MANAGEMENT OF

ALLERGIC RHINITIS AND

ITS IMPACT ON ASTHMA
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POCKET GUIDE
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GLOBAL PRIMARY CARE EDUCATION

BASED ON THE 2007 ARIA WORKSHOP REPORT AND THE IPAG HANDBOOK
In collaboration with WHO, GA2LEN, AllerGen, and Wonca
THE PURPOSE OF THIS GUIDE
This document was prepared by the Wonca Expert Panel, including Bousquet J, Reid J, Van Weel C, Baena
Cagnani C, Demoly P, Denburg J, Fokkens WJ, Grouse L, Mullol K, Ohta K, Schermer T, Valovirta E, and
Zhong N. It was edited by Dmitry Nonikov. This material is based on the IPAG Handbook and the ARIA
Workshop Report, in collaboration with the World Health Organization, GA2LEN (Global Allergy and
Asthma European Network), AllerGen, International Primary Care Respiratory Group (IPCRG), European
Federation of Allergy and Airways Diseases Patients Associations (EFA), and the World Organization of
Family Doctors (Wonca).
Management that follows evidence-based practice guidelines yields better patient results. However, global
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evidence-based practice guidelines are often complicated and recommend the use of resources often not
available in the primary care setting worldwide. The joint Wonca/GARD expert panel offers support to
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primary care physicians worldwide by distilling the existing evidence based recommendations into this
brief reference guide. The guide lists diagnostic and therapeutic measures that can be carried out world-
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wide in the primary care environment and in this way provide the best possible care for patients with allergic
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rhinitis. The material presented in sections 1-5 will assist you in diagnosing and treating allergic rhinitis.
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PRIMARY CARE CHALLENGE

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Allergic rhinitis is a growing primary care challenge since most patients consult primary care physicians.
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General practitioners play a major role in the management of allergic rhinitis as they make the diagnosis,
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start the treatment, give the relevant information, and monitor most of the patients. In some countries,
general practitioners perform skin prick tests. Studies in Holland and the UK found that common nasal aller-
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gies can be diagnosed with a high certainty using simple diagnostic criteria. Nurses may also play an
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important role in the identification of allergic diseases including allergic rhinitis in the primary care of devel-
oping countries and in schools. In addition, many patients with allergic rhinitis have concomitent asthma and
, DO

this must be checked.

ALLERGIC RHINITIS RECOMMENDATIONS

NO
TA

1- Allergic rhinitis is a major chronic respiratory disease due to its:

- Prevalence
LT

- Impact on quality-of-life
- Impact on work/school performance and productivity
ER

- Economic burden
- Links with asthma
OR

2- In addition, allergic rhinitis is associated with co-morbidities such as conjunctivitis.

3- Allergic rhinitis should be considered as a risk factor for asthma along with other known risk factors.
RE

4- A new subdivision of allergic rhinitis has been proposed:

- Intermittent (IAR)
PR

- Persistent (PER)
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5- The severity of allergic rhinitis has been classified as “mild” or “moderate/severe” depending on the
severity of symptoms and quality-of-life outcomes.
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6- Depending on the subdivision and severity of allergic rhinitis, a stepwise therapeutic approach has been
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proposed.
7- The treatment of allergic rhinitis combines:
.

- Pharmacotherapy
- Immunotherapy
- Education
8- Patients with persistent allergic rhinitis should be evaluated for asthma by means of a medical
history, chest examination, and, if possible and when necessary, the assessment of airflow
obstruction before and after bronchodilator.
9- Patients with asthma should be appropriately evaluated (history and physical examination) for
rhinitis.
10- Ideally, a combined strategy should be used to treat the upper and lower airway diseases to
optimize efficacy and safety.

1
1- RECOGNIZE ALLERGIC RHINITIS
ALLERGIC RHINITIS QUESTIONNAIRE1
Instruct io ns : To evaluate the possibility of allergic rhinitis, start by asking the questions below to patients with nasal symptoms.
This questionnaire contains the questions related to allergic rhinitis symptoms that have been identified in peer-reviewed literature
as having the greatest diagnostic value. It will not produce a definitive diagnosis, but may enable you to determine whether a
diagnosis of allergic rhinitis should be further investigated or is unlikely.

All erg ic R hinit is Quest ionn air e

Qu e s ti o n Re s p o n s e C h o ic e s
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1. Do you have any of the following symptoms?

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• Symptoms on only one side of your nose Yes No

• Thick, green or yellow discharge from your nose (see NOTE) Yes No
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• Postnasal drip (down the back of your throat) with thick mucus and/or runny nose (see NOTE) Yes No
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• Facial pain (see NOTE) Yes No

• Recurrent nosebleeds Yes No
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• Loss of smell (see NOTE) Yes No

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2. Do you have any of the following symptoms for at least one hour on most days (or on most days
during the season if your symptoms are seasonal)?
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• Wa ter y r unn y n ose Yes No

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• Sneezing, especially violent and in bouts Yes No

• Nasal obstruction Yes No
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• Nasal itching Yes No

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• Conjunctivitis (red, itchy eyes) Yes No

,

E v al u a t i o n :
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• The symptoms described in Question 1 are usually NOT found in allergic rhinitis. The presence of ANY ONE of them suggests
that alternative diagnoses should be investigated. Consider alternative diagnoses and/or referral to a specialist.
• NOTE: Purulent discharge, postnasal drip, facial pain, and loss of smell are common symptoms of sinusitis. Because most
NO

patients with sinusitis also have rhinitis (though not always allergic in origin), in this situation the clinician should also evaluate
the possibility of allergic rhinitis.
TA

• The presence of watery runny nose with ONE OR MORE of the other symptoms listed in Question 2 suggests allergic rhinitis,
and indicates that the patient should undergo further diagnostic assessment.
• The presence of watery runny nose ALONE suggests that the patient MAY have allergic rhinitis. (Additionally, some patients
LT

with allergic rhinitis have only nasal obstruction as a cardinal symptom.)

• If the patient has sneezing, nasal itching, and/or conjunctivitis, but NOT watery runny nose, consider alternative diagnoses
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and/or referral to a specialist.

• In adults with late-onset rhinitis, consider and query occupational causes. Occupational rhinitis frequently precedes or
accompanies the development of occupational asthma. Patients in whom an occupational association is suspected should be
OR

referred to a specialist for further objective testing and assessment.

ALLERGIC RHINITIS DIAGNOSIS GUIDE1

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Instruct io ns : In patients of all ages with lower nasal symptoms only, whose responses to the Allergic Rhinitis Questionnaire suggest
that this diagnosis should be investigated, use this guide to help you evaluate the possibility of allergic rhinitis. All of the diagnostic
investigations presented in this guide may not be available in all areas; in most cases, the combination of those diagnostic
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investigations that are available and the individual health care professional’s clinical judgement will lead to a robust clinical
diagnosis. This guide is intended to supplement, not replace, a complete physical examination and thorough medical history.
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All erg ic R hinit is D iag nos is Guide

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Di a gn osti c Too l F i n d i ng s th a t S u p p o r t D i a g n os i s
.

Physical examination Transverse crease of nose, allergic shiners, allergic salute.

In persistent rhinitis: Exclusion of other causes.
• anterior rhinoscopy using speculum and mirror gives
limited but often valuable information
• nasal endoscopy (usually performed by specialist) may
be needed to exclude other causes of rhinitis, nasal
polyps, and anatomic abnormalities
Trial of therapy Improvement with antihistamines or intranasal
glucocorticosteroid.
Allergy skin testing or measurement of allergen-specific • Confirm presence of atopy.
IgE in serum (if symptoms are persistent and/or • Specific triggers identified.
moderate/severe, or if quality of life is affected)
Nasal challenge tests (if occupational rhinitis suspected) Confirm sensitivity to specific triggers.

2
1International Primary Care Airways Group (IPAG) Handbook available at http://www.globalfamilydoctor.com.
2- DIFFERENTIAL DIAGNOSIS OF ALLERGIC
RHINITIS2
Symptoms suggestive Symptoms usually NOT associated
of allergic rhinitis
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– u n i l a t e r a l s ym p t o m s
2 or more of the fol lowing sy mptoms for – nasal obstruction without other symptoms
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> 1 h r o n m o s t d ay s : – mu copu ru le nt rh i no rrhe a

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– w at e r y a n t e r i o r r h i n o r r h e a – p o s t e r i o r r h i n o r r h e a ( p o s t n a sa l d r i p )
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– sn eezin g, esp ec ially p ar oxy sm al –w i t h t h i c k m u c o u s

– n a s a l o bs t r u c t i o n –a n d / o r n o a n t e r i o r r h i n o r r h e a
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– na sa l p ru ri t i s – p a in
– re curren t epi s tax is
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± co n j u n ct i v i t i s
– a no s m ia
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C l a s s i f y a n d a s s es s s e ve r i ty
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( se e se c t io n 4 )
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3- MAKE THE DIAGNOSIS OF ALLERGIC RHINITIS2

NO

Symptoms suggestive of allergic rhinitis

TA

Anterior rhinorrhea
Sneezing
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Nasal obstruction
(and possibly other nasal or ocular symptoms)
ER
OR

M M
Primary care Specialist
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M

M M
Phadiatop or Skin prick test
PR

Multi-allergen test
Refer the
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M M
patient to Positive Negative
specialist + correlated
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M M
Negative Positive with
M
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symptoms If strong suggestion of

allergy: perform serum
.

M
allergen specific IgE
Rhinitis is likely to be allergic. M
If more information needed Allergic rhinitis
or immunotherapy to be M M
proposed Negative Positive
M + correlated
Rhinitis is unlikely
M with
Non allergic symptoms
to be allergic
rhinitis
M
Allergic rhinitis

3
2Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
4- CLASSIFY ALLERGIC RHINITIS2
Intermittent Persistent
symptoms symptoms
• <4 days per week • >4 days/week
• or <4 consecutive weeks
CO • and >4 consecutive weeks

Mild Moderate-Severe
all of the following one or more items
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• normal sleep • sleep disturbance

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• no impairment of daily activities, sport, leisure • impairment of daily activities, sport, leisure
• impairment of school or work
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• no impairment of work and school

• symptoms present but not troublesome • troublesome symptoms
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5- TREAT ALLERGIC RHINITIS

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Trea t men t G oa ls
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Goals for the treatment of rhinitis assume accurate diagnosis and assessment of severity as well as any link
with asthma in an individual patient. Goals include:
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· Unimpaired sleep
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· Ability to undertake normal daily activities, including work and school attendance, without limitation or
impairment, and the ability to participate fully in sport and leisure activities
· No troublesome symptoms
NO

· No or minimal side-effects of rhinitis treatment

TA

STRENGTH OF EVIDENCE FOR EFFICACY OF

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RHINITIS TREATMENT2
ER
OR

A RI A 2 0 0 7
I n t e r v en t i o n SAR PAR P ER
RE

a d u l ts ch i l d re n a du lt s c h il dre n
PR

O r a l H 1 A n ti h i s t a m i n e A A A A A
OD

Int ra nas al H1 Anti hist a mi ne A A A A A**

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In t r a n a s a l C S A A A A A**
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In t r a n a s a l c r o m o n e A A A A
.

LTR As A A ( > 6 y rs ) A A**

S u b c u t a n eo u s S I T A A A A A**
Sublingual / nasal SIT A A A B A**
A l l e rg e n a v o id an c e D D A* B*

SAR - Seasonal Allergic Rhinitis *not effective in the general population

PAR - Perennial Allergic Rhinitis **extrapolated from studies in SAR/PAR
PER - Persistent Allergic Rhinitis
CS - Corticosteroids
LTRAs - Anti-Leukotrienes
SIT - Specific Immunotherapy

4
2Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
DIAGNOSIS AND SEVERITY ASSESSMENT OF

Diagnosis of allergic rhinitis

ALLERGIC RHINITIS2
Check for asthma
especially in
patients with
Intermittent Persistent moderate-severe
symptoms symptoms and/or persistent
rhinitis

mild moderate- mild moderate

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severe severe
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Not in preferred order

In preferred order
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oral H1-antihistamine Not in preferred order

or intranasal oral H1-antihistamine intranasal CS
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H1-antihistamine or intranasal H1-antihistamine or LTRA**

and/or decongestant H1-antihistamine
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or LTRA** and/or decongestant review the patient

or intranasal CS* after 2-4 wks
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or LTRA**
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(or cromone)
improved failure
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in persistent rhinitis
review the patient review diagnosis
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after 2-4 weeks step-down review compliance

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and continue query infections

treatment or other causes
,

for 1 month
DO

if failure: step-up
if improved: continue
for 1 month
NO

increase rhinorrhea
intranasal CS add ipratropium
TA

dose itch/sneeze blockage

add H1 antihistamine add
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decongestant
or oral CS
ER

(short-term)
OR

failure
*Total dose of topical CS should be considered if
RE

inhaled steroids are used for concomitant asthma

**In particular, in patients with asthma surgical referral
PR

Allergen and irritant avoidance may be appropriate

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If conjunctivitis add:
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oral H1-antihistamine
or intraocular H1-antihistamine
.

or intraocular cromone
(or saline)

Consider specific immunotherapy

PED IAT RI C A SPEC TS
Allergic rhinitis is part of the "allergic march" during childhood but intermittent allergic rhinitis is unusual before two years
of age. Allergic rhinitis is most prevalent during school age years. In preschool children, the diagnosis of AR is difficult.
In school children and adolescents, the principles of treatment are the same as for adults, but doses may be adapted,
and special care should be taken to avoid the side effects of treatments typical in this age group.

5
2Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
6- ASSESS POSSIBILITY OF ASTHMA2
The patient does not know if he
Patient with a diagnosis of asthma
(she) is asthmatic

4 s i m pl e qu e s t i o n s :
– ha ve you h ad an a ttack or recurrent a ttacks of wheez ing ?
Fol low Won ca /G A RD Ref er en ce Gu id e
– d o yo u ha ve a t ou ble so me c ou gh, e spe ci ally at ni ght ?
Al ler g ic Rh in itis M an a g eme nt Poc ket Ref er en ce 2 0 0 8
– d o yo u c o u gh or w he e ze afte r e xe r ci se ?
– d oe s yo u r c hest fe e l ti ght?
CO
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If YES to a ny of these questions

your pa tient may be asthmat ic
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Need for a sthm a eva lua tion

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GLOSSARY OF RHINITIS MEDICATIONS1

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Na me an d G e n e r i c na m e M e c h a ni s m o f Si de ef fe cts C o m m e nt s
A l s o k no w n a s a c t i on
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O r a l H1 2 n d g e ne r a ti o n - blockage of H1 2 n d g e ne r a ti o n - First-line therapy except in

RI

Moderate/ Severe
a n ti h i s t a m i n e s Cetirizine receptor - no sedation for Persistent Allergic Rhinitis
AL

H 1- b l o c k e r s Ebastine - some anti-allergic most drugs - 2nd generation oral H1-

Fexofenadine activity - no anti-cholinergic blockers are preferred for
,

Loratadine - new generation effect their favorable efficacy/

DO

safety ratio and pharma-

Mizolastine drugs can be used - no cardiotoxicity cokinetics; first generation
Acrivastine once daily - acrivastine has molecules are no longer
- no development of sedative effects
NO

Azelastine recommended because of

Mequitazine tachyphylaxis - oral azelastine their unfavorable safety/
efficacy ratio
N ew p r o d u c t s may induce
TA

- Rapidly effective (less than 1hr)

Desloratadine sedation and a on nasal and ocular symptoms
Levocetirizine bitter taste - Moderately effective on
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nasal congestion
Rupatadine * Cardiotoxic drugs
ER

(astemizole, terfenadine)
are no longer marketed in
most countries
OR

Lo c a l H1 Azelastine - blockage of H1 - Minor local side Rapidly effective

a nt i hi s ta m i n e s Levocabastine receptor effects (less than 30 min)
RE

( i nt r a na s a l , Olopatadine - some anti-allergic - Azelastine: bitter taste on nasal or ocular

i nt r a o c u l a r ) activity for azelastine in some patients symptoms
PR

I nt ra n a sal Beclomethasone - potently reduce - Minor local side - The most effective
g l u c oc o r ti c o - dipropionate nasal inflammation effects pharmacologic
OD

s t er o i d s treatment of allergic
Budesonide - reduce nasal - Wide margin for rhinitis; first-line
Ciclesonide hyperreactivity systemic side
U

treatment for
Flunisolide effects Moderate/ Severe
CE

Fluticasone - Growth concerns Persistent Allergic

propionate with BDP only Rhinitis
.

Fluticasone furoate - In young children - Effective on nasal

congestion
Mometasone furoate consider the - Effective on smell
Triamcinolone combination of - Effect observed after
acetonide intranasal and 6-12 hrs but maximal
inhaled drugs effect after a few days
- Patients should be
advised on the proper
method of administering
intranasal glucocortico-
steroids, including the
importance of directing
the spray laterally rather
than medially (toward
the septum) in the nose

1International Primary Care Airways Group (IPAG) Handbook available at http://www.globalfamilydoctor.com.

6
2Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
 Or a l / I M Dexamethasone - Potently reduce - Systemic side When possible,
g l u c o c or ti c o- Hydrocortisone nasal inflammation effects common in intranasal glucocortico-
s te r oi d s Methylpredisolone particular for IM steroids should replace
Prednisolone - Reduce nasal drugs oral or IM drugs
Prednisone hyperreactivity - Depot injections
Triamcinolone may cause local However, a short
Betamethasone course of oral gluco-
tissue atrophy
corticosteroids may be
Deflazacort needed if moderate/
severe symptoms
L o c a l c r om o n e s Cromoglycate - mechanism of - Minor local side Intraocular cromones
( i n tr a n a s a l , Nedocromil action poorly effects are very effective
CO

i n tr a o c u l a r ) Naaga known
Intranasal cromones
PY

are less effective

and their effect is
RI

short lasting
GH

Overall excellent
safety
TE

O ra l Ephedrine - sympathomimetic - Hypertension Use oral decongestants

D

d e c o ng e s ta n ts Phenylephrine drug - Palpitations with caution in patients

- Restlessness with heart disease
MA

Phenyl- - relieve symptoms - Agitation

propanolamine of nasal - Tremor O ra l H 1 -
TE

Pseudoephedrine congestion - Insomnia an ti h is t am in e

- Headache de c on ge st ant
RI

Oral H1- - Dry mucous c o mbi nati o n

membranes products may be more
antihistamine-
AL

- Urinary retention effective than either

decongestant - Exacerbation of product alone but side
,

combination glaucoma or effects are combined

DO

thyrotoxicosis

I nt r a na s a l Oxymethazoline - sympathomimetic - Same side effects as Act more rapidly and

oral decongestants but more effectively than
NO

d e c o n g e s ta n ts Others drugs
less intense oral decongestants
- relieve symptoms - R h i n i ti s
of nasal
TA

m e d i c am e n t o s a Limit duration of
congestion is a rebound pheno- treatment to less than
menon occurring with 10 days to avoid
LT

prolonged use rhinitis medicamentosa

(over 10 days)
ER

I n tr a na s a l Ipratropium - anticholinergics block - Minor local side Effective in allergic

a nt i - almost effects and nonallergic
OR

c h ol i n e r g i c s exclusively - Almost no systemic patients with

rhinorrhea antioholinergic activity rhinorrhea
RE

C y sLT Montelukast - Block CysLT - Excellent tolerance Effective on rhinitis and

a n ta g o ni s ts Pranlukast receptor asthma
PR

A nt i l e u k ot r i e n e s Zafirlukast Effective on all symptoms

of rhinitis and on
OD

ocular symptoms
U

R ef er enc es : 1) International Primary Care Airways Group (IPAG) Handbook available at http://www.globalfamilydoctor.com.
CE

2) Allergic Rhinitis and its impact on Asthma (ARIA) 2007. Full text ARIA documents and resources: http://www.whiar.org.
.

GINA materials have been used with permission from the Global Initiative for Asthma (www.ginasthma.org). Material from the IPAG
Handbook has been used with permission from the International Primary Care Airways Group.

The pr int in g of th is A RI A P ocket Guide has b een The ARIA Initiative has been supported
by educational grants from:
ALK Abelló Nycomed
suppor ted by an ed uca tiona l gr ant fr om:

GlaxoSmithKline Phadia
Grupo Uriach Sanofi Aventis
Meda Pharma Schering-Plough
MSD Stallergenes
Novartis UCB

ARIA source documents are at www.whiar.org

© MCR Inc.
Copies of this document are available at www.us-health-network.com