Seasonal Allergies

Katarzyna Lalicata, MSN, FNP-C, FNP-BC
Wednesday April 19, 2017

Patients with seasonal allergies, also known as allergic rhinitis (AR) or hay fever, routinely come to convenient care clinics (CCC) seeking resolution of symptoms. Common allergens include trees, grasses, weeds, and outdoor molds.1

AR affects 30 to 60 million people in the United States annually, making it a common complaint among patients.2 Quality of life for these patients may be decreased due to loss of productivity, missed school and work days, and treatment cost.3

Pathophysiology

Seasonal allergies occur due to type I hypersensitivity to an aeroallergen as a result of an immunoglobulin E (IgE)–mediated allergic reaction. Nasal inflammation is triggered by an IgE–mediated allergic reaction, with a type I hypersensitivity secondary to exposure of an inhaled allergen.4 T lymphoctyes, B lymphocytes, and antigen-presenting cells are involved in the allergen sensitization leading to AR. Acute nasal symptoms of AR are in part due to the activation of the cells after repeat exposure to an allergen.5

Common Causes of Seasonal Allergies

Seasonal allergies most commonly can be attributed to grass pollen occurring between May and June, and to ragweed occurring between mid-August and October. Tree pollens can also be a trigger, and they vary based on geographical location: birch trees in the northern United States, mountain cedar in the Southwest, live oak in the South, and oak in the mid-Atlantic. Other causes include outdoor molds that can occur without a corresponding specific season although elevated levels of airborne fungi can be prevalent between March and October.1

Differential Diagnosis

Although AR may be safely treated by a primary care provider, it is essential to differentiate seasonal AR from viral rhinitis, perennial AR, migraines, chronic sinusitis, nonallergic rhinitis, eosinophilia syndrome, vasomotor rhinitis, hormonal changes,1 medication-induced rhinitis, and gustatory rhinitis.12

Perennial allergies include household allergens, animals, and indoor molds. Triggers include Aspergillus, Cladosporium, Penicillum, cats, dogs, rodents, other household pets, cockroaches, dust mites, and other insects. Dust mites and cats are the most common underlying cause of perennial allergies, with dust mites being found to be a larger trigger in areas of humidity occurring greater than 6 months.1 Patients will notice symptoms year-round with no defined peak season.1

Viral rhinitis symptoms may be intermittent and sporadic with associated symptoms such purulent rhinorrhea, sore throat, pain, and headache.1 Uncomplicated viral rhinitis has an observation period lasting anywhere from 7 to 10 days without the need for antimicrobial therapy.2 Atypical migraines patients may present with facial fullness, facial pressure, and sinus headache accompanied by rhinitis complaints of posterior pharyngeal drainage and congestion.1 Patients with chronic sinusitis may have the presence of nasal polyps and an underlying disease process, and not an acute infection.1 Examples include but are not limited to immotile cilia syndrome, cystic fibrosis, and immune deficiencies. Non-AR with eosinophilia syndrome (NARES) presents like vasomotor rhinitis.1 Patients with NARES have perennial symptoms and at times a reduced sense of smell.2

Vasomotor rhinitis, also known as “idiopathic” rhinitis, is induced by irritants such as such as pollution and cigarette smoke.1,2 Drug-induced rhinitis (DIR) can be caused alpha receptor antagonists. Occasionally, DIR can be triggered by angiotensin-converting enzyme inhibitors and beta-blockers.2 Symptoms of nasal congestions can also be attributed to phosphodiesterase-5 selective inhibitors.2

Hormonal rhinitis, most often seen in pregnancy, has complaints of nasal congestion beginning after the second month.2 Gustatory rhinitis is associated with watery rhinorrhea following ingestion of certain foods, such as spicy foods.5

Patient Presentation and Diagnosis

AR is common more in childhood than in adulthood. Furthermore, boys are more likely to be diagnosed in childhood, whereas women are more often diagnosed later in life.2

A diagnosis may be made based on exposure to triggers, family history, and symptoms. Clues in the patient’s history may include complaints of watery, clear rhinorrhea, nasal itching sneezing, congestion, as well as ocular complaints consistent with allergic conjunctivitis.2 The late phase of AR has a predominant congestion component.2 Children may present with a horizontal nasal crease secondary to constant rubbing.6

The first step when making the diagnosis is to assess whether their condition is perennial or intermittent.1 It is essential to perform a head and neck exam using a nasal speculum and headlight to aid in diagnosis.7 If the patient has intermittent complaints, evaluate if there is a presence of sporadic purulent rhinorrhea, sore throat pain, and headache.

If so, then a diagnosis of viral rhinitis may be made. However, if sneezing and rhinnorhea are intermittent in nature, seasonal, accompanied by nasal and palatal pruritus, ocular symptoms, clear rhinorrhea, and paroxysmal sneezing, seasonal AR can be deduced.1 Other physical exam findings consistent with AR include a swollen cyanotic nasal cavity and boggy turbinates.7

Referral to a primary care provider can be made to confirm the diagnosis of AR through specific IgE testing, which involves either a skin-prick test (preferred) or an IgE immunoassay.1 Positive IgE can aid in treatment in preventing environmental triggers.1 A benefit of skin testing is that it enables the clinician to assess the sensitivity to a specific allergen that triggers AR symptoms, which aids in avoidance measures by the patient as well as guide allergen immunotherapy.2 MRI and CT scans are not indicated for the diagnosis of AR, but they can be used to assess other comorbidities such as nasal polyps.2

Management

Establishing goals for the management of AR with patients increases both their compliance and their satisfaction with care received.Identifying allergens or irritants in the environment that trigger symptoms is an essential part of the management and prevention of the disease process.4 Patients can be counseled to use air conditioning and dehumidification.1 Antihistamines are a mainstay treatment although they do not aid with the complaints of nasal congestion, rather with sneezing, itching, rhinnorhea, and associated conjunctivitis.1 Given the significant sedating and anticholinergic effects, caution should be taken when prescribing these medications.1 The nonsedating effects of second-generation antihistamines and longer duration of action are preferred because of their fewer adverse effects.1 First-generation antihistamines are not recommended for older adults because of the anticholinergic properties of these medications.8 Examples of first-generation antihistamines include diphenhydramine and hydroxyzin. Examples of second generation antihistamines include loratadine, fexofenadine, cetirizine, levocetirizine, and desloratadine.8 Second-generation antihistamines can help a patient significantly by not interfering with school, work or driving.1

Prevention of exposure to allergens or irritants can aid in the management of mild AR; however, they can take weeks to months to exhibit significant effects in patients. Oral antihistamines can be used with patients who suffer from mild or occasional seasonal allergies. For patients with a moderate or long duration of AR symptoms, intranasal corticosteroids are an affective alternative.4 Intranasal cromolyn is a good alternative with minimal adverse effects to intranasal corticosteroids. Examples include beclomethasone, budesonide, flutcisone furoate, fluticasone proprionate, mometasone, and triamcinolone.

Intranasal antihistamines, although less affective than intranasal corticosteroids, have been deemed equal if not superior to oral second-generation antihistamines for seasonal AR. Intranasal antihistamines include azelastine and olopatadine. Combinations of intranasal antihistamines and corticosteroids include azelastine/fluticasone.11

Oral decongestants can aid with nasal congestion though less effective than intranasal corticosteroids.1 Nasal decongestants treat nasal stuffiness, and combinations of antihistamines and decongestants can effectively treat mild cases.1

Caution and review of risks versus benefits must be taken when prescribing for children younger than 6 years because of the increased risk of hallucinations, agitated psychosis, ataxia, and death. For children with ADHD, increased stimulatory effects can result such as tachyarrhythmia and insomnia. Patients with a history of cerebral vascular accident, cardiovascular disease, hyperthyroidism, closed angle glaucoma, and bladder neck obstruction.2 Examples include oral phenylephrine and pseudoephedrine, as well as nasal oxymetazoline.8 

Leokotriene (LT) receptor antagonists are effective in the management of seasonal AR, and montekulast is a good option for patients with concurrent asthma and AR. Patients should be instructed to begin treatment a few weeks prior to start of symptoms and throughout pollen season.9 Oral anti-LT agents with the use of antihistamines or monotherapy can aide in the management of AR though inferior to intranasal corticosteroids.2 Allergen immunotherapy can be administered to patients with AR via subcutaneous immunotherapy and sublingual immunotherapy; both effectively alter the immune response to aeroallergens.8 Patients who have not responded to pharmacotherapy or patients who prefer immunotherapy are candidates for this treatment and can be referred. Unlike pharmacotherapy management, immunotherapy effects of managing symptoms of AR continue after therapy is completed.10

As research continues, initial studies have shown improved efficacy of fluticasone furoate and levocabastine when used once daily rather than monotherapy for patients with moderate to severe AR, but further clinical studies are needed before implementation of initial findings.8

Conclusion 

Establishing a plan with effective medication management, prevention strategies, and clear communication with the patient can aide in compliance and improved outcomes. AR and its Impact on Asthma (ARIA) guidelines can aid the health care provider in treatment for patients with this chronic condition to improve their quality of life. 


Katarzyna Lalicata is a nurse practitioner at Minute Clinic and an associate clinical assistant professor at National University. 

References
  1. Boorish L. Allergic rhinitis and chronic rhinitis. In: Goldman, L, Schafer, A.I. Goldman Cecil-Medicine. 25ed. New York, NY, Saunders Elsevier; 2016.
  2. Wallace D, Dykewicz M, Bernstein D, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008;122(2 suppl):S1-s84. doi: 10.1016/j.jaci.2008.06.003.
  3. Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet. 2011;387(9809):2112-2122. doi: 10.1016/S0140-6736(11)60130-X.
  4. Beard S. Rhinitis. Prim Care. 2014;41(1):33-46. doi: 10.1016/j.pop.2013.10.005.
  5. Raphael GD, Hauptschein-Raphael M, Kaliner MA. Gustatory Rhinitis. Am J Rhinology. 1989;3(3):145-149. doi:10.2500/105065889782009697.
  6. Shannon JL. How can I differentiate between allergic rhinitis and chronic rhinitis. Medscape website. http://www.medscape.com/viewarticle/421033 Published January 31, 2002. Accessed February 17, 2017.
  7. Marple B, Fornadley J, Patel A, et al. Keys to successful management of patients with allergic rhinitis: Focus on patient confidence, compliance, and satisfaction. Otolaryngology Head Neck Surg. 2007;136(6 suppl):S107-S124.  doi: 10.1016/j.otohns.2007.02.031.
  8. Murdoch RD, Bareille P, Ignar D, et al. The improved efficacy of a fixed-dose combination of fluticasone furoate and levocabastine relative to the individual components in the treatment of allergic rhinitis. Clin Exp Allergy. 2015;45(8):1346-1355. doi: 10.1111/cea.12556.
  9. Walker S, Sheikh A. Rhinitis. BMJ. 2002;324:403.  doi: http://dx.doi/org.nuls.idm.oclc.org/10.1136/bmj.324.7334.403.
  10. Wheatley LM, Togias A. Allergic rhinitis. N Eng J Med. 2015;372(5):456-463. doi: 10.1056/NEJMcp1412282.
  11. Ayars AG, Altman MC. Pharmacologic therapies in pulmonology and allergy. Med Clin North Am. 2016;100(4):851-868. doi:10.1016/j.mcna.2016.03.010.
  12. Schmitt J, Stadler E, Küster D, Wüstenberg EG. Medical care and treatment of allergic rhinitis: a population-based cohort study based on routine healthcare utilization data. Allergy. 2016;71(6):850-858. doi:10.1111/all.12838.
  13. Kim D-K, Rhee CS, Han DH, Won T-B, Kim D-Y, Kim J-W. Treatment of allergic rhinitis is associated with improved attention performance in children: The Allergic Rhinitis Cohort Study for Kids (ARCO-Kids). PLoS ONE. 2014;9(10). doi:10.1371/journal.pone.0109145.



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