Allergic Rhinitis

Learning objectives

By the end of this chapter, participants will be able to:

• recall the impact of allergic rhinitis on patients’ quality of life and the need for an important and accurate diagnosis
• describe the diagnostic work-flow and tests available to support the diagnosis of allergic rhinitis
• explain how component-resolved diagnostics may aid the diagnosis and management of allergic rhinitis.

Allergic rhinitis

• Rhinitis is a nasal symptomatic disorder caused by inflammation of the nasal mucosa1 that can be driven by various elements, including allergens and infections.²
• Allergic rhinitis is defined as a nasal symptomatic disorder induced after allergen exposure by IgE-mediated inflammation.³
• It is estimated that 100 million Europeans suffer from allergic rhinitis.⁴
• According to the Allergic Rhinitis Impact on Asthma (ARIA) Guidelines, allergic rhinitis can be classified into the following categories:³

Common triggers of allergic rhinitis⁵

• Several allergen sources, seasonal (s) or perennial (p), are associated with allergic rhinitis:

What symptoms must a GP look out for when diagnosing a patient with allergic rhinitis?

Clinical symptoms of allergic rhinitis⁶

Ocular symptoms occur in 50–70% of people with allergic rhinitis and differentiates it from other forms of rhinitis.⁷
Patients may also experience asthma-related symptoms, as rhinitis and asthma often co-exist in patients.⁸

Why is a correct diagnosis important?

• Patients with allergic rhinitis and non-allergic rhinitis may share similar symptoms, for example, sneezing, nasal congestion, rhinorrhoea and nasal itching.9 and may require different treatment.¹⁰
  • Misdiagnosis can prevent the patient from receiving the most effective clinical management and therapies.
• Allergic rhinitis is a risk factor for the development of asthma.¹¹ Recommendations by ARIA suggest that patients diagnosed with allergic rhinitis should also be evaluated for asthma.³
  • A patient correctly diagnosed with allergic rhinitis may also benefit from being evaluated and effectively treated for asthma.
• Symptoms associated with allergic rhinitis, such as sleeping disorders and poorer mental health, may have a significant impact on the patient’s quality of life.^12,13
  • Early and correct diagnosis can significantly improve the patient’s wellbeing.

Recommended tests for allergic rhinitis

What diagnostic work-flow should clinicians follow for the diagnosis of allergic rhinitis?

Component-resolved diagnostics (CRD)

• The use of CRD has been widely studied for the diagnoses of allergic rhinitis. For example:
  • Northern Sweden: In a population-based sample of school children, high-level sensitisation to cat, dog and horse components and sensitisation to multiple components within the same species were shown to have the strongest associations to asthma and rhinitis.¹⁹
  • CRD has also been shown to influence the selection of specific immunotherapy prescriptions to pollen-related allergies due more selective identification of disease-eliciting pollen sources.²⁰
  • Use of dust mite components in patients with allergic rhinitis discriminated primary allergy and cross-reactivity in patients and identified patients who were better suited for immunotherapy.²¹
• Several factors need to be considered when using CRD in patients with allergic rhinitis. For example:
  • Similar to other in vitro IgE tests, a positive result only shows sensitisation¹⁵
  • Medical history and the patient’s symptoms should be used to interpret all allergy-related results¹⁵

Summary

• Common triggers of allergic rhinitis are pollen, house dust mite, mould and furry animals.
• Allergic rhinitis and asthma often co-exist in patients – testing for other co-morbidities may be necessary if the history and examination is suggestive.
• Allergen sensitisation testing in primary care should use in vitro testing.
• Common triggering allergens reported for allergic rhinitis are also available for CRD testing.

References

1. Rowland-Seymour A. Decision Making in Medicine (Third Edition). 2010:32-3.
2. Rondón C. EAACI 2014 (Oral presentation).
3. Bousquet J et al. Allergy. 2008;63(Suppl 86):8–160.
4. EACCI: Advocacy Manifesto. June 2015.
5. Scadding GK et al. Clinic Experiment Allergy. 2008;38(1):19–42.
6. Greiner AN et al. Lancet. 2011;378(9809):2112–22.
7. Cingi C et al. Clin Transl Allergy. 2017;7(17):1–12.
8. Grossman J. Chest. 1997;11(4):837–1148.
9. Schroer B. Cleve Clin J Med. 2012;79(4):285–93.
10. Greiner AN, Meltzer EO. Proc Am Thorac Soc. 2011;8(1):121–31.
11. Guerra et al. Allergy Clin Immunol. 2002;109(3):419–25.
12. Craig TJ et al. J Allergy Clin Immunol. 2004;114(5):S139–45.
13. Leynaert B et al. Am J Respir Crit Care Med. 2000;162(4 Pt 1):1391–6.
14. Akdis C, Hellings P, Agache I (Editors). Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis. EAACI 2015: 151, 173
15. Portnoy JM. Missouri Medicine. 2011;108(5):339–43.
16. National Institute for Health and Care Excellence. https://cks.nice.org.uk/allergic-rhinitis (accessed May 2018).
17. Nevis IF et al. Allergy Asthma Clin Immunol. 2016;12(20):1–12.
18. Auge J et al. J Allergy. 2017;73(8):1597–1608.
19. Bjerg A et al. Pediatr Allergy Immunol 2015;26(6):557–63.
20. Stringari G et al. J Allergy Clin Immunol 2014;134(1):75–81.e2.
21. Yadzir ZHM et al. Iran J Allergy Asthma Immunol. 2014;13(4):240–6.