Physician's Weekly Article - Improving Patient Care for Rhinitis

       A practical guide for the diagnosis and management of rhinitis has been released, highlighting recent developments and aiding clinicians in managing the condition.

      Rhinitis is a disease characterized by symptoms of a runny nose, nasal congestion, sneezing, and an itching nose that affects most Americans. Although it is typically easy for clinicians to diagnose, determining the type of rhinitis—a critical aspect of managing the disease—can be challenging.

      To help clinicians better manage the various types of rhinitis that may be encountered, the Joint Task Force of Practice Parameters, composed of representatives from the American Academy of Allergy, Asthma, & Immunology, the American College of Asthma, Allergy, & Immunology, and the Joint Council of Asthma, Allergy, & Immunology, recently updated its rhinitis practice parameter. Published in the August 2008 Journal of Allergy and Clinical Immunology, the parameter provides physicians with comprehensive recommendations for the management of the most common categories of rhinitis. “Many new medications and several new diagnostic procedures have become available since the rhinitis practice parameter was published in 1998,” says Dana V. Wallace, MD, PA, chief editor of the new parameters. “Thus, there was a need to bring new information to the forefront for all physicians who treat rhinitis.”

      Determining the Type of Rhinitis

      The rhinitis parameter features a diagnostic algorithm to help clinicians determine the type of rhinitis that is present (Figure). Established types of rhinitis include infectious, seasonal, perennial, and non-allergic rhinitis. A greater emphasis has been placed on allergic rhinitis (AR), and the parameters introduce a new subcategory called episodic AR, which is neither seasonal nor perennial. Rather, episodic AR is triggered by periodic exposure to an allergen; it requires a modified treatment plan. “The physical exam, contrary to popular belief, may not be helpful in determining the type of rhinitis because there are no distinguishing findings that will establish the diagnosis of allergic or non-allergic rhinitis,” explains Dr. Wallace. “Nasal problems such as a deviated septum, ciliary dyskinesia, and nasal polyps may mimic rhinitis but aren’t truly rhinitis. A diagnosis of AR requires a detailed patient history in which clinicians must correlate environmental exposures with rhinitis symptoms. To confirm the specific allergen responsible for AR symptoms, physicians often need to perform allergy skin testing or obtain blood tests that show the presence of a specific allergen.”

      The most important new recommendation, according to Dr. Wallace, is for clinicians to keep in mind that patients with AR have a high incidence of comorbid conditions such as asthma and chronic sinusitis. “Use of pulmonary function studies is encouraged when there are symptoms (eg, unexplained cough or chest tightness) suggesting that patients may be developing asthma. Additionally, the sinus CT scan continues to be the gold standard for diagnosing chronic sinusitis when this comorbid condition requires confirmation.”

      Current & New Treatment Options

      Several new treatments have emerged for rhinitis, including topical intranasal antihistamines, which appear to be as or more effective than oral antihistamines. These agents also appear to work more rapidly and help reduce congestion. Second generation oral antihistamines and intranasal steroids have become available since 1998, and there is now more evidence to show the positioning of leukotriene receptor antagonists in the treatment of AR, Dr. Wallace says. “The parameter does not identify any one drug as first-line therapy, but maintains that many of these agents can be used for mild and moderate-to-severe rhinitis. While intermittent use of these agents may be effective in mild and controlled AR, these therapies may be required on a daily basis initially when symptoms are more persistent and severe.”

      Another key update to the parameters is the fact that most medications can be used in children. Intranasal steroids have been approved for children as young as age 2, and oral antihistamines and leukotriene antagonists are approved for children as young as 6 months. “When used in recommended doses,” says Dr. Wallace, “the intranasal steroids appear to be safe and don’t cause adrenal suppression or interfere with long-term growth, but physicians should continue to closely monitor height.” The parameters note that use of sedating antihistamines and decongestants are discouraged in young children, especially below the age of 2, for treating cough and nasal symptoms of the common cold.

      Continual Management Required

      An individualized strategy that focuses on patient education is important in the management of AR (Table), a condition for which there is no cure. The rhinitis practice parameter notes that several safe and effective oral and topical medications are available and should be combined with environmental control measures. “A new Rhinitis Action Plan has been introduced to assist clinicians in educating patients,” says Dr. Wallace. “When medications are discontinued, the symptoms often return. Immunotherapy, often referred to as allergy injections, should be used in appropriately selected patients and administered in appropriate doses. It can control AR and help prevent the possible progression of AR to asthma.”

      Dana V. Wallace, MD, PA, has indicated to Physician’s Weekly that she is on the speakers’ bureau for Schering-Plough, Aventis, Pfizer, and Merck and is on the advisory board for AstraZeneca.