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Acknowledgments
This is a presentation of the
American Academy of Family Physicians
supported by an educational grant from
Aventis Pharmaceuticals
The AAFP gratefully acknowledges
Harold H. Hedges, III, M.D.
and
Susan M. Pollart, M.D.
for developing the content for the AAFP
and
Harold H. Hedges, III, M.D. and Lincoln Diagnostics for providing the photo
images included
in this slide presentation.
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Acknowledgments
Harold H. Hedges, III, M.D.
Private Practice
Little Rock Family Practice Clinic
Little Rock, Arkansas
and
Susan P. Pollart, M.D.
Associate Professor of Family Medicine
University of Virginia Health System
Charlottesville, Virginia
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Evidence-Based Recommendations
Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis
with prophylactic medications (antihistamines and/or intranasal corticosteroids).
Practice Recommendation: Prescribe intranasal corticosteroids to control allergic
rhinitis symptoms.
Practice Recommendation: Educate patients with allergic rhinitis about avoidance
activities.
Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis
for whom optimal avoidance measures and medication therapy are insufficient to
control symptoms.
All recommendations available at: http://www.icsi.org/knowledge/detail.asp?
catID=29&itemID=158.
Accessed August 2003.
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Epidemiology Of Rhinitis
Affects 100% of the population
Often self-limited and associated with viral URI
With chronic symptoms, determining etiology guides
therapy
Major separation is between allergic, nonallergic and
mixed rhinitis
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Epidemiology Of Rhinitis
Allergic rhinitis was reported the second most prevalent
chronic condition in the United States in 1994
Affects 40 to 50 million people
Incidence highest in people ages 15-25 years
Estimates of nonallergic rhinitis lacking
In one study, 57% of patients with chronic rhinitis had
nonallergic or mixed rhinitis
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Allergic Rhinitis
50% patients symptomatic > 4 months/year
20% patients symptomatic > 9 months/year
10,000 children out of school daily
10,000,000 office visits annually
2,000,000 days of missed school
And this accounts only for allergic rhinitis, nonallergic rhinitis is
another issue
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prod
uctio
ism n
e
e
nt
e
s
abdiseases
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Allergic or Nonallergic?
A dilemma for family care physicians
Allergic? Nonallergic? Mixed?
Can we distinguish rapidly in the course
of a busy day?
Is there a quick, cost-effective test?
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Approach to Dx and Rx
Hypertension, diabetes, infections
Hx/Px>>>>Lab>>>>Dx>>>>Rx
Rhinitis
Hx/Px>>>>Dx>>>>Rx
Dx may be wrong up to half of the time
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Classification of Rhinitis
Allergic Rhinitis
Seasonal allergic rhinitis (SAR)
Perennial allergic rhinitis (PAR)
Nonallergic Rhinitis
Infectious
Idiopathic or vasomotor
Drug-induced
Rhinitis medicamentosa
Hormonal
Anatomical
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Types of Rhinitis
Pure allergic rhinitis
43%
23%
Mixed
34%
100%
National Allergy Advisory Council meeting, The broad spectrum of rhinitis: etiology,
diagnosis, and advances in treatment. St. Thomas, US Virgin Islands; 1999.
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Quality-of-Life Issues
Fatigue
Missing school/work
Concentration
Halitosis
Nuisance
Decreased daily
production
Sleep disturbance
Emotional well being
Social interactions
Impaired studying
Sniffing/snorting
Blowing nose
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0.0
-0.4
-0.8
Lor vs placebo: NS
Fex vs placebo: P <0.005
Fex vs Lor: P 0.03
-1.2
-1.6
Fex 120 mg qd
Placebo
Lor 10 mg qd
Baseline score ~ 3.0
van Cauwenberge, et al. Clin Exp Allergy: 2000;30:891.
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Pathophysiology
Direct effects of histamine
Indirect effects of histamine
Other mediators of the immune response
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Early Response
Leakage of blood vessels
Mucosal edema
Rhinorrhea
Secretion of mucoglycoconjugates
Congestion
Nasal itching
Sneezing
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Case Study
Patient presents with runny nose, nasal congestion, constantly
clearing his throat, sniffing, snorting, disruptive to fellow
students. Requests a prescription for an antihistamine like the
one I saw on TV.
What else do you need to know before prescribing medication?
What physical signs can help you?
What quick, in-office tests can help you with a diagnosis?
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Causes of Rhinitis
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Allergy
Irritants
NARES syndrome
Occupational
Emotional
Hormonal
Atrophic
Drug induced
Ciliary dyskinesia
Anatomic defects
Immunodeficiency
diseases
Allergic Rhinitis
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Evaluation of Rhinitis
History and physical
Sinus transillumination
Direct visualization with nasal specula
Rhinoscopy
Nasal smear
Allergy screening tests (skin tests or RAST)
Imaging for persistent disease
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Allergy
History Screen
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Physical Exam-NARES
External appearance, evidence of trauma
Color, consistency of nasal discharge
Mucosal swelling
Presence of odor
Polyps, septal deviation, concha bullosa
Tenderness over sinuses
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Physical Examination
Eyes: conjunctivitis, dark circles, Dennies lines
Ears: OM, TM mobility, serous otitis
Mouth: mouth breathing
Lungs: wheezing
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Nasal Smear
Clear nose of secretions
Gently scrape sample from mucosa of inferior or middle
turbinate with plastic ear spatula or cotton swab
Wrights or Hansels stain
Eosinophilia
Allergy (present in 90% of allergic patients)
NARES syndrome
Aspirin sensitivity
Neutrophilia
Infection
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Rhinoscopy
Nasal polyps
Septal deviation
Concha bullosa
Eustachian tube dysfunction
Causes of hoarseness
Adenoid tissue
Tumors
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Nasal irrigation
Leukotrienes
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Nasal Irrigation
Commercial buffered sprays
Bulb syringe
1/4 tsp of salt to 7 ounces water
Waterpik with lavage tip
1 tsp salt to reservoir
Disposable enema bucket
2 tsp salt, 1 tsp soda per quart of water
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Nasal Irrigation
Washes away irritants
Moistens the dry nose
Waterpik with nasal irrigator
Ceramic irrigators
Enema bucket with normal saline and soda
hose-in-the-nose-- $2.50
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Step 1
Immunotherapy
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step 3
Environmental control
Normal saline irrigation
NSA+/- decongestant
High-dose nasal steroid
Afrin 3 days or fewer
Oral steroid
Immunotherapy
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Environmental Control/Avoidance
Dust mites
Controls: plastic covers, frequent vacuuming of carpet
Avoid: overstuffed chairs, curtains, stuffed animals, dust-collecting
boxes under bed
Cockroaches
Poisoning
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Environmental Control
Air conditioning
Frequent dusting, cleaning surfaces
Air filters
Hepa filtration
Vacuum cleaners
Dry versus water filtration
Ionizers
Wood burning stoves
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Pharmacotherapy
Allergic rhinitis
Antihistamines
OTC
Nonsedating
Nonallergic rhinitis
Antihistamines
Drying effect
Decongestants
Nasal steroids
Astelazine
Nasal cromolyn
Ipatropium
Nasal steroids
Decongestants
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NARES syndrome
Nasal Steroids
Flonase
Beconase
Nasonex
Nasacort
Rhinocort
Vancenase
Tri-Nasal
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Sneezing
Discharge
Itch
Congestion
Side effects
+++
+++
+++
+++
+++
+++
++
++
+
+++
+++
+
+
+++
to +
to +
++
+++
+ to ++
++
+++
++++
+++
+++
+ to ++
+
+++
++++
+++
+++
+ to ++
+
+++
++++
+++
+++
++
+
+++
++++
+++
++
to +
+
+
+ to ++
* = Presumed; no data on individual symptoms Nayak AS, et al. Ann Allergy Asthma Immunol.
2002;88:592-600. ++++ = Strongly positive effect; + = Minimal effect
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Nonallergic Rhinitis
As important as allergic rhinitis
Present in 57% of patients with rhinitis
66
Nonallergic/Vasomotor Rhinitis
Perennial or episodic symptoms
Chronic, nonpruritic rhinorrhea/congestion
Negative nasal eosinophils
Negative allergy screening
Nonallergic excitants
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Viruses
Chemicals, tobacco smoke, potpourri
Nonallergic foods
Weather changes
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Rhinitis Medicamentosa
Rebound congestion from overuse of topical
decongestants; oxymetazolone, phenylephrine, cocaine
Erythematous mucosa, congestion, punctate bleeding
Interstitial edema and vasoconstriction
Withdrawal of medication, topical steroids, oral steroids
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Aldomet
Minipres
Cardura
Moduretic
Catapres
Normodyne
Corgard
Trandate
Hytrin
Viagra
Ismelin
Wytensin
Puberty
Oral contraceptives
Hypothyroid state
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Rhinitis of Pregnancy
Mild symptoms may have been present before (pregnancy
aggravated symptoms)
Increase in circulating blood volume
Progesterone induced smooth muscle relaxation
Hormonal effect on nasal mucosa
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NARES Syndrome
Nasal smear revealed marked eosinophilia
Diagnosis: NARES syndrome nonallergic rhinitis with
eosinophilia
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NARES Syndrome
Perennial symptoms
Sneezing
Rhinorrhea
Pruritis
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Diagnosis?
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Occupational Rhinitis
Patients experience symptoms in workplace
Symptoms improve on weekends/vacation
May be allergic or nonallergic
May coexist with occupational asthma
Treatment is avoidance
Move to another area in the workplace
Move to another job
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Perfumes
Paints, carpet, carpet glue
Laboratory animals
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Beauty salons
Tanneries
Clothing stores
Paper industry
Supermarkets
Gardening products
Insecticides
Service stations
Food industry
Woodworking
Laboratory animals
Pesticide industry
Office machinery
Plastic manufacturing
Paints, chemicals
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Gasoline/diesel fuels
Chlorine
Perfumes
Cleaning agents
Room deodorizers
Hair dyes
Permanent solutions
Paints
Auto body paints
Herbicides
Potpourri
Burning candles
Petroleum products
Formaldehyde
New clothing odor
Hair spray
Toluene
Ammonia
Acids
Meningocoele
Nasal polyps
Adenoid hypertrophy
Foreign body
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Concha bullosa
Gustatory Rhinitis
Rhinorrhea and/or nasal congestion related to eating
Treatment is identification and elimination
Common causes of gustatory rhinitis
Wines
Cheeses
Spicy foods
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Food Reactions
Diagnosed by skin prick tests, RAST or elimination diet
Skin prick tests, in-vitro testing will only diagnose
IgE-related foods
Elimination diet will diagnose all types adverse food reactions
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Pharmacotherapy
Allergic rhinitis
Antihistamines
OTC
Nonsedating
Antihistamines
Drying effect
Decongestants
Nasal steroids
Astelazine
Nasal cromolyn
Ipatropium
Nasal steroids
Decongestants
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Nonallergic rhinitis
NARES syndrome
Saline sprays
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Nasal Polyps
Grape-like clusters
Maxillary sinus
Inflammatory process
One third associated with asthma
Asthma-aspirin-polyp triad
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Nasal Polyps
Allergy control
Intranasal steroids
Systemic steroids
Avoidance of ASA, NSAIDs
Polypectomy
Ethmoidectomy
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Cardiac problems
History of hymenoptera sensitivity
History of anaphylaxis of any kind
Shellfish
Medications
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Refer to an Allergist
Hymenoptera sensitivities
Antibiotic desensitization
Anesthetic testing
Patients with history of anaphylaxis
Medication
Shellfish
Peanut or other food reactions
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Invitro tests
Modified in-vitro testing
CAP system
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Patient discomfort
Rare possibility of anaphylaxis
Dermagraphism
Chronic skin disorders
Very young and atrophic skin
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Puncture/Prick Testing
Disease-free site
Swipe with alcohol
Apply drop of antigen
(1:10 or 1:20 conc.)
Prick skin at 45 to 60 degree
angle, or puncture at 90 degrees
Gently lift device, no bleeding
should occur
Read positive control in
10 minutes
Read allergens in 15-20 minutes
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Figure 1
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Example of multiple-puncture
device allowing simultaneous
placement of six allergens plus a
positive and negative control
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contd
Figure 3
Example of multiple-puncture
device in its loading dock
Example of application of a
multiple-puncture
device to the forearm
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contd
Figure 5
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Grading of MultiTest
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No reaction-1-3 mm wheal
1+
2+
3+
4+
5+
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In-Vitro Testing
Reference laboratory
Many available
In-office labs
Weigh expense involved
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RAST Procedure
Allergen coupled to paper disc
Add patients serum
Antigen-antibody complex formed
Radioactive anti IgE added
Anti IgE-antibody-allergen complex formed
Gamma counter scoring
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RAST Scoring
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Class 0
200-500
No allergy
Class 0/1
500-750
Questionable allergy
Class 1
750-1,600
Mild allergy
Class 2
1,600-3,600
Moderate allergy
Class 3
3,600-8,000
More allergic
Class 4
8,000-18,000
More allergic
Class 5
Over 18,000
Most allergic
Advantages of In-Vitro
Patient safety, no anaphylaxis
Cost-effective screening
Not affected by medication
No irritating skin reactions
Sets safe starting doses for immunotherapy
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Disadvantages of In-Vitro
Patient does not experience the reaction
Less sensitive than skin tests (?)
Cost per test may be higher
RAST requires 3-14 days to get results
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Allergy Screening
A most cost effective test to do!
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Allergy Screening
Use of 6-10 antigens to determine the presence or absence
of allergy
Prevalence of sensitization
Same allergens common to patients in a geographic area
Incidence varies from 20% to 80% per antigen
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References
Nalebuff, DJ. Use of RAST screening in clinical allergy: a
cost-effective approach to patient care. Ear Nose Throat J.
1985; 64:107-21.
Blok et al. Reported use of 5 antigen screens. Allergy. 1991
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Negative control
Positive control
Weed (ragweed)
Grass (June)
Mold (alternaria)
Cat
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Interpretation of Screen
All tests negative (except positive control) no allergy is
present
Positive control and all other test sites negative,
hypoactive skin, proceed with in-vitro test
Any grass, tree, weed or mold positive
panel
House dust mite only positive
Cat only positive
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avoidance
complete allergy
avoidance
Advantages of Screen
Identifies the allergic and nonallergic
Eliminates need for unnecessary testing of nonallergic patients
Helps direct pharmacotherapy
Demonstrates antigens needing avoidance
Cost-effective, reliable
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Cross-Reacting Pollens
June: rye, sweet vernal, timothy, brome, red top
Oak tree species
Hickory and pecan trees
Ragweed species
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Bibliography
The Allergy Report. American Academy of Allergy,
Asthma and Immunology, Milwaukee, WI: 2000. Available
at www.aaaai.org.
Middleton E, et al. Allergy: principles and practices 5th ed.
St. Louis, Mosby: 1998.
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Bibliography
Altman LC, Becker JW, Williams PV. Allergy in Primary Care.
Philadelphia: Saunders; 2000.
Squillace S, Hedges H. Asthma, allergic rhinitis and
immunotherapy. American Academy of Family Physicians;
1998.
Kaliner MA, ed. Current reviews of rhinitis. Curr Med; 2002.
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Evidence-Based Recommendations
Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis
with prophylactic medications (antihistamines and/or intranasal corticosteroids).
Practice Recommendation: Prescribe intranasal corticosteroids to control allergic
rhinitis symptoms.
Practice Recommendation: Educate patients with allergic rhinitis about avoidance
activities.
Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis
for whom optimal avoidance measures and medication therapy are insufficient to
control symptoms.
All recommendations available at: http://www.icsi.org/knowledge/detail.asp?
catID=29&itemID=158.
Accessed August 2003.
001903
Thank You
This has been a presentation of the
American Academy of Family Physicians
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