1. Management of Rhinitis in Patients with Asthma Michael Schatz, MD, MS Chief, Department of Allergy Kaiser Permanente, San Diego, CA

2. Rhinitis is a trivial illness. All rhinitis is allergic. All non-allergic rhinitis is homogeneous. Some Misconceptions About Rhinitis

3. Outline of Presentation Practical classification of chronic rhinitis Diagnostic approach in primary care Specific syndromes Distinguishing features Treatment

4. Practical Classification Allergic Rhinitis Allergic Rhinitis Seasonal versus Perennial Seasonal versus Perennial Frequency Frequency Persistent (> 4 days/week for > 4 weeks/year) Persistent (> 4 days/week for > 4 weeks/year) Intermittent (less than above) Intermittent (less than above) Severity Severity Mild Mild Moderate-severe (interference with sleep or daily activities or “troublesome symptoms”) Moderate-severe (interference with sleep or daily activities or “troublesome symptoms”) Other Other

5. Practical Classification: Other Other Other Rhinitis medicamentosa Rhinitis medicamentosa Septal deviation Septal deviation Eosinophilic non-allergic rhinitis Eosinophilic non-allergic rhinitis Nasal polyps Nasal polyps Cholinergic rhinitis Cholinergic rhinitis Vasomotor rhinitis Vasomotor rhinitis GERD induced “post nasal drip” GERD induced “post nasal drip” Turbinate hypertrophy Turbinate hypertrophy Chronic sinusitis Chronic sinusitis

6. Practical Classification: Asthmatic Patient Other Other Rhinitis medicamentosa Rhinitis medicamentosa Septal deviation Septal deviation Eosinophilic non-allergic rhinitis Eosinophilic non-allergic rhinitis Nasal polyps Nasal polyps Cholinergic rhinitis Cholinergic rhinitis Vasomotor rhinitis Vasomotor rhinitis GERD induced “post nasal drip” GERD induced “post nasal drip” Turbinate hypertrophy Turbinate hypertrophy Chronic sinusitis Chronic sinusitis

7. 1.History 2.Physical Exam 3.Tests Chronic Rhinitis: Diagnostic Approach

8. Chronic Rhinitis: Diagnostic Tests Nasal smear (eosinophilic disease) Nasal smear (eosinophilic disease) Specific IgE (allergic versus non-allergic) Specific IgE (allergic versus non-allergic) Skin tests Skin tests RAST (blood tests) RAST (blood tests) Total IgE (AFS) Total IgE (AFS) Immunoglobulins G, A, M (hypogammaglobulinemia with chronic sinusitis) Immunoglobulins G, A, M (hypogammaglobulinemia with chronic sinusitis) Fungal precipitating antibody Fungal precipitating antibody Sinus radiology Sinus radiology

9. Skin Tests versus Blood Tests Skin Tests Skin Tests Time-honored method Time-honored method Results immediately available Results immediately available More sensitive for some allergens or patients More sensitive for some allergens or patients Potential for systemic reactions Potential for systemic reactions Antihistamines interfere Antihistamines interfere Blood tests Blood tests Easier for patient Easier for patient May be more specific May be more specific No interference by medications or potential for systemic reactions No interference by medications or potential for systemic reactions

10. Outline of Presentation Practical classification of chronic rhinitis Diagnostic approach in primary care Specific syndromes Distinguishing features Treatment

11. Allergic Rhinitis Distinguishing Features Distinguishing Features Sneezing, itching, rhinorrhea prominent Sneezing, itching, rhinorrhea prominent May be seasonal May be seasonal Triggered by freshly cut grass, cleaning house, or pet exposure Triggered by freshly cut grass, cleaning house, or pet exposure Treatment Treatment Indoor allergen avoidance Indoor allergen avoidance Intermittent: Antihistamines, intranasal corticosteroids (INS) as needed Intermittent: Antihistamines, intranasal corticosteroids (INS) as needed Persistent: Regular INS; add antihistamines (oral and/or intranasal) and montelukast if needed) Persistent: Regular INS; add antihistamines (oral and/or intranasal) and montelukast if needed) Consider immunotherapy Consider immunotherapy

12. Immunotherapy Consider for patients with definite allergic rhinitis not controlled by other means Consider for patients with definite allergic rhinitis not controlled by other means Because of potentially life-threatening allergic reaction, it should be carried out only by specialists trained in its use Because of potentially life-threatening allergic reaction, it should be carried out only by specialists trained in its use Goal: symptom and/or medication reduction, not usually eradication or cure Goal: symptom and/or medication reduction, not usually eradication or cure

13. Immunotherapy 2 Used less for rhinitis now than it used to be due to better medications Used less for rhinitis now than it used to be due to better medications Less effectiveness data for mold and animal dander Less effectiveness data for mold and animal dander One year trial One year trial If effective, continue for 3-5 years and then consider discontinuation If effective, continue for 3-5 years and then consider discontinuation Sublingual immunotherapy (SLIT) now being studied Sublingual immunotherapy (SLIT) now being studied

14. Eosinophilic Non-Allergic Rhinitis Distinguishing features Distinguishing features Prominent mucosal edema Prominent mucosal edema Nasal eosinophilia Nasal eosinophilia No relevant allergy No relevant allergy Treatment Treatment Intranasal corticosteroids Intranasal corticosteroids Oral antihistamine or antihistamine-decongestant combination if needed Oral antihistamine or antihistamine-decongestant combination if needed Oral prednisone for recalcitrant disease Oral prednisone for recalcitrant disease

15. Nasal Polyps Distinguishing Features Distinguishing Features Nasal obstruction Nasal obstruction Anosmia Anosmia Nasal polyps on exam Nasal polyps on exam Treatment Treatment Intranasal corticosteroids Intranasal corticosteroids Course of doxycycline (20 days) Course of doxycycline (20 days) Oral corticosteroids Oral corticosteroids Treatment of complicating infection Treatment of complicating infection Consider montelukast Consider montelukast Surgery (polyp, sinus) Surgery (polyp, sinus)

16. GERD Induced “Post Nasal Drip” Distinguishing features Distinguishing features Feeling of post-nasal drip or mucus in throat with minimal or no other nasal symptoms Feeling of post-nasal drip or mucus in throat with minimal or no other nasal symptoms May be associated with hoarseness, throat clearing, cough, pyrosis, regurgitation May be associated with hoarseness, throat clearing, cough, pyrosis, regurgitation May be worse after eating May be worse after eating Treatment Treatment Reflux precautions Reflux precautions Protein pump inhibitors Protein pump inhibitors

17. Practical Classification: Other Other Other Rhinitis medicamentosa Rhinitis medicamentosa Septal deviation Septal deviation Eosinophilic non-allergic rhinitis Eosinophilic non-allergic rhinitis Nasal polyps Nasal polyps Cholinergic rhinitis Cholinergic rhinitis Vasomotor rhinitis Vasomotor rhinitis GERD induced “post nasal drip” GERD induced “post nasal drip” Turbinate hypertrophy Turbinate hypertrophy Chronic sinusitis Chronic sinusitis

18. Symptoms Suggestive of Chronic Sinusitis Nasal congestion Nasal congestion Pain or pressure around the forehead, nose, or eyes Pain or pressure around the forehead, nose, or eyes Discolored nasal discharge or discolored mucus in the throat Discolored nasal discharge or discolored mucus in the throat Reduced sense of smell Reduced sense of smell Symptoms for > 12 weeks by definition Symptoms for > 12 weeks by definition Tomassen P, et al. Allergy 2011; 66:556

19. Allergy and Chronic Sinusitis Conflicting data regarding increased prevalence of chronic sinusitis in allergic patients Conflicting data regarding increased prevalence of chronic sinusitis in allergic patients Data suggests chronic sinusitis may be more severe in allergic patients Data suggests chronic sinusitis may be more severe in allergic patients Appropriate to aggressively treat allergic rhinitis in patients with coexistent chronic sinusitis Appropriate to aggressively treat allergic rhinitis in patients with coexistent chronic sinusitis Immunotherapy not convincingly shown to improve sinusitis in allergic patients Immunotherapy not convincingly shown to improve sinusitis in allergic patients

20. Medical Approach to Chronic Sinusitis Saline lavage Saline lavage Intranasal corticosteroids Intranasal corticosteroids Treat acute infections Treat acute infections Treat coexistent allergic rhinitis Treat coexistent allergic rhinitis Rule out hypogammaglobulinemia Rule out hypogammaglobulinemia Medical treatment of hyperplastic eosinophilic sinusitis Medical treatment of hyperplastic eosinophilic sinusitis Post operative treatment of Allergic Fungal Sinusitis Post operative treatment of Allergic Fungal Sinusitis

21. Chronic Hyperplastic Eosinophilic Sinusitis Eosinophilia does not indicate allergy Eosinophilia does not indicate allergy Associated with nasal polyps, asthma, aspirin sensitivity Associated with nasal polyps, asthma, aspirin sensitivity Poorer prognosis after surgery Poorer prognosis after surgery Consider montelukast Consider montelukast Aspirin desensitization for patients with aspirin sensitivity Aspirin desensitization for patients with aspirin sensitivity

22. Allergic Fungal Sinusitis: Diagnostic Criteria Radiologic evidence of sinusitis Radiologic evidence of sinusitis Allergic mucin in the sinus Allergic mucin in the sinus Fungal hyphae in the mucin or positive sinus fungal culture Fungal hyphae in the mucin or positive sinus fungal culture Absence of diabetes, immunodeficiency, or immunosuppressive therapy Absence of diabetes, immunodeficiency, or immunosuppressive therapy Absence of fungal invasion Absence of fungal invasion

23. Allergic Fungal Sinusitis: Immunologic Findings Elevated total IgE level (67-74 %) Elevated total IgE level (67-74 %) May correlate with course of disease May correlate with course of disease Increases ≥ 10 % provides high sensitivity for disease progression but lower specificity Increases ≥ 10 % provides high sensitivity for disease progression but lower specificity Atopy (76-100 %) Atopy (76-100 %) Specific IgE against fungus (58-100 % positive skin tests) Specific IgE against fungus (58-100 % positive skin tests) Precipitating antibody against fungus (8-89 %) Precipitating antibody against fungus (8-89 %)

24. Allergic Fungal Sinusitis: Management Surgery Surgery Post-operative prednisone Post-operative prednisone 0.5 mg/kg daily for 14 days 0.5 mg/kg daily for 14 days 0.5 mg/kg every other day, tapered over 3 months to 5 mg every other day 0.5 mg/kg every other day, tapered over 3 months to 5 mg every other day Continue 5 mg every other day for at least 12 months Continue 5 mg every other day for at least 12 months Intranasal steroids Intranasal steroids ? Antifungal agents ? Antifungal agents

25. Conclusions Rhinitis is NOT a trivial illness Rhinitis is NOT a trivial illness All rhinitis is NOT allergic All rhinitis is NOT allergic All non-allergic rhinitis is NOT homogeneous All non-allergic rhinitis is NOT homogeneous Appropriate diagnosis and management (medical and surgical) can substantially improve the quality of life of patients with chronic rhinitis or sinusitis and improve asthma control as well Appropriate diagnosis and management (medical and surgical) can substantially improve the quality of life of patients with chronic rhinitis or sinusitis and improve asthma control as well