The Curbsiders podcast

#447 Rhinitis and Environmental Allergies with Dr. Olajumoke Fadugba

July 8, 2024 | By

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Elevate your rhinitis management!

Learn from expert allergist Dr. Olajumoke Fadugba about rhinitis and environmental allergies. You’ll review how to distinguish between allergic and non-allergic rhinitis, and how to decode the drugstore allergy aisle for your patients!

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Show Segments

  • Intro
  • Rapid Fire Questions
  • Case Part 1
  • Allergic vs Non-Allergic Rhinitis
  • The Rhinitis History and Physical
  • Allergy skin testing
  • The Pathophysiology of Allergies
  • Oral, intranasal and ocular treatments
  • Case Part 2
  • Allergy immunotherapy
  • Chronic sinusitis
  • Sinus rinses
  • Climate Change and Allergies
  • Outro

Rhinitis and Seasonal Allergies Pearls

  1. Understanding the differences between allergic and non-allergic rhinitis is crucial for effective diagnosis and treatment.
  2. Both allergic and non-allergic rhinitis can be seasonal, but for different reasons. Allergic rhinitis can be seasonal due to variations in pollen levels. Non-allergic rhinitis can be seasonal due to temperature/barometric changes.
  3. Intranasal corticosteroids and antihistamines are useful for both allergic and non-allergic rhinitis. Oral antihistamines and ocular antihistamines can be used as adjunctive therapy for allergic rhinitis.
  4. Proper patient education on the use of nasal sprays and the importance of regular use is essential for successful management of rhinitis. If you taste it you waste it!
  5. Nasal irrigation with saline rinses can be effective in reducing symptoms of rhinitis.
  6. Allergy testing and allergy shots can be considered for evaluation and management of severe and difficult to control environmental allergies and allergic rhinitis.
  7. Climate change and pollution have increased the prevalence and severity of seasonal allergies and rhinitis.

Rhinitis and Allergies

Allergic vs Non-Allergic Rhinitis: Definitions & Classification

Important historical elements to elicit include (Bernstein 2024): 

  • Onset: later adulthood suggests non-allergic rhinitis, though allergies can be developed in adulthood
  • Timing: seasonal or perennial
  • Triggers: particular season, weather/temperature change, strong fragrances/smells/fumes, exposures (pets, carpeting, visible mold)
  • Symptoms: more common in allergic rhinitis include sneezing, ocular/nasal pruritus, sinus pressure/pain/hyposmia, and atopic symptoms (eczema and asthma). Non-allergic and allergic rhinitis can both have post-nasal drip, rhinorrhea, and nasal congestion. Understanding symptoms helps clarify diagnosis and treatment plan
  • History is more important than skin testing! 

A focused oral/nasal physical exam is helpful for diagnosis. Look for post-nasal drip, cobblestoning, inflamed turbinates, pale/edematous turbinates, polyps

Dr. Fadugba recommends that Instead of calling everything “allergic rhinitis”, consider “chronic rhinitis” if you aren’t sure of the diagnosis!

Non-Allergic Rhinitis

30-40% with rhinitis have NON-allergic rhinitis. It is more common if the onset is in later adulthood. This is a diagnosis for exclusion, so you should have evaluated for allergies. Typical is the ABSENCE of allergy symptoms like ocular itching and sneezing but PRESENCE of rhinorrhea, congestion and/or post-nasal drip.

 Vasomotor rhinitis

  • This is the most common non-allergic rhinitis
  • Triggers can be weather/season changes due to barometric pressure/temperature changes (which can be confusing because you think it is seasonal!) and strong fragrances/smells/fumes.
  • Pathophysiology: imbalance in the parasympathetic/sympathetic input to the nose/sinuses. Explain to patients that this is a “migraine” of the sinuses”

Gustatory rhinitis

  • Rhinorrhea with eating

 Medication-induced rhinitis

  • Drug examples: estrogen/progesterone, erectile dysfunction meds, anti-hypertensives (eg vasodilators)
  • Example: acute onset in older man who just start an ED medication

 Mixed rhinitis

  • Multiple types of rhinitis eg vasomotor PLUS allergic rhinitis

 How to break the news to a patient that they *don’t* have allergic rhinitis

Yes, you have rhinitis that is seasonal, but it is not mediated by IgE (the allergic immune system) and histamine (therefore you do not need antihistamines or immunotherapy).


The Pathophysiology of Environmental Allergies

The players: IgE, mast cells, histamine and other mediators (leukotrienes, prostaglandins, cytokines)

The why: not clear yet why some are susceptible to allergies and others are not

The how: repeatedly exposed to an antigen (eg birch tree pollen). At some point, they will start making excess IgE to birch tree pollen, which then binds to receptors on mast cells (which live on skin, upper/lower respiratory tract, and GI tract). At some (unknown) threshold, when they have another antigen exposure, the receptors on the surface of the mast cells cause degranulation and mediators such as histamine, leukotrienes, prostaglandins, cytokines. These mediators cause the allergy symptoms (Bernstein 2024).

Allergy testing

Test for cats, dogs, dust mites, mold and pollens (tree, weed, grass), mouch, cockroach

Procedure: 

  1. Patient stops all antihistamines for 5 days before the procedure
  2. percutaneous prick of forearm with liquid extracts of allergen as well as a positive (histamine) and negative (saline) control
  3. 15 min later, the response is evaluated– If there is an allergen specific IgE, reaction will be a wheal with erythema. The wheel and erythema size will be measured. If the wheal is 3mm greater than the negative control, this is a positive result. 
  4. If they respond to the negative control, the test is invalid (and suggests dermatographia). If they do not respond to the histamine control, the test is also invalid.

If positive: discuss avoidance measures, though usually difficult to fully avoid allergens, with the exception of pets (if they are willing to remove their pet…)

Treatment of environmental allergies and associated symptoms as well as non-allergic rhinitis (the treatments overlap!)

  1. Avoidance measures: either eliminate or reduce antigens as much as possible (eg if you don’t want to get rid of cat, don’t let them sleep in your room). Keep windows closed during high pollen periods.
  2. Environmental treatment: purchase a HEPA filter and vacuum with HEPA filter. Purchase dust mite covers for bed/pillow cases
  3. Intranasal and oral medications: pick the cheapest one, try to prescribe (even OTC) in case insurance covers
    1. Intranasal corticosteroids: first line for all forms of rhinitis. These are more effective than oral antihistamines for allergic rhinitis! Make sure to counsel patients that this is a preventative therapy and anti-inflammatory–it takes time to work. Technique is CRITICAL! Advise the patient to bend forward, put nozzle in nose, spray ipsilaterally toward direction of outer eye, take light sniff like smelling a flower. Very little should go down the throat–”if you taste it you waste it!”. Examples include fluticasone (which can have a bothersome flowery smell), mometasone, budesonide and triamcinolone.
    2. Intranasal antihistamines: add on if intranasal corticosteroids are not adequate. Can be effective in non-allergic rhinitis as well. Examples include azelastine (now over the counter) and olopatadine. 
    3. Combination intranasal corticosteroid/antihistamine: azelastine/fluticasone, may be hard to get covered by insurance.
    4. Oral antihistamine: should be used only for allergic rhinitis. Choose a second-generation antihistamine (less sedating than first-generation antihistamine like diphenhydramine). Can double the dose of antihistamines at night if a single dose is not effective. Examples include loratadine (least potent), desloratadine, cetirizine (more sedating), levocetirizine, and fexofenadine (least sedating/least cholinergic effects).
    5. Ocular antihistamine: if ocular symptoms like itching/redness, drops such as olopatadine, cetirizine and azelastine are more effective than oral antihistamines for these symptoms..
    6. Other treatments include ipratropium (beneficial with rhinorrhea), cromolyn (a mast cell stabilizer beneficial when an antigen exposure is anticipated), oxymetazoline (a very effective vasoconstrictor that immediately reverses nasal congestion, however should not be used more than a few days due to the risks of rebound congestion), and montelukast (a leukotriene inhibitor that can be used if co-morbid asthma, but caution about neuropsychiatric effects)
  4. Immunotherapy (“allergy shots”): for highly motivated patients with allergies such as from pollen and animals, immunotherapy is an effective option. The treatment is time intensive. It involves injecting a small amount of allergen intradermally, slowly increasing the antigen dose in regular intervals (e.g. weekly initially), and when the maintenance dose is reached the treatment becomes monthly. The full duration of therapy is typically 3-5 years. . Oral immunotherapy is available for grass, dust mites and ragweed.

Read Bernstein et al’s incredible review in JAMA on allergic rhinitis for more high yield information!

Chronic Sinusitis

Chronic sinusitis can be a feature of allergic rhinitis. Alongside treatment as above, saline irrigation of the sinuses are very effective in reducing associated symptoms from environmental allergies. Before ordering imaging and referring to ENT– get the sinuses as good as you can with an aggressive regimen!


Patients can make their own sinus rinse solution (non-iodized salt and baking soda in a 3:1 ratio with distilled water) or purchase pre-made solutions, using devices such as Neti Pot, NeilMed or Navage. Watto recommends sending patients the “how to” video on YouTube from Dr. Adappa and Dr. Palmer!

Climate change

Seasonal allergies ARE getting worse with climate change– the pollen season starts earlier and lasts longer due to longer growing seasons. Pollen is also more allergenic because of the effect of climate change on how pollen is dispersed. Increased particulate matter (pollution), including from wildfires partially caused by climate change, are irritants that trigger asthma and rhinitis (D’Amato 2020, NYT 2024).

Links

  1. Bernstein JA, Bernstein JS, Makol R, Ward S. Allergic Rhinitis: A Review. JAMA. 2024 Mar 12;331(10):866-877. doi: 10.1001/jama.2024.0530. PMID: 38470381.
  2. Spring Allergy Season Is Getting Worse. Here’s What to Know (NYT).
  3. American College of Allergy Asthma & Immunology Seasonal Allergies info

Goal

Listeners will level up their management of rhinitis and environmental allergies.

Learning objectives

  1. Learn to differentiate between allergic and non-allergic rhinitis
  2. Recognize the most common sequelae and co-morbidities of environmental allergies: allergic rhinitis, conjunctivitis, chronic sinusitis, asthma, atopic dermatitis.
  3. Develop a framework for initial outpatient management of allergic and non-allergic rhinitis as well as practical patient education tips
  4. Prepare to manage refractory environmental allergy symptoms including when to refer to an allergy specialist for skin testing and/or immunotherapy

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Witt LJ, Olajumoke F,, Williams PN, Watto MF. #447 Rhinitis and Environmental Allergies”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast July 1, 2024.

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Episode Credits

Producer: Leah Witt, MD & Matthew Watto MD
Writer, Show Notes, Infographic, and Cover Art: Leah Witt, MD
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Sai S Achi, MD MBA
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Olajumoke Fadugba MD

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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