Allergic Rhinitis

Author

Reviewer

Share Article

Published on : April 25, 2023

(2)  (593)  

The Birds and Bees and Allergies:

The Forgotten Burden of Allergic Rhinitis

‘Tis the season of sneezing, runny noses, and allergies.  Generally perceived as an inconvenience due to the non-life-threatening nature of symptoms, we forget that approximately 20-25% of Canadians suffer from allergies.  These numbers continue to increase.  Furthermore, allergic rhinitis may be related to other conditions such as allergic conjunctivitis, asthma and even food allergies.  It is a lion cloaked as a lamb.  Our approach and treatment need re-framing.

Author Reviewer
Christine Palmay, MD, CCFP, FCFP
Midtown Health and Wellness Clinic
Toronto, ON 

Nina Jindal, FRCPC, Internal Medicine, Clinical Immunology & Allergy

Lecturer, Department of Medicine

Division of Clinical Immunology and Allergy

University of Toronto

Toronto, ON

Do not underestimate the burden of allergic rhinitis

Midst the fever and fury of catching up post COVID, we must pause and recognize that allergic rhinitis, whether seasonal or perennial, have a significant impact on quality of life.  Research has shown that allergy suffers experience sleep disturbances/poor sleep quality, cognitive impairment, and mental health issues such as anxiety and depression.  Allergies can be a leading cause for work absenteeism and can negatively affect workplace and academic performance.  Older anti-allergy medications (more to come about this) also pose a challenge as they themselves may lead to drowsiness and brain fog.  Allergic rhinitis is more than just a runny nose and as such, we need to be proactive in asking our patients how allergies affect them.

Missed clinical opportunities

Allergic rhinitis is often underrecognized by sufferers themselves.  Firstly, patients may not correlate their symptoms with other adverse health outcomes such as cognitive changes or sleep disturbances.  Afterall, it’s just a sneeze, right?  Access to medical care continues to be limited and anti-allergy over the counter options are limitless and readily available.  Just pass through a drugstore and see what lies on the shelves.  Patients can access over-the-counter medication and often undertreat, overtreat or mistreat.  I have had so many conversations with patients, whom out of desperation fill their medication cabinets with first generation antihistamines (good reliable diphenhydramine, Benadryl) or use the sedating power of other medications such as dimenhydrinate (Gravol).  These medications come with a myriad of side effects such as drowsiness, poor cognition, reduced reflex time and general brain fog.  Think of the implications for fall risk or driving errors. Furthermore, interaction with other medications are of equal concern.   When assessing a patient with allergic rhinitis, we must take time to record a detailed drug history, including what they are accessing over-the-counter.  You don’t know what you don’t know until you ask (and then know!).

So where do I start?

Let’s start by reviewing what we should NOT do – namely prescribing first-generation anti-histamines. There should be a war cry unified front to ban first generation antihistamines such as diphenhydramine) from the shelves due to their ability to cross the blood brain barrier thus invoking sedation and drowsiness. Other options such as decongestants in all forms can lead to worsening symptoms due to rebound vasodilation.  Safer options exist (again, more to come). 

Guidelines emphasize that first line options include lifestyle modifications:  avoiding carpets/drapes if possible, cleaning sheets regularly, investing in a high-efficiency air filters, avoiding outdoor activates during peak pollen season….and……having a difficult conversation about that new family pet that may be the allergen source. While these measures seem basic, they are often overlooked.  Intranasal steroids may also be a viable first line option, but from a clinical perspective, I do not find that they address the full burden of symptoms in many patients.  We need to follow-up and not just “treat and street.”

Are you equipped to protect high-risk populations from COVID-19?

Friend our second generation anti-histamines – more than just cetirizine!

Current guidelines steer us AWAY from first generation anti-histamines and focus on the benefits of our second generation anti-histamine class. The real benefit of these newer second generation antihistamines is reduction in concerning side effects compared to older first generation agents. Side effects such as reduced drowsiness and cognitive impairment, not to mention the potential for drug interactions.  Our medication options within this class have only recently been updated with two new options and quite frankly, game changers: bilastine (Blexten) and rupatadine (Rupall). These new kids on the block have less side effects such as drowsiness and cognitive impairment. Equally as important, they have less interaction potential with other medications.  Conveniently, pediatric formulations exist for both options and truly make them safer selections for a wide age range (because we know now how much daycares revel in runny noses!).  From a clinical perspective, patient feedback has been excellent, and my use of these newer options has replaced my old practice patterns of simply renewing a longstanding cetirizine prescription.

How do we identify patients at high and very high risk of fracture?

When to refer?

Failure of treatment or lack of tolerability to medications warrant a comprehensive assessment as patients may be eligible for consideration of higher level treatment options such as immunotherapy (subcutaneous or sublingual) if appropriate. As well, if any red flags exist (complicated medical history, severe symptoms, severe quality of life impairment), it may be important initiate a referral.  Additionally, patients who want to know what they are allergic to or have multiple allergic co-morbidities will benefit from specialist consultation .

 

In summary, allergic rhinitis does not get the air time it deserves, but when treated comprehensively, results in a measurable improvement in patient’s quality of life. “NOSE” your options (cue unified groan..).

 

Up Next: That houseguest that won’t leave:  Chronic Urticaria

 What are the key strategies to relieve chronic urticaria and provide my patients with lasting relief?

Continuing learning with MDLearn webcasts and podcasts:

Are You Prepared to Identify and Safeguard High-Risk Patients from Osteoporosis-Related Fractures? - ACCREDITED PODCAST

Are you equipped to identify and treat high-risk patients with osteoporosis for long-term management?

The development of this blog was overseen by the Canadian Collaborative Research Network and was supported through an educational grant from Aralez Pharmaceuticals Canada Inc.

copyright © 2024 MDLearn
Any views expressed above are the author's own and do not necessarily reflect the views of MDLearn.

Continue learning with MDRead

Published on October 10, 2023

Preparing for Fall: Insights on Respiratory Infection Prevention and COVID Vaccination Guidance

FALLING BACK FOR DAYLIGHT SAVINGS TIME, JUMPING AHEAD IN RES...

Published on May 31, 2023

Covid-19 Protection for High-Risk Populations

Covid-19 Protection for High-Risk Populations...

Published on May 22, 2023

Chronic Urticaria

Chronic Urticaria: That Unrelenting and Nagging Itch &nb...

Published on April 06, 2023

PCSK9 inhibitors: For Which Patient and When?

PCSK9 inhibitors: For Which Patient and When?...

Published on February 10, 2023

Osteoporosis Management in Primary Care – Sinking Your Teeth Into ONJ – Debunking Myths and Unde...

Sinking Your Teeth Into ONJ – Debunking Myths and Unde...

Published on January 25, 2023

Osteoporosis Management in Primary Care – Helping patients understand the risks and benefits of os...

Denosumab 101 Safety, Tolerability and Calcium Monitoring&...

Published on January 13, 2023

Osteoporosis Management in Primary Care – Identifying when to use anabolic therapies

Osteoporosis Management in Primary Care – Anabolic The...

Published on December 10, 2022

Dyslipidemia Management in Primary Care

Dyslipidemia Management in Primary Care   This blog...

Published on December 06, 2022

Dietary Supplements

What advice do I give to my patients who use dietary supplem...

Published on October 13, 2022

Shingles Vaccination Keeping Pandora’s Box Closed

What has changed in terms of Herpes Zoster guidance and why...

Published on October 13, 2022

SOME CALL IT SLEEP

What’s New in Insomnia Management and Treatment &ld...

Published on September 16, 2022

When Plan B is Plan A… Meningitis B Vaccination

Meningitis B vaccination - a call to action. Why should Men...

Published on June 02, 2022

The Impact of the COVID-19 Pandemic in Canadians with Cardiovascular Disease

What has been the impact of COVID-19 on Canadians with cardi...

Published on May 06, 2022

Hypertension- A Salty Topic

Why are we still talking about hypertension?   &nbs...

Published on March 31, 2022

I’m ready to use natriuretic peptide testing in my patients with dyspnea to diagnose heart failure...

How to incorporate BNP testing into primary care....

Back