Rhinitis
 

What are your thoughts on rhinitis and what do you use to treat it?

I would like to hear the good, bad, and ugly.

Doc

Any comments on the "one airway, one disease" correlation with asthma and rhinitis?

:munchin

I'd be hesitant to say one airway one disease. Rhinitis is an upper airway issue where asthma is an issue below the carina. Oh well, off to medline to get data to either support or refute my position

There are 751 hits on medline. One common theme I kept coming across though was allergic rhinitis as a comorbidity for asthma. I'm still not convinced the two are directly associated yet. It's getting late, so I'll do the statistics tomorrow if anyone is interested.

Erik

Please

After digging through the data, I've come across what's called the integrated airway hypothesis (what Doc referred to as one airway one disease) A study from the Allergy and Asthma Medical Group and Research Center showed by doing a metanalysis of several studies that 19 to 38 percent of patietns with rhinitis also have asthma.

The belief is that local inflammation in the upper airways by an allergen also causes inflammation in the lower airways leading to worsening of asthma. The same metanalysis of the data showed a moderate improvement in asthma symptoms in those who had their allergic rhinitis appropriately treated.

I learn something new everyday!!!!!
Erik

Based on my own experience, I believe that rhinitis exacerbates asthmatic symptoms. I have very mild asthma which is principally (and only occasionally) induced by strenuous exercise, and I have severe allergies which have been controlled through shots. I also use Rhinocort and have HEPA filters in the house because we have cats and I am allergic to them. Had a bad allergy attack in Oregon (probably from Juniper), and needed Ventolin . . .

:munchin

That's close to what I'm reading/seeing in the clinics too. Approx. 38% of rhinitis patients have asthma and approx. 75% of asthma patients have rhinitis according to what study you read.


:cool:

For both rhinitis and asthma we use low dose corticosteroids to reduce inflammation, the leading culprit in both disease processes. Problem is, patient compliance can be an issue. Patients take medicine, symptoms improve, patient forgets to take medicine and symptoms re-occur. While this isn't really bad for a rhinitis patient, it can be really bad for an asthma patient when they have an exacerbation.

Does anyone know what an asthma medicine holiday is?

Exercise is the number one "trigger" of an exacerbation.

It sounds like you have perennial allergic rhinitis which is a year round condition. Rhinocort is a good medicine for a variety of reasons; it has a low volume of spray compared to the competition, no alcohol or perfume additives and a nice safety factor.

Hepa filters are good too IMHO.

My ENT feels very strongly that the Ionic Breeze and similar machines are horrible for allergy sufferers. They magnetize particles, which causes them to stick to anything -- not just the collector tray, but also the inside of your nose.

The Ionic Breeze produce(s)(d) ozone which irritates mucosal tissue, hence the need for the ozone filter which they currently use to correct that problem.

You are on the right path with the HEPA filters from what I'm being told.

You might be better off to keep pets out of the bedroom and make it a "trigger" resistant sleeping room. I have two cats too btw.

You obviously have not met Catwoman. One of the cats sleeps next to my head. :boohoo

Understood.

Does anyone have a preference for what inhaled nasal spray they use and/or prescribe???

:munchin

Doc based on the recommendation from someone here I've used Afrin Sinus, found it very effective. I don't have to use it very often however.

Doc,
Sir, I use two different ones depending on how bad off the patient is. Bear in mind I can only give what my preceptor will allow me to, so sometimes that ties my hands, but very rarely. For just a straight decongestant I reach of Genasal with VERY detailed instructions to only to take it for three days. I've never had a patient have a "rebound" reaction to it, but I am told it's bad. Has anyone seen this? Why give Goldline Genasal instead of Afrin brand? My pharmacy stocks one and not the other, that's the only reason.
If I suspect allergies to be the cause then I reach for Flonase. Again I talk the patient to death about how long it takes for this stuff to kick in and to stick with it. I've had patients go as long as a week before they saw any effects. Consequently I tell the patient not to take it just on the days they think they need it, but for the whole allergy season so the levels stay up in their system. That piggybacks on regime compliance that you mentioned. I’m a really simple person, I like simple solutions. A GYN doc told me one time that she tells her patients to attach their BCP’s to their toothbrush with a rubber band. As long as the patient brushes their teeth everyday they will “remember” to take their BCP’s. I like it, I’ll steal it. I tell my allergic rhinitis patients to do the same with the bottle of corticosteroid. It’s hard to grab a toothbrush with a bottle attached to it and not remember why it’s there. :D
Are there faster acting corticosteroids out there that would be suitable for allergies? Time for me to call my pharmacy and look it up on-line. I don’t run across many drug reps out here in the woods.

Edited--because I can't spell. . .

1. Inhaled corticosteroids (ICSs) may take anywhere from a couple of days to a couple of weeks to exert their total therapuetic effect on a patient. That is why you need to find out the answer to number 2 down below. If you know for instance that a certain allergen that the patient is allergic to is coming on in April, the patient should start taking his meds a couple of weeks prior to that; say March 15th.

I think ICSs do a better job of taking on the underlying cause of rhinnitis which is inflammation than the other preparations out there.

2. I would send my guy with rhinnitis to an allergy clinic to find out what he is allergic to. Could immunology play a role in treatment?

3. If you have those two pieces of information, you can devise a long term treatment plan that he can understand and implement.

Patient compliance has always been an issue and your idea of attaching the medicine to a tooth brush could work. I would still keep an eye on him to make sure he's taking his meds.


Hope this helps,

Doc

I couldn't agree more. A little planning can do wonders.

Absolutely. I can think of no reason why is shouldn't play a role. Yes, ICS will take down the inflammation, as you said, and why not get the body to stop freaking out about the allergen in the first place. I can't remember the exact phrasing but I remember hearing, "Give them just enough medicine that their own body can take over and heal itself." in IDMT school. With a course of allergy shots wouldn't we be setting the patient's body up to take care of itself in the future?

I have a few "fire and forget" patients but the majority of mine need a little help now and again. The advantage I have is with such a small patient population I am GOING to see them again outside the clinic. :D Thanks for the help, Doc.

I got sensitized to something in all of my travels and it finally hit me when I went to live in FWTX after getting out of SF. Nothing worked properly - I tried Rhinocort, Afrin, Claritin... all the prescription stuff, until I started using a normal saline spray, that was pH balanced - it just got rid of the little nasties in the air. My.02 from experience.

I apologize for resuscitating such an old thread but I have a question that I can't seem to find an answer to anywhere. I was wondering if there was any possibility for someone in the 18x pipeline to get immunotherapy.

I may be simplistic but I reserve nasal steroids as a last line treatment. I used to think, steroids were wonderful. The longer I’m in the business, the less I like them. Steroids are steroids, whatever the form.

I deal with AR a lot in my practice. When I tell them it’s AR, they look horrified and cry, “But I’ve NEVER had allergies before.” All are from other places than AZ. I tell them, “You never have allergies until you have allergies. Just like you never have a heart attack until you have a heart attack.”

I treat with the second generation antihistamines first if nasal lavage has failed. I give them a list of the top three with instructions to buy the 5 pack to try as some react or don’t react based on their body chemistry. If the fail all, I suggest diphenhydramine 25mg TABLETS cut into quarters. 1 quarter q 3hrs to effect. This, in theory, gives the patient the antihistamine effect without or less drowsiness.

Then it’s nasal steroids.

I used to use kenalog IM, but have stopped due to the, what I call the “bullet effect”. If they have a bad reaction, you can’t just stop the medication as with tablets. They are going to ride it out or go to the ER.

If the Pt. is absolutely miserable and puffy eyed, clear mucous running out their nares, I’ll give them a burst dose of prednisone 20mg-50mg for 5 days.

Is any of this backed by literature, nope.

Aside from the proposal for OTC rinses, that goes almost the opposite direction of my practice - topical (nonabsorbable) steroids to the nasal mucosa is extremely effective in treating the symptoms without any systemic effects of steroids (immunosuppression, hyperglycemia, hypertension, and with long-term use, osteopenia/avascular necrosis) or other systemic effects of oral/injected medications.

If symptoms are disruptive to sleep, I recommend a trial of benadryl at night time given its propensity for making people sleepy. Leukotriene inhibitors (e.g.g montelukast) can be additive, but typically is more than is needed for rhinitis.

Systemic steroids is typically a last resort for me, whether they be oral prednisolone/methylprednisolone, IM kenolog, or any other systemic formulation/route of administration. Given the risk of both long and short term toxicities.

Thank you both for your replies and recommendations. I have been looking into getting immunotherapy. It is a concentration of what you are allergic to (molds in my case) and administered via syringe just under the skin in the elbow or drops under the tongue over the period of a few years. It is supposed to make your body stop looking at the allergen as a foreign invader thus no longer reacting to it. Some people can be allergy free for a decade and for some I hear they are actually cured of their allergies. At the moment I am not taking any medication, but in the past I tried a nasal spray that I think was a glucocorticoid and antihistamine combination that seemed to work very well. I can't remember what it was called and I am not sure if it would have any negative long term effects.