C). Topical decongestants (pregnancy category C) can
provide good short-term relief. Exercise appropriate for physical condition and gestational age also may
reduce symptoms. 1

OLDER ADULTS

Symptoms of vasomotor rhinitis may be exacerbated by certain odors, alcohol, spicy foods,
emotions, and environmental factors.

Three types of nonallergic rhinitis commonly occur in older patients. The first, vasomotor rhinitis, is
thought to be caused by increased cholinergic activity and is similar to that occurring in younger
patients. The second type, gustatory rhinitis, is associated with profuse, watery rhinorrhea that may be
exacerbated by eating. The third form is believed to arise from alpha-adrenergic hyperactivity,
stimulated by the regular use of antihypertensives. All three types respond well to ipratropium nasal
2

spray. Narrow-angle glaucoma is a relative contraindication to the use of ipratropium. 2

Prognosis and Additional Therapies

Although no single agent is uniformly effective in controlling the many and varied symptoms of
vasomotor rhinitis, available evidence supports a stepwise application of several agents after a careful
history and physical examination. Additional therapies, for which AHRQ felt there was no strong
evidence base, may be tried if the approved approaches fail. These therapies include topical
decongestants, oral decongestants, and local application of silver nitrate solutions by an
otolaryngologist. Sphenopalatine blocks, also performed by otolaryngologists, are reserved for
21,22

seriously affected patients who do not respond to other interventions and whose lives are altered
significantly by their symptoms. The submucosal injection of botulinum toxin type A (Botox) has been
23

studied in dog models and may yet prove to be of value.

24,25

Author disclosure: Nothing to disclose.

Members of various family medicine departments develop articles for "Practical Therapeutics." This article is one in
a series coordinated by the Department of Family and Geriatric Medicine at the University of Louisville School of
Medicine. Coordinator of the series is James G. O'Brien, M.D.

The Authors
PATRICIA W. WHEELER, M.D., is assistant professor and director of faculty development in the Department of Family and
Geriatric Medicine at the University of Louisville (Ky.) School of Medicine. Dr. Wheeler received her medical degree from the
University of Louisville, where she also completed a family medicine residency.

STEPHEN F. WHEELER, M.D., is associate professor in the Department of Family and Geriatric Medicine at the University of
Louisville School of Medicine, where he also serves as program director of the Family and Geriatric Medicine residency program.
Dr. Wheeler received his medical degree from the University of Louisville, where he also completed a family medicine residency.

Address correspondence to Patricia W. Wheeler, M.D., University of Louisville, Department of Family and Geriatric Medicine,
3430 Newburg Rd., Suite 202, Louisville, KY 40218. Reprints are not available from the authors.

REFERENCES
1. Dykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R, Blessing-Moore J, et al. Diagnosis and management of
rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and
Immunology. American Academy of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81(5
pt 2):478-518.
2. Druce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF,
Busse WW, eds. Allergy principles and practice. 5th ed. St. Louis: Mosby, 1998:1005-16.
3. Lau J, Long A. Chronic rhinitis: allergic or nonallergic? [Editorial] Am Fam Physician 2003;67:705-6.
4. Jaradeh SS, Smith TL, Torrico L, Prieto TE, Loehrl TA, Darling RJ, et al. Autonomic nervous system evaluation of
patients with vasomotor rhinitis. Laryngoscope 2000;110:1828-31.
5. Settipane RA, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001;86:494-507.
6. Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. AHRQ
Publication No. 02-E024, May 2002. Rockville, Md.: Agency for Healthcare Research and Quality, 2002.
Accessed online August 5, 2005, at: http://www.ahrq.gov/clinic/rhininv.htm.
7. Li JT. Allergy testing. Am Fam Physician 2002;66:621-4.
8. Ng ML, Warlow RS, Chrishanthan N, Ellis C, Walls R. Preliminary criteria for the definition of allergic rhinitis: a
systematic evaluation of clinical parameters in a disease cohort. Clin Exp Allergy 2000;30:1314-31.
9. Banov CH, Lieberman P; for the Vasomotor Rhinitis Study Groups. Efficacy of azelastine nasal spray in the
treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol 2001;86:28-35.
10. Gehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine
nasal spray in comparison with placebo. ORL J Otorhinolaryngol Relat Spec 2001;63:76-81.
11. Schenkel EJ, Skoner DP, Bronsky EA, Miller SD, Pearlman DS, Rooklin A, et al. Absence of growth retardation
in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal
spray. Pediatrics 2000;105:E22.
12. Skoner DP, Rachelefsky GS, Meltzer EO, Chervinsky P, Morris RM, Seltzer JM, et al. Detection of growth
suppression in children during treatment with intranasal beclomethasone dipropionate. Pediatrics 2000;
105:E23.
13. Meltzer EO, Orgel HA, Biondi R, Georgitis J, Milgrom H, Munk Z, et al. Ipratropium nasal spray in children with
perennial rhinitis. Ann Allergy Asthma Immunol 1997;78:485-91.
14. Dolovich J, Kennedy L, Vickerson F, Kazim F. Control of the hypersecretion of vasomotor rhinitis by topical
ipratropium bromide. J Allergy Clin Immunol 1987;80
(3 pt 1):274-8.
15. Broms P, Malm L. Oral vasoconstrictors in perennial non-allergic rhinitis. Allergy 1982;37:67-74.
16. Graf P, Enerdal J, Hallen H. Ten days' use of oxymetazoline nasal spray with or without benzalkonium chloride
in patients with vasomotor rhinitis. Arch Otolaryngol Head Neck Surg 1999;125:1128-32.
17. Benninger MS, Ahmad N, Marple BF. The safety of intranasal steroids. Otolaryngol Head Neck Surg
2003;129:739-50.
18. World Anti-Doping Agency. The World Anti-Doping Code. The 2005 prohibited list: international standard.
Accessed online August 5, 2005, at: http://www.wada-ama.org/rtecontent/document/list_2005.pdf.
19. U.S. Anti-Doping Agency. Drug Reference Online. Accessed online August 5, 2005, at:
http://www.usantidoping.org/dro/.
20. Lekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. Otolaryngol Head Neck Surg 1992;107(6 pt
2):845-9.
21. Bhargava KB, Abhyankar US, Shah TM. Treatment of allergic and vasomotor rhinitis by the local application of
silver nitrate. J Laryngol Otol 1980;94:1025-36.
22. al-Samarrae SM. Treatment of "vasomotor rhinitis" by the local application of silver nitrate. J Laryngol Otol
1991;105:285-7.
23. Prasanna A, Murthy PS. Vasomotor rhinitis and sphenopalantine ganglion block. J Pain Symptom Manage
1997;13:332-8.
24. Shaari CM, Sanders I, Wu BL, Biller HF. Rhinorrhea is decreased in dogs after nasal application of botulinum
toxin. Otolaryngol Head Neck Surg 1995;112:566-71.
25. Bushara KO. Botulinum toxin and rhinorrhea [Letter]. Otolaryngol Head Neck Surg 1996;114:507.

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September 15, 2005 Contents | AFP Home Page | AAFP Home | Search

Nonallergic rhinitis is a diagnosis of rhinitis without any Quick Find

immunoglobulin E (IgE) mediation, as documented by allergen
skin testing. Hence, the rhinorrhea, sneezing, pruritus, and
congestion do not result from allergy or hypersensitivity and
continue to persist, whether continuously or sporadically.
Nonallergic rhinitis affects 5-10% of the population. However, only
2-4% of patients actually seek treatment for relief of their
symptoms. Nonallergic rhinitis has 7 basic subclassifications,
including infectious rhinitis, nonallergic rhinitis with eosinophilia
syndrome (NARES), occupational rhinitis, hormonal rhinitis, drug-
induced rhinitis, gustatory rhinitis, and vasomotor rhinitis. Patients
may or may not present with the same symptoms seen in allergic
rhinitis.

Elevated concentrations of immunoglobulin G subclass 1 (IgG1)

and immunoglobulin G subclass 4 (IgG4) anti-IgE autoantibodies
have been found in patients with nonallergic rhinitis relative to Author Information
concentrations found in placebo patients. However, these elevations Introduction
Distinguishing The
are far lower than those found in patients with allergic rhinitis. In
Various Types Of
addition to skin testing, serum-soluble Fas concentrations (inherent Nonallergic Rhinitis
signals for causing cell death) are not elevated in patients with Pharmacotherapy
nonallergic rhinitis, unlike in patients with allergic rhinitis. Investigational Or
Increased concentrations of serum-soluble Fas are often present in International Drug
patients with autoimmune diseases and cancer. Therapy
Rhinitis
Pharmacotherapy
Autonomic stimuli have a greater effect on patients with
In Special Patient
nonallergic rhinitis than on those with allergic rhinitis. Patients can Populations
reduce nasal airway resistance up to 50% through isotonic exercise, Summary
which is mediated by increases in sympathetic tone. Changes in Tables
body posture, from erect to supine position, can also increase nasal Bibliography
airway resistance. Once in the supine position, the right nostril will
have lower pressure relative to the left nostril if the patient lies on Click for related
the right side. Temperature can also impact nasal blood flow and images.
compliance. Nasal compliance is decreased with cold air and
increased with hot air, whereas nasal blood flow is independent of
changes in hot air but decreases in the presence of cold air.
Continuing
Education
Section 3 of
DISTINGUISHING THE VARIOUS 9 CME available for
TYPES OF NONALLERGIC RHINITIS this topic. Click
here to take this
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis
Pharmacotherapy Investigational Or International Drug Therapy Rhinitis Pharmacotherapy
CME.
In Special Patient Populations Summary Tables Bibliography

Patient Education
Infectious rhinitis
Click here for
Infectious rhinitis is usually caused by an upper respiratory tract patient education.
infection, either of viral or bacterial origin. Viral infections are
generally self-limited and resolve within 7-10 days. However,
bacterial infections require the use of antibiotics. Typically, patients
with infectious rhinitis present with mucopurulent nasal discharge,
rather than watery rhinorrhea, accompanied by facial pain and
pressure, altered sense of smell, and postnasal drainage with cough.

Nonallergic rhinitis with eosinophilia syndrome

Eosinophilic rhinitis (ie, perennial intrinsic rhinitis) accounts for up

to 20% of rhinitis diagnoses. Some researchers believe that this
may be a precursor to the aspirin triad of intrinsic asthma, nasal
polyposis, and aspirin intolerance. Abnormal prostaglandin
metabolism has also been implicated as a cause of NARES.
Elevated eosinophil counts are present in approximately 20% of the
general population's nasal smears; however, not everyone with
eosinophilia has symptoms of rhinitis. A distinguishing feature of
NARES is the presence of eosinophils, usually between 10-20%, on
nasal smear. Generally, patients with NARES present with nasal
congestion, sneezing, rhinorrhea, nasal pruritus, and hyposmia.

Occupational rhinitis

Patients with occupational rhinitis experience symptoms of rhinitis

only in the workplace. These symptoms are usually initiated as a
result of an inhaled irritant (eg, laboratory animal antigens, grains,
wood dusts, chemicals). Frequently, patients with occupational
rhinitis present with concurrent occupational asthma.

Hormonal rhinitis

Some persons may experience symptoms of rhinitis when hormonal

imbalances occur (eg, pregnancy, hypothyroid states, puberty, oral
contraceptive use, conjugated estrogen use). Estrogens are believed
to cause an increase in hyaluronic acid in the nasal mucosa. Initial
presentation of hormonal rhinitis in pregnancy usually occurs
during the second month, continues through the duration of
pregnancy, and ceases following delivery. In patients with
hypothyroidism, edema increases in the turbinates as a result of
thyrotropic hormone release. Nasal congestion and rhinorrhea are
the chief manifesting symptoms in hormonal rhinitis.

Drug-induced rhinitis

Several medications have been implicated in the development of

rhinitis, including angiotensin-converting enzyme inhibitors,
reserpine, guanethidine, phentolamine, methyldopa, beta-blockers,
chlorpromazine, gabapentin, penicillamine, aspirin, nonsteroidal
anti-inflammatory drugs, inhaled cocaine, exogenous estrogens,
and oral contraceptives.

Rhinitis medicamentosa is considered a drug-induced rhinitis and

results from prolonged use (ie, longer than 5-10 days) of nasal
sympathomimetics. During this process, the alpha-receptors in the
nose gradually are desensitized to endogenous and exogenous
stimulation. Typically, these patients present with extensive nasal
congestion and rhinorrhea, resulting from loss of adrenergic tone,
rather than from the original cause of rhinitis. Normal nasal
function should resume within 7-21 days following cessation of
sympathomimetics.

Gustatory rhinitis

Gustatory rhinitis occurs following consumption of food,

particularly hot and spicy foods. The end result of profuse watery
rhinorrhea secondary to nasal vasodilation is vagally mediated,
generally occurring within a few hours of oral ingestion. Symptoms
of rhinitis are rarely secondary to ingestion of specific preservatives
or dyes contained within food.

Vasomotor rhinitis

Vasomotor rhinitis (ie, nonallergic noninfectious rhinitis without

eosinophilia) is a lump-sum category of all remaining types of
nonallergic rhinitis. Therefore, the term vasomotor may be
misleading in some cases. For the most part, vasomotor rhinitis is
believed to result from a disturbance in the regulation of the
parasympathetic and sympathetic systems, where the
parasympathetic system dominates, resulting in vasodilation and
edema of the nasal vasculature. The resulting symptoms are
rhinorrhea, sneezing, and congestion. Symptoms may be
exacerbated by cold air, strong odors, stress, or inhaled irritants.
Women with vasomotor rhinitis have been shown to have higher
rates of state anxiety, trait anxiety, and depression when compared
to healthy women without rhinitis. Patients with profuse rhinorrhea
and those with predominant nasal congestion are distinguished by
using the terms runners and blockers, respectively.

Section 4 of 9
PHARMACOTHERAPY
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis
Pharmacotherapy Investigational Or International Drug Therapy Rhinitis Pharmacotherapy
In Special Patient Populations Summary Tables Bibliography
A wide variety of etiologies are involved in nonallergic rhinitis.
Therefore, treatment options should not be implemented randomly
but rather should be aimed primarily at resolution of the underlying
causative physiology. Historically, medications helpful in the
treatment of allergic rhinitis were used. Unfortunately, often these
medications had unsuccessful results, depending on individual
responses.

Anticholinergics

Ipratropium bromide is the only topical anticholinergic medication

for nasal application available in the United States. In addition to
the basic structure of atropine, ipratropium contains an isopropyl
group, resulting in a quaternary ammonium structure. This
ammonium addition limits ipratropium's systemic absorption (less
than 10%) through mucous membranes, which in turn diminishes
the frequency of side effects.

Ipratropium is ideal for patients presenting with only rhinorrhea. It

is best in combination if patients present with rhinorrhea and other
concurrent symptoms, as it possesses no activity for treatment or
prevention of sneezing, itching, or nasal congestion. Clinical
studies have shown ipratropium reduces the duration and severity
of rhinorrhea by 33% and 29%, respectively, compared to that of
patients receiving a placebo. Fewer than 10% of patients
experience headache, epistaxis, pharyngitis, nasal dryness, nausea,
and nasal irritation.

Ipratropium nasal spray is packaged in 2 different concentrations,

0.03% and 0.06%. The 0.03% concentration is intended specifically
for treatment of rhinitis. The 0.06% nasal spray is intended for
management of rhinorrhea without a specific diagnosis of rhinitis
(eg, common cold). Each actuation of the 0.03% strength delivers
21 mcg. An ideal dose for patients older than 6 years is 168-252
mcg daily or 2 actuations to each nostril 2-3 times daily. Doses for
children younger than 6 years have not been established.

Nasal corticosteroids

Nasal corticosteroids follow the same pathway of reducing

inflammation as medications taken systemically, but their anti-
inflammatory activity is localized to the lungs. Although the direct
relationship between the mechanism and response is unknown, they
are believed to permit smooth-muscle relaxation, reduce airway
hyper-responsiveness, and reduce the quantity and activity of
inflammatory mediators. This class of medications is particularly
useful for rhinorrhea, sneezing, pruritus, and congestion. Nasal
corticosteroids are also useful in patients with NARES, as evidence
has suggested that they inhibit inactivation of eosinophils and the
resultant cascade leading to inflammation.

Because of the local activity of these drugs, adverse reactions have

been limited to nasal irritation and nasal bleeding, which can be
reduced with the use of an aqueous formulation. Advise patients not
to spray nasal corticosteroids directly onto the nasal septum.
Repeated long-term use may result in trauma to the nasal septum.

The main difference in the activity of various inhaled

corticosteroids is the binding affinity. An analysis of potency
relative to binding affinity to human glucocorticoid receptors
among flunisolide, triamcinolone, beclomethasone, budesonide,
and fluticasone revealed fluticasone to be the most potent. Clinical
relevance is demonstrated by a magnified patient response relative
to other inhaled corticosteroids.

Comparative data in the form of clinical trials between nasal

corticosteroids, specifically in patients with nonallergic rhinitis, are
scarce. A study comparing budesonide to beclomethasone
demonstrated that budesonide was superior regarding total nasal
symptom score at the midpoint (ie, 6 months) and at the conclusion
(ie, 12 months) of the study. The total nasal symptom score was
composed of 3 parts: sneezing, nasal congestion, and rhinorrhea.
The influencing factor was that patients treated with budesonide
had more optimal resolution of sneezing episodes relative to
patients treated with beclomethasone.

Another study compared the outcomes of 317 patients who had

either allergic or nonallergic rhinitis and had received 12 weeks of
treatment with fluticasone, 200 mcg twice daily; beclomethasone,
200 mcg twice daily; or a placebo. All patients were given
terbinafine to cover rhinitis symptoms not relieved by the
randomized therapy. No statistically significant differences were
demonstrated between the fluticasone and beclomethasone groups
regarding nasal blockage on waking, nasal blockage throughout the
day, sneezing, rhinorrhea, overall assessment of symptoms, or
terbinafine usage. When the data was analyzed between patients
with allergic and nonallergic rhinitis, no difference in responses
was demonstrated.

Nasal corticosteroids have a delayed onset of action, typically

within 1-2 weeks, across the class. Continuous use, rather than as-
needed use, yields more optimal results. Patient response is key to
determining an appropriate dose for nasal corticosteroids. Control
symptoms with the lowest effective therapeutic dose possible.

Antihistamines

Antihistamines are useful in relieving rhinorrhea, sneezing, and

nasal pruritus. However, as the name implies, they block histamine,
a factor more common to patients with allergic rhinitis. Therefore,
unless the symptoms result from histamine release, antihistamines
have limited benefit. All antihistamines competitively and
reversibly block type 1 histamine receptors (H1). Additionally,
newer antihistamines (second-generation) may inhibit the release of
certain inflammatory mediators, specifically mast cells and
basophils.

The distinction between the 2 generations of antihistamines can be

made regarding their lipid-penetrating ability. First-generation
agents are lipophilic and readily cross the blood-brain barrier,
leading to an increased frequency of CNS side effects (eg,
sedation). A decreased affinity for cholinergic and 5-
hydroxytryptaminergic receptors and an increased affinity for
peripheral H1 receptors contribute to the decrease in CNS adverse
events with second-generation agents relative to first-generation
agents. With the exception of cetirizine, which is cleared renally,
antihistamines pass through the cytochrome P450 system.
Differences in efficacy between the 2 generations do not exist.
Furthermore, antihistamines are broken down into
subclassifications based on similarities in their chemical structure.

Unique to the class of antihistamines is azelastine, a nasal

antihistamine with a labeled indication for the treatment of
vasomotor rhinitis. Two multicenter clinical trials showed that,
compared to placebo, azelastine was more efficacious in patients'
perceptions of rhinorrhea, sneezes, nasal congestion, and postnasal
drip. Before the blinding was lifted, nearly twice as many patients
randomized to receive azelastine versus placebo stated that they
would continue taking the study medication. If this efficacy is
specific to azelastine or if it can be applied to the entire class of
antihistamines is not clear. Larger clinical trials and trials
evaluating the role of azelastine on a cellular level relative to other
antihistamines would be helpful.
Sympathomimetics

Nasally applied sympathomimetics are imidazoline derivatives that

cause local vasoconstriction through alpha 2-adrenergic agonistic
properties, ultimately reducing nasal edema and obstruction. This
alpha 2-receptor specificity results in reduced blood flow to nasal
mucosa (approximately 30-40%), rather than a direct decongestant
effect.

Systemically administered sympathomimetics, pseudoephedrine

and phenylpropanolamine (recalled from US market), are beta-
phenylethylamine derivatives, pharmacologically similar to
ephedrine. Both medications possess combined alpha-adrenergic
stimulation while augmenting the release of norepinephrine.
However, pseudoephedrine additionally stimulates beta-adrenergic
receptors. While this combined adrenergic stimulation makes
pseudoephedrine strikingly similar to ephedrine, its potency and
degree of CNS stimulation are less than that of ephedrine. Both
local and systemic types of sympathomimetics are useful for short-
term treatment of nasal obstruction. If the topical formulations are
used beyond 5-10 days, patients may develop rhinitis
medicamentosa, a condition in which the alpha-adrenergic
receptors become down-regulated secondary to constant
stimulation. Systemic accumulation may lead to insomnia,
anorexia, and nervousness.

Use extreme caution in patients with glaucoma, benign prostatic

hypertrophy, or hypertension, as these conditions may be
exacerbated by sympathomimetics.

INVESTIGATIONAL OR INTERNATIONAL DRUG Section 5 of 9

THERAPY
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis Pharmacotherapy Investigational
Or International Drug Therapy Rhinitis Pharmacotherapy In Special Patient Populations Summary Tables Bibliography

Capsaicin

Capsaicin is a phenolic chemical contained within the oil of the Capsicum pepper. Capsaicin
is initially very irritating to its targeted area. However, the area becomes desensitized to the
irritation after repeated use. The nerves responsible for rhinorrhea, sneezing, and congestion
become desensitized when capsaicin is applied to the nasal mucosa. Therefore, symptoms
are halted. Capsaicin use has been targeted to patients presenting with congestion,
rhinorrhea, sneezing, or a combination of these symptoms.

Clinical studies have revealed a 60% reduction in nasal airway resistance. Treatment had
continued efficacy more than 4 months after study completion in most patients. Most
patients had significant improvement in visual analogue scores. However, no significant
difference was documented for nasal blockage, rhinorrhea, sneezing, coughing, mucous
production, or eye irritation before, during, or after study completion. Documented adverse
reactions were limited to initial nasal irritation and increased nasal airway resistance. No
consensus on capsaicin dosages seems to exist. Suggested regimens ranged from 3.3 x 10-3
mol capsaicin dissolved in 70% ethanol sprayed into each nostril once a week for 5 weeks,
to a solution containing 0.15 mg/0.5 mL capsaicin applied to each nostril every 2 or 3 days
for 7 treatments. To date, no commercially available form of capsaicin nasal spray exists in
the United States.

Ribomunyl

Many patients with infectious rhinitis develop recurrent episodes year after year.
Ribomunyl is aimed at preventing infectious rhinitis in predisposed patients. It is
composed of ribosomal fractions from Klebsiella pneumoniae, Streptococcus
pneumoniae, Streptococcus pyogenes, and Haemophilus influenzae, as well as membrane
fractions of K pneumoniae. Ribomunyl's production of humoral-specific and secretory-
specific antibodies is believed to occur through an unidentified mechanism.

In one study, more than 38% of patients treated with Ribomunyl were free of infectious
rhinitis, compared to 29.6% of placebo recipients. Additionally, significantly more
patients assigned to the placebo group required antibiotics when compared to those of the
treatment group. Patients receiving antibiotics in the placebo group required longer
treatment with antibiotics. Ribomunyl demonstrated continued protection from infectious
rhinitis throughout the peak season (ie, autumn to winter). Although adverse reactions
occurred in some patients, they were not reported specifically. Patients were initially
started on 1 tablet (strength and quantity of individual components not stated), 4 times
weekly for a total of 3 weeks, which then was reduced to 4 consecutive days monthly for
a total treatment duration of 5 months.

To date, Ribomunyl is not available in the United States but is widely marketed in
Europe.

Silver nitrate

While not widely implemented in clinical practice, topically applied silver nitrate is
believed to down-regulate nasal mucous membranes to stimuli through a local astringent
action of coagulated albumin. Patients presenting with rhinorrhea, sneezing, and
congestion are most likely to benefit from silver nitrate. Patients in clinical trials had
significant improvement in nasal symptoms, accompanied by significant changes in nasal
mucosal pathology, versus both flunisolide and placebo after 6 months of treatment. Most
patients had no reoccurrence for up to 6 months following study completion. However,
some patients may show signs of reoccurrence at 1 month. Most patients have not
reported any side effects, with the exception of local irritation and a case of anosmia.
A dose-escalating trial using concentrations of silver nitrate ranging from 5-25% was
conducted to determine the most effective concentration. A 20% solution was the most
effective concentration that did not cause harmful nose irritation. Each dose is applied
with a cotton-tip applicator and held in place for 1 minute once weekly for 5 weeks.

RHINITIS PHARMACOTHERAPY IN SPECIAL Section 6 of 9

PATIENT POPULATIONS
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis Pharmacotherapy Investigational Or
International Drug Therapy Rhinitis Pharmacotherapy In Special Patient Populations Summary Tables Bibliography

Pregnancy

Patients who are pregnant and present with symptoms of rhinitis are not limited to the
specific diagnosis of hormonal rhinitis. Rather, if the cause is rhinitis medicamentosa,
beclomethasone nasal inhalation may be beneficial in treating symptoms while weaning
the patient from topical sympathomimetics. Pregnancy may be complicated by infectious
rhinitis, which may require the use of antibiotics. Additionally, some patients may present
with vasomotor rhinitis. Nasal saline solution, exercise, and pseudoephedrine usually are
beneficial in these cases.

Ipratropium is safe for use in humans without evidence of teratogenicity. Although

ipratropium is excreted in human breast milk, it has not been identified as a harmful agent
to infants.

As a class, inhaled corticosteroids are rated as pregnancy category C, implying

documented teratogenicity in animals but not in humans. Some experts recommend the
use of beclomethasone over other corticosteroids due to its consistent track record. This
comment has not been formally evaluated. No conclusive data has been published for use
of any inhaled corticosteroids during lactation and breast-feeding.

All antihistamines have been given a pregnancy category rating of B by the Food and
Drug Administration (FDA), with the exceptions of brompheniramine, fexofenadine, and
tripelennamine, all of which are category C. Patients should exercise caution if taking
antihistamines while breast-feeding. Based on a case report of an infant's increased
crying, irritability, and disturbed sleep, the manufacturer has recommended that
brompheniramine be contraindicated during breast-feeding. Antihistamines are also likely
to reduce the milk volume in lactating women.

Both topical and systemic sympathomimetics are rated as pregnancy category C. Because
of the nature of these drugs as powerful vasoconstrictors, potential exists for uterine
blood flow reduction. However, human teratogenicity has not been reported specifically.
These drugs are excreted in breast milk, the clinical significance of which is unknown.

Pediatrics
Nonallergic rhinitis of all types is rare in children. Even children presenting with NARES
account for less than 2% of children with nasal eosinophilia. Second-generation oral
antihistamines may be used to control symptoms of rhinitis. If possible, first-generation
oral antihistamines should be avoided to prevent adverse reactions, particularly
paroxysmal hyperactivity. Nasal corticosteroids may be beneficial in pediatric patients
presenting with rhinorrhea, sneezing, pruritus, and congestion. Although stunted growth
has not been a factor in long-term studies, the FDA recommends routine monitoring of
height in children treated with corticosteroids.

Renal/Hepatic Insufficiency

Patients with renal insufficiency, hepatic insufficiency, or both are prone to augmentation
of adverse events, resulting from a reduced clearance through these pathways.
Fortunately, many of the drugs recommended for use in nonallergic rhinitis are
administered intranasally. Therefore, subsequent systemic absorption is minimal. Still,
antihistamines and some sympathomimetics are administered systemically.

Cetirizine and fexofenadine largely are excreted unchanged in the urine, 50% and 95%
respectively. Although this is advantageous in hepatically impaired patients, the dose
should be reduced to 5 mg of cetirizine daily and 60 mg of fexofenadine daily in patients
who are renally impaired.

Loratadine passes through the cytochrome P450 isoenzyme system, specifically 2D6 and
3A4. Therefore, an initial regimen of 10 mg every other day is recommended in patients
with hepatic insufficiency.

Diphenhydramine, clemastine, brompheniramine, chlorpheniramine, and tripelennamine

are metabolized extensively in the liver. However, no dosage adjustments are required in
patients with renal or hepatic impairment.

Pseudoephedrine and phenylpropanolamine both are metabolized in the liver, forming

active metabolites. Dosage reduction in hepatically impaired patients is not necessary.
However, a large percentage of these drugs are eliminated unchanged in the urine.
Therefore, a reduced dosage of pseudoephedrine should be given to patients with renal
impairment.

Elderly Patients

Cholinergic and alpha-adrenergic hyperactivity are common causes of rhinitis in elderly

patients. The increased cholinergic response in part may be the result of activation by
various foods (ie, gustatory rhinitis). While ipratropium may be the obvious choice for
this type of watery rhinorrhea, some elderly patients may be troubled by unwanted side
effects, particularly loss of bladder control. Therefore, antihistamines (eg, fexofenadine,
cetirizine, loratadine) are preferable.

Athletes
Athletes with nonallergic rhinitis who actively compete on state and national levels may
be difficult to treat. Strict compliance with guidelines set forth by the US Olympic
Committee and International Olympic Committee must be observed. Athletes are not
permitted to use any oral decongestants. The Olympic committee does however permit
oral antihistamines. Nasal corticosteroids may be permitted for use as approved on a
case-by-case basis. Each sporting event is likely to have its own regulations. The
prescribing physician should verify accepted medications in advance through written
communication to the appropriate supervising committees.

SUMMARY Section 7 of 9
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis Pharmacotherapy Investigational Or
International Drug Therapy Rhinitis Pharmacotherapy In Special Patient Populations Summary Tables Bibliography

Nonallergic rhinitis is a distinct disease classification, separate from allergic rhinitis, the
presence of IgE-mediated response being present in the latter. The diagnosis of
nonallergic rhinitis encompasses several individual classifications, including NARES,
vasomotor, occupational, hormonal, infectious, drug-induced, and gustatory. A wide
variety of medications are available for treatment of associated symptoms. However, no
individual class of medications or single medication is ideal in managing the entire
spectrum of symptoms. Patients are best treated from the perspective of their unique
symptoms, along with correction of the causative factors.

TABLES Section 8 of 9
Author Information Introduction Distinguishing The Various Types Of Nonallergic Rhinitis Pharmacotherapy Investigational Or
International Drug Therapy Rhinitis Pharmacotherapy In Special Patient Populations Summary Tables Bibliography

Table 1. Nasal Corticosteroids

Concentration Per Daily Dose (mcg)

Generic Name Trade Name(s)
Actuation
Low Medium High
Beconase
Beconase AQ* 42 mcg
Beclomethasone 168-
Vancenase Pockethaler 504-840 840+
dipropionate 504
Vancenase AQ Double 84 mcg
Strength*
200-
Budesonide Rhinocort 200 mcg 600-400 600+
400
Nasarel 500- 1000-
Flunisolide 250 mcg 2000+
Nasalide 1000 2000
Fluticasone propionate Flonase* 44, 110, 220 mcg 88-264 264-660 660+
Mometasone Nasonex 50 mcg <200 200 200+
Nasacort 400- 1000-
Triamcinolone acetonide 100 mcg 2000+
Nasacort AQ* 1000 2000
*aqueous formulations

Table 2. Distinctions Among the Classifications of Antihistamines

Class Distinction
Ethanolamines High degree of antimuscarinic activity – sedation
Ethylenediamines Highest specificity for the H1 receptor
Alkylamines Highest potency
Piperazines No major distinctions
Phenothiazines High degree of anticholinergic activity - sedation
Poor CNS penetration, highly selective, low
Piperidines
anticholinergic activity

Table 3. Dosing of Available Antihistamines

Generic Name Trade Name(s) Prescription Status Daily Dose

First-Generation Antihistamines
Alkylamines
Brompheniramines Dimetane* OTC 4 mg q4-6h; not to exceed
24 mg/d
Chlorpheniramines†‡ Chlor-Trimeton* OTC 4 mg q4-6h; not to exceed
24 mg/d

Ethanolamines
1.34 mg bid OR 2.68 mg
Clemastine* Tavist† OTC
tid
Not to exceed 8.04 mg/d
Diphenhydramine‡ Benadryl† OTC
25-50 mg q6-8h

Ethylenediamines 25-50 mg q4-6h OR 100

Tripelennamines PBZ Rx mg bid
Not to exceed 300 mg/d

Phenothiazines
Not routinely used for
Promethazines† Phenergan‡ Rx
rhinitis

Piperazine Class Not routinely used for

Hydroxyzine†§ Atarax‡ Rx rhinitis
Meclizine Antivert/Bonine Rx/OTC Not routinely used for
rhinitis
Second-Generation Antihistamines
Alkylamines
Acrivastine|| Semprex-D Rx 1 capsule tid-qid
Piperazines
Cetrizines¶ Zyrtec‡ Rx 5-10 mg/d
Piperidines
Fexofenadines* Allegra Rx 60 mg bid
Loratadines*§ Claritin‡ Rx 10 mg/d
Desloratadine** Clarinex Rx 5 mg/d

* available as a liquid formation

† also available with a decongestant, pseudoephedrine

‡ available generically

§ active metabolite possesses more activity than parent compound

** Major metabolite of loratadine

|| only available in combination with pseudoephedrine

¶ active metabolite of hydroxyzine

Table 4. Sympathomimetic Agent Dosing

Generic Name Trade Name(s) Daily Dose

Systemic
Phenylpropanolamine Propagest and various generics 25 mg q4h OR 50mg q8h
Not to exceed 150 mg/d
Pseudoephedrine Sudafed and various generics 30-60 mg q4-6h OR 120 mg q12h
Not to exceed 240 mg/d
Topical
Oxymetazoline Afrin 2-3 sprays in each nostril bid
Xylometazoline Otrivin 2-3 sprays in each nostril q8-10h

Table 5. Choosing a Class of Medications for a Specific Symptom of Nonallergic Rhinitis

Medications Presenting Symptoms

Rhinorrhea Sneezing Pruritus Obstruction Congestion
Corticosteroids X X X X
Antihistamines X X X
Anticholinergics X
Sympathomimetics X
Capsaicin* X X X
Ribomunyl*
Silver Nitrate* X X X

* Investigational or international drug therapy

Table 6. Choosing a Class of Medications for a Particular Type of Nonallergic Rhinitis

Type of Nonallergic Rhinitis

Medications
Drug-
NARES Vasomotor Occupational* Hormonal Infectious Gustatory
Induced*
Corticosteroids X X X X
Antihistamines X X
Anticholinergics X X X
Sympathomimetics X X X
Capsaicin† X
Ribomunyl† X
Silver Nitrate† X

* Avoidance of the irritant is the most successful treatment

† Investigational or international drug therapies

Table 7. Treatment Options for Nonallergic Rhinitis in Pregnant Patients

Pregnancy Class
Medication
Antihistamines
Brompheniramine C
Chlorpheniramine B
Clemastine B
Diphenhydramine B
Tripelennamine C
Acrivastine B
Cetirizine B
Fexofenadine C
Loratadine B
Desloratadine C
Sympathomimetics
Phenylpropanolamine C
Pseudoephedrine C
Oxymetazoline C
Xylometazoline C
Corticosteroids
Beclomethasone C
Flunisolide C
Fluticasone C
Mometasone C
Dexamethasone C
Budesonide C
Anticholinergics
Ipratropium B

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