A leading expert outlines practical steps for GPs to differentiate the conditions and manage comorbidities.
Allergic and non-allergic rhinitis are extremely common and distressing conditions. Dr Jessica Tattersall discusses the importance of history in order to differentiate between the two and to maximise improvement. She also discusses the co-morbidities and updated management options. This is part one.
Practice points
- Allergic rhinitis is a type 1 IgE-mediated hypersensitivity to airborne allergens (mainly house dust mites, pollens, pets and moulds).
- Allergic rhinitis has an early onset, generally before 20 years of age. Aeroallergen sensitisation will generally begin sometime in the person’s later-adolescence-to-teen years, up until age 20.
- Non-allergic rhinitis is not IgE mediated; it can be inflammatory, but can also be neurogenic in pathway. There are many potential causes including seasonal, hormonal, occupational, drug-induced and gustatory, but idiopathic is most common.
- Non-allergic rhinitis tends to have an older age of onset; the nasal symptoms generally begin over the age of 35 years.
- Both allergic and non-allergic rhinitis are called “mixed rhinitis” and is very common.
- It is really important that we identify other presentations, such as sleep disturbances and, especially in children, irritability and behavioural disorders, as well as fatigue.
- Adult allergic rhinitis patients may be presenting as acute recurrent sinus infections.
- Children can also get dental malocclusions and expansive growth of the maxillary bone because of the sleep-disordered breathing related to chronic allergic rhinitis.
- Except for those with intermittent, mild symptoms, the first line treatment for chronic allergic rhinitis is a combination of intranasal corticosteroid plus topical anti-histamine if cost is not an issue. Otherwise, corticosteroid monotherapy is better than nothing and is better than oral antihistamines alone.
My name is Dr Jessica Tattersall and I am an allergist and medical rhinologist. I am a Fellow of the RACGP and I hold a graduate certificate in allergic diseases from the University of Western Sydney and a masters of medicine in allergic diseases. I have a special interest in allergic, non-allergic and inflammatory diseases of the airway and sinuses, and I am actively involved in research and education in this area. I am a member of the Australasian Society of Allergy and Clinical Immunology, the Australian and New Zealand Rhinological Society and the American Rhinological Society.
Today we’re going to be talking about chronic rhinitis, including allergic and non-allergic rhinitis. Chronic rhinitis is a very common problem in Australia, affecting about 30% to 40% of the population. It has a significant impact on the quality of life in about 50% of sufferers. To define “chronic rhinitis” would require the patient to have chronic inflammation of the nasal mucosa. Rhinorrhoea is a symptom of this, as are sneezing, nasal blockage and itch. Symptoms can range from mild to severe, and generally need to last more than 12 weeks to be called “chronic”. There is a strong association with asthma and that doesn’t depend on whether the chronic rhinitis is allergic or non-allergic; both types have a predisposition to asthma as a co-morbidity.
The four major types of rhinitis include infectious, non-infectious, acute rhinitis (self-limiting, mostly viral induced; you may get the typical symptoms of discoloured discharge as well as nasal crusting and secretions) and chronic rhinitis. Bacterial infections can be more severe in those who do suffer allergic rhinitis, especially at times of high allergen exposure, as during the pollen season.
However, today we’re going to concentrate on chronic rhinitis and that will include allergic rhinitis, that is, the type 1 IgE-mediated hypersensitivity to airborne allergens (mainly house dust mites, pollens, pets and moulds). We’ll also talk about non-allergic rhinitis, which is not an IgE-mediated problem. It can be inflammatory, but also can be neurogenic in pathway. There are many different subtypes that I’ll touch on. Now, complicating things, patients can have both allergic and non-allergic rhinitis; that’s what we call “mixed rhinitis” and it is very common, affecting about 60% to 70% of people who have a history of allergic rhinitis in their younger years.
What is allergic rhinitis?
So let’s start with allergic rhinitis. We know this is common in Australia and roughly one in four people will suffer from the condition. It has an early onset, generally before 20 years of age. The patient will be sensitised to one of the particular aero-allergens, such as house dust mite or pollen. This sensitisation will generally begin sometime in their later adolescence to teen years, up until age 20. There are the classic symptoms of repetitive sneezing; itching of the nose, palate, throat and ears; some anterior rhinorrhoea; nasal blockage and ocular symptoms. These symptoms mostly will be induced by house dust mite, pets, moulds and pollens. However, it is really important that we pick up on the other presentations, such as sleep disturbances and, especially in children, irritability and behavioural disorders, as well as fatigue. Two out of three of these patients will not contact their doctor about this, so it is important we pick it up when they do present, because with a condition like rhinitis, the nose is just the tip of the iceberg! The problems that can be associated with it are also very important to consider.
It is really important to understand that your adult allergic rhinitis patients may be presenting as acute recurrent sinus infections. They come into the office roughly four or five times a year when they have an acute infective rhino-sinusitis and have the typical symptoms of discharge and pressure sensation. What they are not coming to you for is the periods in between, and this is when they’re going through packets of antihistamines to control their allergic disease. So these patients have what I like to call “bad plumbing”: their nose isn’t working very functionally, they get a secondary insult, like a viral infection, and the plumbing backs up and they’re left with their symptoms of acute pain, pressure and discharge. Children can get hypertrophy of their tonsils and adenoids as well as many other ear, nose and throat infections, including in the middle ear. Obviously, ocular symptoms can also be quite troublesome. Once again, there is the association with asthma.
It is really important to identify the child with sleep-disordered breathing due to chronic allergic rhinitis. Sleep-disordered breathing can include anything from primary snoring to obstructive sleep apnoea. Children can also get dental malocclusions and expansive growth of the maxillary bone due to the sleep-disordered breathing. They often present from their dentist with the high, arched palate and require spreading of their crowded teeth that are due to the ongoing mouth breathing. This is very important to Identify. The cognitive issues that are associated with chronic allergic rhinitis include loss of function in both work and schooling, poor concentration, poor sleep and fatigue. This obviously can have a great impact on the child’s quality of life.
Classifying allergic rhinitis and first-line treatment
So once we think we have the diagnosis of allergic rhinitis, we need to classify it. Is it intermittent or persistent, does it happen all the time, or is it once in a while? Are the symptoms mild, or are they moderate to severe? Notice that in the moderate-to-severe category, it is not about how many times that you sneeze or how many boxes of tissues you use, it is about how it affects your quality of life (that is, abnormal sleep, impairing your daily activities, schoolwork being disturbed by this problem).
The people I don’t think we see very often are those who find their symptom relief in the pharmacy. The past management was changed in 2020 from monotherapy with intranasal glucocorticoids. Now, I’m going to highlight the current management here, because almost everybody except those with intermittent, mild symptoms need as the first-line treatment a combination of intranasal corticosteroid plus topical anti-histamine. These have become the first-line treatment options for everybody, from persistent, mild symptoms through to persistent, moderate or severe symptoms, because of the superior performance they have in randomised control trials.
The only contraindication to starting someone on a combined therapy is the cost. It is not an insignificant cost; it is quite an expensive medication combination to start someone on. So you need to make sure they will be able to cover that cost. Otherwise, intranasal corticosteroid monotherapy is better than nothing and it surely is better than oral antihistamines alone. Notice the first line therapy of oral antihistamines is just for intermittent and mild symptoms. Those people again we tend not to see in practice because they are treating themselves quite well in the pharmacy.
Note also that both the moderately and severely symptomatic people, whether they have intermittent or persistent symptoms, are candidates for immunotherapy. This should always be considered in someone with troubling symptoms.
Which is better: Ryaltris or Dymista?
So just to reiterate, the best choice for persistent allergic rhinitis are intra-nasal glucocorticosteriods with a topical antihistamine in those patients over 12 years old. The two on the market at the moment are Ryaltris and Dymista. Dymista is fluticasone with azelastine, and Ryaltris is mometasone furoate with olopatadine. Now, there is a lot of confusion about which is better and what the differences are. They are quite similar, but there are a couple of noticeable differences that might make it easier for you to decide which is best for your patient.
The first thing I want to highlight in this comparison of the product information is the daily dose. Both Dymista and Ryaltris are quite comparable in price. However, when you look at the dose for Dymista, being one spray both nostrils twice a day compared with Ryaltris being two sprays both nostrils twice a day, you are using double the amount of Ryaltris, so you will go through the bottle faster. However, if the patient tends to be a bit drier or crusty around the nose from using nasal sprays, they might benefit from the half dose of Ryaltris. The dose of Ryaltris is 25ug of mometasone, whereas the over-the-counter intranasal mometasone is 50ug, so you are getting the same dose as this by using one spray of Ryaltris twice a day. The patient may get much better by having that half dose of Ryaltris, so this is something to consider.
The other thing to consider is the taste. Anyone who has had a patient try Dymista® and then refuses to use it because of the taste will know this. In the product information it does not look as if the percentage of such patients is high. However clinically, we all know patients that refuse to use the Dymista because of the taste. In a way, this is a trick question, because really, you shouldn’t taste a nasal spray. So the first thing you should check is the patient’s technique, to make sure they are not spraying it in their nostril and taking a massive sniff. That would means all the medication is just wasted down the back of their throat. I like to teach a technique with a mild tilting of the neck to get this spray to go all around the lateral side wall of the nose, and then for them to have a gentle sniff at the end if required.
The other thing to note is the glass bottle of Dymista. If you have someone who keeps their nasal spray by their bedside table on a carpeted floor, this is no problem. However, once you have a patient who spills an entire bottle of Dymista on their bathroom tiles, right after they bought the $47 bottle of medication, this becomes a problem. The plastic bottle of Ryaltris is a good choice for people who travel, or for those who do need a little bit more flexibility regarding where they are taking and carrying their nasal sprays.
Other than these issues, they are both good products that I have used both personally and in my clinical rooms. I have some patients who prefer one or the other. They are both great as first-line choices. You just have to think of any of those little differences when you prescribe.
If you are looking for more information on allergic rhinitis, ASCIA, which is the Australian Society of Clinical Immunology and Allergy, has a great health professional information sheet that describes what I have just discussed, and more. There’s also an e-training component that you can go through that explains a lot more, with question and answers.
A word on non-allergic rhinitis
Now we get to the slightly more complicated non-allergic rhinitis. This is a diagnosis of exclusion, as there is an absence of a specific serum IgE in the blood test, the skin prick test is negative and the rhinitis being infective has also been ruled out. Here the history is very, very important because there could be many causes at play, including seasonal, hormonal, occupational, drug-induced and gustatory. Some may be preventable. However, the most common cause you will see in practice is idiopathic.
Now, any of these causes can have an inflammatory or a neurogenic pathway and then we can see the typical symptoms of non-allergic rhinitis being very similar to allergic rhinitis, with a runny nose, sneezing and nasal congestion, but a little less itch. On one side, you can see the typical IgE-mediated allergic reaction, with the mast cells and histamines causing the acute symptoms. Then, with the neurogenic pathway, we see how the parasympathetic, the sympathetic and the cholinergic nervous systems are at play, causing and driving these symptoms.
This is also known as ”nasal hypersensitivity”, “non-allergic”, “non-infectious rhinitis”, “vasomotor rhinitis” and “neurogenic rhinitis”. Non-allergic rhinitis tends to have an older age of onset; these patients do not get their nasal symptoms until generally over the age of 35 years. There is a theory that there is a slight a female predominance and there is generally not a history of allergies in the past. There is no family history of allergy that you have to classify, but you have one or more of the following symptoms: sneezing, post-nasal drip, congestion, rhinorrhoea. As mentioned, I have highlighted post-nasal drip because this tends to be one of the primary presenting symptoms.
To be continued as part two, the final part of this article.
We would like to thank Dr Jessica Tattersall very much for her expertise and time.
This was first published on Healthed. To listen to the full podcast, please click here.
