8.9 Social history .uk
BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)Glenis K. Scadding*, Harsha H Kariyawasam*?, Guy Scadding?, Rita Mirakian*, Roger J. Buckley?, Tina Dixon?, Stephen R. Durham?, Sophie Farooque?, Nicholas Jones?, Susan Leech, Shuaib M. Nasser#, Richard Powell, Graham Roberts||, Giuseppina Rotiroti*, Angela Simpson≠, Helen Smith§, Andrew T. Clark#*The Royal National Throat Nose and Ear Hospital, London UK? UCLH NHS Foundation Trust#Cambridge University Hospital NHS Foundation Trust, Cambridge UK?Dpartment of Upper Respiratory Medicine, Imperial College NHLI, Guy Scadding Building Royal Brompton Campus, London UK ≠ Division of Infection, Immunity and Respiratory Medicine, , University of Manchester, Manchester UK? Chest and Allergy Department, St Mary’s Hospital, Imperial College NHS Trust, London UK?Royal Liverpool and Broad green University Hospital NHS Trust, Liverpool UK?The Park Hospital, Nottingham UK§Division of Primary Care and Public Health, University of Sussex, Brighton UK||Department of Child Health, University of Southampton Hospital, Southampton UKDepartment of Child Health, King’s College Hospital, London UK Department of Clinical Immunology and Allergy, Nottingham University, Nottingham UK?Vision and Eye Research Unit, Anglia Ruskin University, East Road, Cambridge, UKAddress for Correspondence:Dr AT ClarkCambridge University Hospitals NHS Foundation TrustBox 40Allergy ClinicCambridge CB2 0QQ, Tel: 01223 762603Email: Andrew.clark@addenbrookes.nhs.ukABSTRACTAllergic rhinitisIs common and affects 10-15% of children and 26% of adults in the UKAffects quality of life, school and work attendance, and performanceIs diagnosed by history and examination, supported by specific allergy testsIs a risk factor for the development of asthmaTopical nasal corticosteroids are the treatment of choice for moderate to severe disease. (Grade A)Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. (Grade B)Treatment of rhinitis is associated with benefits for asthma. (Grade A)Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. (Grade A) Non-allergic rhinitisIs a risk factor for the development of asthmaHas a variety of causesMay be eosinophilic and steroid- responsive or neurogenic and non- inflammatoryMay be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis Infective rhinitisCan be caused by viruses, and less commonly by bacteria, fungi and protozoa.Keywords: allergic, allergen, allergy, antihistamine, anti-leukotriene, aspirin, asthma, BSACI, quality of life, cat allergen, child, corticosteroid, cromoglicate, decongestant, guideline, house dust mite, idiopathic rhinitis, IgE, immunotherapy, ipratropium bromide, lactation, nitric oxide, non-allergic, non- infectious rhinitis, NINAR, occupational, pregnancy, rhinitis, rhinitis control, skin prick test, SOCC, subcutaneous immunotherapy, sublingual immunotherapy, surgery.IntroductionAllergic rhinoconjunctivitis (AR) remains the most common immunological disease in man and is still subject to under-recognition and poor management. This matters because AR significantly reduces quality of life (QOL) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxhZm9yZXN0PC9BdXRob3I+PFllYXI+MjAwNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Blaiss 2004; Cockburn and others 1999), and results in substantial societal costs ADDIN REFMGR.CITE <Refman><Cite><Author>Blaiss</Author><Year>2000</Year><RecNum>5</RecNum><IDText>Cognitive, social, and economic costs of allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>5</Ref_ID><Title_Primary>Cognitive, social, and economic costs of allergic rhinitis</Title_Primary><Authors_Primary>Blaiss,M.S.</Authors_Primary><Date_Primary>2000/1</Date_Primary><Keywords>Absenteeism</Keywords><Keywords>Chronic Disease</Keywords><Keywords>Cognition Disorders</Keywords><Keywords>Cost of Illness</Keywords><Keywords>diagnosis</Keywords><Keywords>economics</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Learning</Keywords><Keywords>Male</Keywords><Keywords>physiopathology</Keywords><Keywords>Quality of Life</Keywords><Keywords>Questionnaires</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Socioeconomic Factors</Keywords><Keywords>standards</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>7</Start_Page><End_Page>13</End_Page><Periodical>Allergy Asthma Proc.</Periodical><Volume>21</Volume><Issue>1</Issue><Address>University of Tennessee, Memphis, USA</Address><Web_URL>PM:10748946</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy Asthma Proc.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Blaiss 2000). In addition, since the nose is the gateway to the respiratory tract, rhinitis is associated with symptoms in the eyes ADDIN REFMGR.CITE <Refman><Cite><Author>Hom</Author><Year>2013</Year><RecNum>1586</RecNum><IDText>The anatomical and functional relationship between allergic conjunctivitis and allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1586</Ref_ID><Title_Primary>The anatomical and functional relationship between allergic conjunctivitis and allergic rhinitis</Title_Primary><Authors_Primary>Hom,M.M.</Authors_Primary><Authors_Primary>Bielory,L.</Authors_Primary><Date_Primary>2013</Date_Primary><Keywords>Conjunctivitis</Keywords><Keywords>Inflammation</Keywords><Keywords>innervation</Keywords><Keywords>Nasal Cavity</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nose</Keywords><Keywords>Rhinitis</Keywords><Keywords>secretion</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>e110</Start_Page><End_Page>e119</End_Page><Periodical>Allergy Rhinol.(Providence.)</Periodical><Volume>4</Volume><Issue>3</Issue><User_Def_5>PMC3911799</User_Def_5><Misc_3>10.2500/ar.2013.4.0067 [doi];AR001-13 [pii]</Misc_3><Address>private practice, Azusa, CA and
Department of Medicine, Rutgers University, Robert Wood Johnson University Hospital, New Brunswick, New Jersey</Address><Web_URL>PM:24498515</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy Rhinol.(Providence.)</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Hom and Bielory 2013), sinuses ADDIN REFMGR.CITE <Refman><Cite><Author>Slavin</Author><Year>1998</Year><RecNum>7</RecNum><IDText>Complications of allergic rhinitis: implications for sinusitis and asthma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>7</Ref_ID><Title_Primary>Complications of allergic rhinitis: implications for sinusitis and asthma</Title_Primary><Authors_Primary>Slavin,R.G.</Authors_Primary><Date_Primary>1998/2</Date_Primary><Keywords>Animals</Keywords><Keywords>Asthma</Keywords><Keywords>complications</Keywords><Keywords>etiology</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>physiopathology</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sinusitis</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>S357</Start_Page><End_Page>S360</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>101</Volume><Issue>2 Pt 2</Issue><Address>Department of Internal Medicine, Saint Louis University School of Medicine, Mo. 63104, USA</Address><Web_URL>PM:9500727</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Slavin 1998), middle ear ADDIN REFMGR.CITE <Refman><Cite><Author>Doyle</Author><Year>2002</Year><RecNum>8</RecNum><IDText>The link between allergic rhinitis and otitis media</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>8</Ref_ID><Title_Primary>The link between allergic rhinitis and otitis media</Title_Primary><Authors_Primary>Doyle,W.J.</Authors_Primary><Date_Primary>2002/2</Date_Primary><Keywords>Animals</Keywords><Keywords>Comparative Study</Keywords><Keywords>complications</Keywords><Keywords>Ear,Middle</Keywords><Keywords>epidemiology</Keywords><Keywords>etiology</Keywords><Keywords>Eustachian Tube</Keywords><Keywords>Histamine</Keywords><Keywords>Humans</Keywords><Keywords>Inflammation</Keywords><Keywords>Interleukin-6</Keywords><Keywords>Nose</Keywords><Keywords>Otitis Media</Keywords><Keywords>physiopathology</Keywords><Keywords>Prevalence</Keywords><Keywords>Rats</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Risk</Keywords><Keywords>Risk Factors</Keywords><Keywords>secretion</Keywords><Reprint>Not in File</Reprint><Start_Page>21</Start_Page><End_Page>25</End_Page><Periodical>Curr.Opin.Allergy Clin.Immunol.</Periodical><Volume>2</Volume><Issue>1</Issue><Address>Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA. Docdoyle2@</Address><Web_URL>PM:11964746</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Doyle 2002), the nasopharynx and lower airways ADDIN REFMGR.CITE <Refman><Cite><Author>Passalacqua</Author><Year>2004</Year><RecNum>6</RecNum><IDText>An update on the asthma-rhinitis link</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>6</Ref_ID><Title_Primary>An update on the asthma-rhinitis link</Title_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Authors_Primary>Ciprandi,G.</Authors_Primary><Authors_Primary>Pasquali,M.</Authors_Primary><Authors_Primary>Guerra,L.</Authors_Primary><Authors_Primary>Canonica,G.W.</Authors_Primary><Date_Primary>2004/6</Date_Primary><Keywords>Asthma</Keywords><Keywords>Attention</Keywords><Keywords>Bronchi</Keywords><Keywords>Disease</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Infection</Keywords><Keywords>Italy</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nose</Keywords><Keywords>pathology</Keywords><Keywords>physiopathology</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sinusitis</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>177</Start_Page><End_Page>183</End_Page><Periodical>Curr.Opin.Allergy Clin.Immunol.</Periodical><Volume>4</Volume><Issue>3</Issue><Address>Allergy and Respiratory Diseases, Department of Internal Medicine, Genoa University, Italy. passalacqua@unige.it</Address><Web_URL>PM:15126938</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Passalacqua and others 2004). Both AR and non-allergic rhinitis (NAR) are risk factors for the development of asthma ADDIN REFMGR.CITE <Refman><Cite><Author>Barry</Author><Year>2000</Year><RecNum>9</RecNum><IDText>Rhino-sinus manifestations of systemic diseases</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>9</Ref_ID><Title_Primary>Rhino-sinus manifestations of systemic diseases</Title_Primary><Authors_Primary>Barry,B.</Authors_Primary><Date_Primary>2000/9/15</Date_Primary><Keywords>Chronic Disease</Keywords><Keywords>Churg-Strauss Syndrome</Keywords><Keywords>Comparative Study</Keywords><Keywords>complications</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>English Abstract</Keywords><Keywords>etiology</Keywords><Keywords>Humans</Keywords><Keywords>Nasal Septum</Keywords><Keywords>Nose Diseases</Keywords><Keywords>Paris</Keywords><Keywords>pathology</Keywords><Keywords>Polychondritis,Relapsing</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sarcoidosis</Keywords><Keywords>Sinusitis</Keywords><Keywords>Wegener's Granulomatosis</Keywords><Reprint>Not in File</Reprint><Start_Page>1548</Start_Page><End_Page>1550</End_Page><Periodical>Rev.Prat.</Periodical><Volume>50</Volume><Issue>14</Issue><Address>Service ORL Hopital Bichat-Claude-Bernard, Paris. pierre.gehanno@bch.ap-hop-paris.fr</Address><Web_URL>PM:11068618</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rev.Prat.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Barry 2000). 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ADDIN EN.CITE.DATA (Thomas and others 2005). All patients presenting with nasal symptoms require accurate diagnosis and appropriate treatment. These guidelines are intended to facilitate this. Evidence for the recommendations was obtained by using electronic literature searches using the primary keyword – rhinitis. Further searches were carried out by combining this search term with key words listed above through Medline and Embase from 2007-2014. Additional references were hand searched and provided by committee members, experts and reviewers from 2014 to 2017. Recent advances since the 2007 guidelines include evidence for local allergic rhinitis, demonstration of the greater effectiveness than either alone of combined topical preparations of antihistamine and corticosteroids, the concept of rhinitis control and of severe chronic upper airways disease (SCUAD) and better evidence for the efficacy of sublingual immunotherapy. Each article was reviewed according to criteria for suitability for inclusion. Recommendations were evidence graded, see appendix A PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJyaXRpc2ggVGhvcmFjaWMgU29jaWV0eTwvQXV0aG9yPjxZ
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ADDIN EN.CITE.DATA (British Thoracic Society 2003; Shekelle and others 1999). During guideline development, a web-based system was used to allow consultation with all BSACI members. The draft guidelines were amended by the Standards of Care Committee (SOCC) after careful consideration of all comments and suggestions. Where evidence was lacking, a consensus was reached among the experts on the committee. Conflicts of SOCC members’ interests were recorded. Definitions / classificationRhinitis describes inflammation of the nasal mucosa but is clinically defined by symptoms of nasal discharge, itching, sneezing and nasal blockage or congestion. When the conjunctivae are also involved, the term rhinoconjunctivitis is more accurate. Involvement of the sinus linings in more widespread disease is known as rhinosinusitis. Rhinitis has multiple phenotypes, usually divided into allergic, non-allergic and infective as well as mixed forms.3.1 Classification of Allergic Rhinitis (AR) The WHO ARIA workshop ‘Allergic Rhinitis and its impact on Asthma’ classification ADDIN REFMGR.CITE <Refman><Cite><Author>Bousquet</Author><Year>2001</Year><RecNum>41</RecNum><IDText>Allergic rhinitis and its impact on asthma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>41</Ref_ID><Title_Primary>Allergic rhinitis and its impact on asthma</Title_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Authors_Primary>Van,Cauwenberge P.</Authors_Primary><Authors_Primary>Khaltaev,N.</Authors_Primary><Date_Primary>2001/11</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>complications</Keywords><Keywords>Developing Countries</Keywords><Keywords>Disease</Keywords><Keywords>Disease Management</Keywords><Keywords>France</Keywords><Keywords>genetics</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>immunology</Keywords><Keywords>Patient Education</Keywords><Keywords>Quality of Life</Keywords><Keywords>Research</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>S147</Start_Page><End_Page>S334</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>108</Volume><Issue>5 Suppl</Issue><Address>Department of Allergy and Respiratory Diseases, University Hospital and INSERM, Montpellier, France</Address><Web_URL>PM:11707753</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bousquet and others 2001) of AR based on frequency and severity of symptoms has been validated ADDIN REFMGR.CITE <Refman><Cite><Author>Demoly</Author><Year>2003</Year><RecNum>42</RecNum><IDText>Validation of the classification of ARIA (allergic rhinitis and its impact on asthma)</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>42</Ref_ID><Title_Primary>Validation of the classification of ARIA (allergic rhinitis and its impact on asthma)</Title_Primary><Authors_Primary>Demoly,P.</Authors_Primary><Authors_Primary>Allaert,F.A.</Authors_Primary><Authors_Primary>Lecasble,M.</Authors_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Date_Primary>2003/7</Date_Primary><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>Comparative Study</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>epidemiology</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>France</Keywords><Keywords>Hay Fever</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Physicians</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rural Health</Keywords><Keywords>Severity of Illness Index</Keywords><Keywords>Urban Health</Keywords><Reprint>Not in File</Reprint><Start_Page>672</Start_Page><End_Page>675</End_Page><Periodical>Allergy</Periodical><Volume>58</Volume><Issue>7</Issue><Address>Unite d'Explorations des Allergies, Service des Maladies Respiratoires, INSERM, Hopital Arnaud de Villeneuve, Montpellier Cedex, France</Address><Web_URL>PM:12823130</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Demoly and others 2003a). 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ADDIN EN.CITE.DATA (Asher and others 2006), and 26% in UK adults ADDIN REFMGR.CITE <Refman><Cite><Author>Bauchau</Author><Year>2004</Year><RecNum>565</RecNum><IDText>Prevalence and rate of diagnosis of allergic rhinitis in Europe</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>565</Ref_ID><Title_Primary>Prevalence and rate of diagnosis of allergic rhinitis in Europe</Title_Primary><Authors_Primary>Bauchau,V.</Authors_Primary><Authors_Primary>Durham,S.R.</Authors_Primary><Date_Primary>2004/11</Date_Primary><Keywords>Adult</Keywords><Keywords>Belgium</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>diagnosis</Keywords><Keywords>epidemiology</Keywords><Keywords>Europe</Keywords><Keywords>Female</Keywords><Keywords>France</Keywords><Keywords>Germany</Keywords><Keywords>Great Britain</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>Interviews</Keywords><Keywords>Italy</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Prevalence</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Spain</Keywords><Reprint>Not in File</Reprint><Start_Page>758</Start_Page><End_Page>764</End_Page><Periodical>Eur.Respir.J.</Periodical><Volume>24</Volume><Issue>5</Issue><Address>UCB Pharma SA, R&D, Clinical Epidemiology and Outcomes Research, Chemin du Foriest, B-1420, Braine-l'Alleud, Belgium. vincent.bauchau@ucb-</Address><Web_URL>PM:15516669</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Respir.J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bauchau and Durham 2004). Peak prevalence occurs in the 3rd and 4th decades PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVyaWtzc29uPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Blomme and others 2013; Eriksson and others 2012), with some evidence for remission during adult life ADDIN REFMGR.CITE <Refman><Cite><Author>Warm</Author><Year>2012</Year><RecNum>618</RecNum><IDText>Low incidence and high remission of allergic sensitization among adults</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>618</Ref_ID><Title_Primary>Low incidence and high remission of allergic sensitization among adults</Title_Primary><Authors_Primary>Warm,K.</Authors_Primary><Authors_Primary>Backman,H.</Authors_Primary><Authors_Primary>Lindberg,A.</Authors_Primary><Authors_Primary>Lundback,B.</Authors_Primary><Authors_Primary>Ronmark,E.</Authors_Primary><Date_Primary>2012/1</Date_Primary><Keywords>Adult</Keywords><Keywords>Age Factors</Keywords><Keywords>Aged</Keywords><Keywords>Aging</Keywords><Keywords>Allergens</Keywords><Keywords>Animals</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>immunology</Keywords><Keywords>Incidence</Keywords><Keywords>Longitudinal Studies</Keywords><Keywords>Lung</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Pollen</Keywords><Keywords>Prevalence</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Research</Keywords><Keywords>Risk</Keywords><Keywords>Risk Factors</Keywords><Keywords>Skin</Keywords><Keywords>Sweden</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>136</Start_Page><End_Page>142</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>129</Volume><Issue>1</Issue><Misc_3>S0091-6749(11)01399-6 [pii];10.1016/j.jaci.2011.08.033 [doi]</Misc_3><Address>Obstructive Lung Disease in Northern Sweden Studies, Norrbotten County Council, Lulea, Sweden</Address><Web_URL>PM:21975174</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Warm and others 2012). The prevalence in the UK and Western Europe has increased dramatically over the past 4-5 decades PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkd1cHRhPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Braback and others 2004; Gupta and others 2007). Some studies suggest a plateau may have been reached PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkFzaGVyPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Asher and others 2006; Bjorksten and others 2008; Braun-Fahrlander and others 2004; Gupta and others 2007), whilst others report continued increases since the 1990s PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1jTmVpbGw8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Asher and others 2006; Katelaris and others 2012). Post-communist Eastern Europe has seen accelerating occurrence ADDIN REFMGR.CITE <Refman><Cite><Author>von Mutius E.</Author><Year>1998</Year><RecNum>665</RecNum><IDText>Increasing prevalence of hay fever and atopy among children in Leipzig, East Germany</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>665</Ref_ID><Title_Primary>Increasing prevalence of hay fever and atopy among children in Leipzig, East Germany</Title_Primary><Authors_Primary>von Mutius E.</Authors_Primary><Authors_Primary>Weiland,S.K.</Authors_Primary><Authors_Primary>Fritzsch,C.</Authors_Primary><Authors_Primary>Duhme,H.</Authors_Primary><Authors_Primary>Keil,U.</Authors_Primary><Date_Primary>1998/3/21</Date_Primary><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>Child</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Europe</Keywords><Keywords>Female</Keywords><Keywords>Germany</Keywords><Keywords>Hay Fever</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>Life Style</Keywords><Keywords>Logistic Models</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Parents</Keywords><Keywords>Prevalence</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>trends</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>862</Start_Page><End_Page>866</End_Page><Periodical>Lancet</Periodical><Volume>351</Volume><Issue>9106</Issue><Misc_3>S0140-6736(97)10100-3 [pii];10.1016/S0140-6736(97)10100-3 [doi]</Misc_3><Address>University Children's Hospital, Munich, Germany</Address><Web_URL>PM:9525363</Web_URL><ZZ_JournalStdAbbrev><f name="System">Lancet</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(von Mutius E. and others 1998). Local AR, confirmable only by nasal provocation, has been found to have a prevalence of over 25% in some centres PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJvbmRvbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Rondon and others 2012). A prevalence ratio of allergic to non-allergic rhinitis of 3:1 has been suggested ADDIN REFMGR.CITE <Refman><Cite><Author>Settipane</Author><Year>2009</Year><RecNum>4</RecNum><IDText>Epidemiology of vasomotor rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Epidemiology of vasomotor rhinitis</Title_Primary><Authors_Primary>Settipane,R.A.</Authors_Primary><Date_Primary>2009</Date_Primary><Reprint>Not in File</Reprint><Start_Page>115</Start_Page><End_Page>118</End_Page><Periodical>World Allergy Organ J.</Periodical><Volume>2</Volume><Issue>6</Issue><User_Def_5>PMC3650980</User_Def_5><Misc_3>1939-4551-2-6-115 [pii];10.1097/WOX.0b013e3181ac91ae [doi]</Misc_3><Address>From the Allergy & Asthma Center, a clinical teaching site of the Warren Alpert School of Medicine at Brown University, Providence, RI , 95 Pitman Street, Providence, RI 02906. setti5@</Address><Web_URL>PM:24229078</Web_URL><ZZ_JournalStdAbbrev><f name="System">World Allergy Organ J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Settipane</Author><Year>2009</Year><RecNum>4</RecNum><IDText>Epidemiology of vasomotor rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Epidemiology of vasomotor rhinitis</Title_Primary><Authors_Primary>Settipane,R.A.</Authors_Primary><Date_Primary>2009</Date_Primary><Reprint>Not in File</Reprint><Start_Page>115</Start_Page><End_Page>118</End_Page><Periodical>World Allergy Organ J.</Periodical><Volume>2</Volume><Issue>6</Issue><User_Def_5>PMC3650980</User_Def_5><Misc_3>1939-4551-2-6-115 [pii];10.1097/WOX.0b013e3181ac91ae [doi]</Misc_3><Address>From the Allergy & Asthma Center, a clinical teaching site of the Warren Alpert School of Medicine at Brown University, Providence, RI , 95 Pitman Street, Providence, RI 02906. setti5@</Address><Web_URL>PM:24229078</Web_URL><ZZ_JournalStdAbbrev><f name="System">World Allergy Organ J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Settipane 2009) (Settipane 2007)Rhinitis is strongly associated with asthma: 74-81% of asthmatics report symptoms of rhinitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxleW5hZXJ0PC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Guerra and others 2002; Shaaban and others 2008). AETIOLOGYGenetic predisposition is probably the most important factor in rhinitis development but identification of specific susceptibility genes has proved difficult. Large scale genome wide association studies (GWAS) have allowed identification of several candidate loci and genes for asthma and atopic dermatitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1vZmZhdHQ8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Moffatt and others 2010; Moffatt and others 2007; Paternoster and others 2012; Portelli and others 2014). To date, only one such GWAS has been carried out for AR PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJhbWFzYW15PC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48
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ADDIN EN.CITE.DATA (Ramasamy and others 2011). Of note, classical genetic change (i.e. change in DNA nucleotide sequence) is unable to account for the rapid increase in prevalence of AR seen in recent years, suggesting environmental factors (and possible gene-environment interactions) are important. Epidemiological evidence suggests smaller family size, urban environments, and reduced exposure to infectious diseases is involved and appear to have a particular effect during early life PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlN0cmFjaGFuPC9BdXRob3I+PFllYXI+MTk4OTwvWWVhcj48
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ADDIN EN.CITE.DATA (Matricardi and others 2002; Riedler and others 2001; Strachan 1989a; Strachan 1989b). Epigenetic modifications, such as DNA methylation, may be involved in the mechanism of gene-environment interactions in allergic diseases ADDIN REFMGR.CITE <Refman><Cite><Author>Kabesch</Author><Year>2014</Year><RecNum>680</RecNum><IDText>Epigenetics in asthma and allergy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>680</Ref_ID><Title_Primary>Epigenetics in asthma and allergy</Title_Primary><Authors_Primary>Kabesch,M.</Authors_Primary><Date_Primary>2014/2</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Asthma</Keywords><Keywords>Disease</Keywords><Keywords>DNA Methylation</Keywords><Keywords>Environment</Keywords><Keywords>Environmental Exposure</Keywords><Keywords>Epigenesis,Genetic</Keywords><Keywords>genetics</Keywords><Keywords>Germany</Keywords><Keywords>Histones</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>immunology</Keywords><Keywords>Lung</Keywords><Keywords>MicroRNAs</Keywords><Keywords>Research</Keywords><Keywords>Smoking</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>62</Start_Page><End_Page>68</End_Page><Periodical>Curr.Opin.Allergy Clin.Immunol.</Periodical><Volume>14</Volume><Issue>1</Issue><Misc_3>10.1097/ACI.0000000000000025 [doi]</Misc_3><Address>aHannover Medical School, Department of Pediatric Pneumology, Allergy and Neonatology, Hannover, Member of the German Lung Research Center bDepartment of Pediatric Pneumology and Allergy, KUNO University Children's Hospital Regensburg, Regensburg, Germany</Address><Web_URL>PM:24345787</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Kabesch 2014). ALLERGIC RHINITIS6.1 PathophysiologyThe basic mechanisms of AR are illustrated in Figure1. 6.2 Co-morbid associations of rhinitis (Table 2)AR -associated comorbid disorders can be subdivided into:other allergic diseases, particularly asthmaproblems related anatomically to the nose: conjunctivitis, rhinosinusitis,hyposmia, middle ear problems, throat and laryngeal effectsSleep problems and secondary effects of symptoms on concentration, mood and behaviourThe most important co-morbidity is asthma: not only is rhinitis a risk factor for subsequent asthma but 80% of asthma sufferers according to ARIA have concomitant rhinitis, poor control of which is a risk factor for asthma exacerbations PFJlZm1hbj48Q2l0ZT48QXV0aG9yPmRlIEdyb290PC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Powe and others 2001), the other without inflammation or local IgE production ADDIN REFMGR.CITE <Refman><Cite><Author>Kleinjan</Author><Year>2000</Year><RecNum>689</RecNum><IDText>Local production and detection of (specific) IgE in nasal B-cells and plasma cells of allergic rhinitis patients</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>689</Ref_ID><Title_Primary>Local production and detection of (specific) IgE in nasal B-cells and plasma cells of allergic rhinitis patients</Title_Primary><Authors_Primary>Kleinjan,A.</Authors_Primary><Authors_Primary>Vinke,J.G.</Authors_Primary><Authors_Primary>Severijnen,L.W.</Authors_Primary><Authors_Primary>Fokkens,W.J.</Authors_Primary><Date_Primary>2000/3</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Allergens</Keywords><Keywords>Antibodies</Keywords><Keywords>B-Lymphocytes</Keywords><Keywords>Biopsy</Keywords><Keywords>biosynthesis</Keywords><Keywords>Disease</Keywords><Keywords>Dust</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>Immunohistochemistry</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Netherlands</Keywords><Keywords>Nose</Keywords><Keywords>pathology</Keywords><Keywords>Plasma Cells</Keywords><Keywords>Pollen</Keywords><Keywords>Radioallergosorbent Test</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>491</Start_Page><End_Page>497</End_Page><Periodical>Eur.Respir.J.</Periodical><Volume>15</Volume><Issue>3</Issue><Address>Department of Otorhinolaryngology, Erasmus University Medical Centre Rotterdam, The Netherlands</Address><Web_URL>PM:10759442</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Respir.J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Kleinjan and others 2000). The former includes local allergic rhinitis ADDIN REFMGR.CITE <Refman><Cite><Author>Rondon</Author><Year>2010</Year><RecNum>1764</RecNum><IDText>Local allergic rhinitis: concept, clinical manifestations, and diagnostic approach</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1764</Ref_ID><Title_Primary>Local allergic rhinitis: concept, clinical manifestations, and diagnostic approach</Title_Primary><Authors_Primary>Rondon,C.</Authors_Primary><Authors_Primary>Fernandez,J.</Authors_Primary><Authors_Primary>Canto,G.</Authors_Primary><Authors_Primary>Blanca,M.</Authors_Primary><Date_Primary>2010</Date_Primary><Keywords>Allergens</Keywords><Keywords>Antibodies</Keywords><Keywords>diagnosis</Keywords><Keywords>Eosinophil Cationic Protein</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>immunology</Keywords><Keywords>metabolism</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nasal Provocation Tests</Keywords><Keywords>physiopathology</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>secretion</Keywords><Keywords>Skin</Keywords><Keywords>Skin Tests</Keywords><Keywords>Spain</Keywords><Keywords>Th2 Cells</Keywords><Keywords>Tryptases</Keywords><Reprint>Not in File</Reprint><Start_Page>364</Start_Page><End_Page>371</End_Page><Periodical>J.Investig.Allergol.Clin.Immunol.</Periodical><Volume>20</Volume><Issue>5</Issue><Address>Allergy Service, Carlos Haya Hospital, Malaga, Spain. carmenrs61@</Address><Web_URL>PM:20945601</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Investig.Allergol.Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Rondon and others 2010) and non- allergic rhinitis with eosinophilia (NARES). A proportion of patients within this latter group are aspirin / NSAID sensitive ADDIN REFMGR.CITE <Refman><Cite><Author>Szczeklik</Author><Year>2000</Year><RecNum>690</RecNum><IDText>Natural history of aspirin-induced asthma. AIANE Investigators. European Network on Aspirin-Induced Asthma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>690</Ref_ID><Title_Primary>Natural history of aspirin-induced asthma. AIANE Investigators. European Network on Aspirin-Induced Asthma</Title_Primary><Authors_Primary>Szczeklik,A.</Authors_Primary><Authors_Primary>Nizankowska,E.</Authors_Primary><Authors_Primary>Duplaga,M.</Authors_Primary><Date_Primary>2000/9</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Anti-Inflammatory Agents</Keywords><Keywords>Anti-Inflammatory Agents,Non-Steroidal</Keywords><Keywords>Aspirin</Keywords><Keywords>Asthma</Keywords><Keywords>chemically induced</Keywords><Keywords>Child</Keywords><Keywords>Databases,Factual</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>etiology</Keywords><Keywords>Europe</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>metabolism</Keywords><Keywords>Middle Aged</Keywords><Keywords>Physical Examination</Keywords><Keywords>physiopathology</Keywords><Keywords>Prednisone</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sex Factors</Keywords><Keywords>Steroids</Keywords><Keywords>Syndrome</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>432</Start_Page><End_Page>436</End_Page><Periodical>Eur.Respir.J.</Periodical><Volume>16</Volume><Issue>3</Issue><Address>Dept of Medicine, Jagellonian University School of Medicine, Cracow, Poland</Address><Web_URL>PM:11028656</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Respir.J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Szczeklik and others 2000). 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ADDIN EN.CITE.DATA (Powe and others 2001), ADDIN REFMGR.CITE <Refman><Cite><Author>Powe</Author><Year>2010</Year><RecNum>1</RecNum><IDText>'Entopy': local allergy paradigm</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1</Ref_ID><Title_Primary>'Entopy': local allergy paradigm</Title_Primary><Authors_Primary>Powe,D.G.</Authors_Primary><Authors_Primary>Bonnin,A.J.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Date_Primary>2010/7</Date_Primary><Keywords>B-Lymphocytes</Keywords><Keywords>immunology</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity,Immediate</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>metabolism</Keywords><Keywords>Mucous Membrane</Keywords><Keywords>Th2 Cells</Keywords><Reprint>Not in File</Reprint><Start_Page>987</Start_Page><End_Page>997</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>40</Volume><Issue>7</Issue><Misc_3>CEA3536 [pii];10.1111/j.1365-2222.2010.03536.x [doi]</Misc_3><Address>Division of Histopathology, Queen's Medical Centre, Nottingham University Hospitals Trust, Nottingham, UK. des.powe@nottingham.ac.uk</Address><Web_URL>PM:20642577</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Powe and others 2010), ADDIN REFMGR.CITE <Refman><Cite><Author>Powe</Author><Year>2003</Year><RecNum>2</RecNum><IDText>'Entopy': localized mucosal allergic disease in the absence of systemic responses for atopy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>'Entopy': localized mucosal allergic disease in the absence of systemic responses for atopy</Title_Primary><Authors_Primary>Powe,D.G.</Authors_Primary><Authors_Primary>Jagger,C.</Authors_Primary><Authors_Primary>Kleinjan,A.</Authors_Primary><Authors_Primary>Carney,A.S.</Authors_Primary><Authors_Primary>Jenkins,D.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Date_Primary>2003/10</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Allergens</Keywords><Keywords>immunology</Keywords><Keywords>Animals</Keywords><Keywords>B-Lymphocytes</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>blood</Keywords><Keywords>Male</Keywords><Keywords>Mast Cells</Keywords><Keywords>Middle Aged</Keywords><Keywords>Mites</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>pathology</Keywords><Keywords>Plasma Cells</Keywords><Keywords>Pollen</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Reprint>Not in File</Reprint><Start_Page>1374</Start_Page><End_Page>1379</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>33</Volume><Issue>10</Issue><Misc_3>1737 [pii]</Misc_3><Address>Department of Clinical Laboratory Sciences, Erasmus University, Dr Molewaterplein 50, Rotterdam, The Netherlands. Des.Powe@Nottinghan.ac.uk</Address><Web_URL>PM:14519143</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Powe and others 2003). Patients with non-inflammatory type rhinitis are thought to suffer from dysfunction of the autonomic nerve supply to the nasal mucosa PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNldHRpcGFuZTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+
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ADDIN EN.CITE.DATA (Settipane and Kaliner 2013; Van Gerven L. and others 2012). 7.2 Occupational rhinitisOccupational rhinitis, which can be allergic or non-allergic, describes abnormalities of the nasal mucosa mediated by airborne substances in the work environment. It is distinct from work-exacerbated rhinitis, which refers to individuals with pre-existing rhinitis who experience an exacerbation of symptoms due to workplace exposures. Over 300 agents can cause occupational rhinitis, and these are the same as those which can induce occupational asthma ADDIN REFMGR.CITE <Refman><Cite><Author>Bernstein</Author><Year>2006</Year><RecNum>699</RecNum><IDText>Definition and classification of asthma in the workplace.</IDText><MDL Ref_Type="Book Chapter"><Ref_Type>Book Chapter</Ref_Type><Ref_ID>699</Ref_ID><Title_Primary>Definition and classification of asthma in the workplace.</Title_Primary><Authors_Primary>Bernstein,I.L.</Authors_Primary><Authors_Primary>Chan-Yeung,M.</Authors_Primary><Authors_Primary>Malo,J.L.</Authors_Primary><Authors_Primary>Bernstein,D.I.</Authors_Primary><Date_Primary>2006</Date_Primary><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>Workplace</Keywords><Reprint>Not in File</Reprint><Start_Page>9</Start_Page><End_Page>35</End_Page><Volume>3rd edn.</Volume><Title_Secondary>Asthma in the Workplace</Title_Secondary><Authors_Secondary>Bernstein,I.L.</Authors_Secondary><Authors_Secondary>Chan-Yeung,M.</Authors_Secondary><Authors_Secondary>Malo,J.L.</Authors_Secondary><Authors_Secondary>ernstein,D.I.</Authors_Secondary><Pub_Place>New York</Pub_Place><Publisher>Taylor & Francis</Publisher><ZZ_WorkformID>3</ZZ_WorkformID></MDL></Cite></Refman>(Bernstein and others 2006). HMW agents are protein allergens derived from plants or animals e.g. flour, latex, laboratory animals and evidence of sensitisation is usually seen on skin testing or serum specific IgE PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJhdWxmPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Karjalainen and others 2003; Siracusa and others 2000). The early identification of a causative occupational agent and the avoidance of exposure are important for the prevention of progression to occupational asthma PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk8mYXBvcztNZWFyYTwvQXV0aG9yPjxZZWFyPjIwMDU8L1ll
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ADDIN EN.CITE.DATA (Colloff and others 1992; Filon and Radman 2006; Kronqvist and others 1999; O'Meara and others 2005) (Grade B).Diagnosis is based on a detailed history, including symptom diary review, improvement of nasal symptoms during weekends and holidays, skin prick testing and measurement of specific IgE when appropriate. Latex is a cause of both occupational rhinitis and asthma. Prevention of latex allergy by removing powdered gloves or substituting non-latex ones is essential. All healthcare environments should have a latex policy PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkZpbG9uPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Filon and Radman 2006; Hemery and others 2004) (Level of evidence=2+ and 4; Grade of recommendation=D, C for adults and children with perennial rhinitis or adults and children with latex allergy).Diagnosis of Rhinitis 8.1 HistoryA detailed history is required, including seasonality (pollen, moulds), indoors/outdoors location (dust mite, presence of house pets), work location (occupational), improvement of holidays and, relationship to potential triggers which can impact on the patient’s quality of life. Symptoms of sneezing, nasal itching, itching of the palate are more likely to lead to allergic rhinitis. 8.2 Rhinorrhoea Rhinorrhoea is either anterior, posterior or both.Clear - infection unlikely if continuously clear, though secretions are clear early in viral rhinitisUnilateral - is uncommon and cerebrospinal fluid (CSF) leak should be excluded ADDIN REFMGR.CITE <Refman><Cite><Author>Marshall</Author><Year>2001</Year><RecNum>15</RecNum><IDText>CSF rhinorrhoea: the place of endoscopic sinus surgery</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>15</Ref_ID><Title_Primary>CSF rhinorrhoea: the place of endoscopic sinus surgery</Title_Primary><Authors_Primary>Marshall,A.H.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Authors_Primary>Robertson,I.J.</Authors_Primary><Date_Primary>2001/2</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cerebrospinal Fluid Rhinorrhea</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>diagnosis</Keywords><Keywords>Endoscopy</Keywords><Keywords>Humans</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Neurosurgical Procedures</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Smell</Keywords><Keywords>surgery</Keywords><Keywords>Tomography,X-Ray Computed</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>8</Start_Page><End_Page>12</End_Page><Periodical>Br.J.Neurosurg.</Periodical><Volume>15</Volume><Issue>1</Issue><Address>Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Nottingham, UK</Address><Web_URL>PM:11303672</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Neurosurg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Marshall and others 2001)Colouredyellow - allergy or infection; green - usually infection; blood tingedunilateral – tumour, foreign body, nose picking or misapplication of nasal spray bilateral – misapplication of nasal spray, granulomatous disorder, bleeding diathesis, infection, nose picking. 8.3 Nasal obstructionCan be partial or complete; severity often correlates with systemic manifestations Bilateral –most likely rhinitis or nasal polyps but maybe septal (sigmoid) deviation Unilateral – usually septal deviation but also consider foreign body, antrochoanal polyp and tumoursAlternating – due to rhinitis exposing the nasal cycle ADDIN REFMGR.CITE <Refman><Cite><Author>Flanagan</Author><Year>1997</Year><RecNum>248</RecNum><IDText>Spontaneous changes of unilateral nasal airflow in man. A re-examination of the 'nasal cycle'</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>248</Ref_ID><Title_Primary>Spontaneous changes of unilateral nasal airflow in man. A re-examination of the 'nasal cycle'</Title_Primary><Authors_Primary>Flanagan,P.</Authors_Primary><Authors_Primary>Eccles,R.</Authors_Primary><Date_Primary>1997/7</Date_Primary><Keywords>Adult</Keywords><Keywords>Airway Resistance</Keywords><Keywords>Animals</Keywords><Keywords>Cold</Keywords><Keywords>Common Cold</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Nasal Cavity</Keywords><Keywords>Periodicity</Keywords><Keywords>physiology</Keywords><Keywords>Pulmonary Ventilation</Keywords><Keywords>Time Factors</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>590</Start_Page><End_Page>595</End_Page><Periodical>Acta Otolaryngol.</Periodical><Volume>117</Volume><Issue>4</Issue><Address>Common Cold Centre, University of Wales, Cardiff, UK</Address><Web_URL>PM:9288218</Web_URL><ZZ_JournalStdAbbrev><f name="System">Acta Otolaryngol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Flanagan and Eccles 1997)8.4 Nasal crustingSevere crusting especially high inside the nose is an unusual symptom in rhinitis and requires further investigation. Consider: chronic rhinosinusitis ADDIN REFMGR.CITE <Refman><Cite><Author>Jennings</Author><Year>1998</Year><RecNum>251</RecNum><IDText>Wegener's granulomatosis--a review of diagnosis and treatment in 53 subjects</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>251</Ref_ID><Title_Primary>Wegener's granulomatosis--a review of diagnosis and treatment in 53 subjects</Title_Primary><Authors_Primary>Jennings,C.R.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Authors_Primary>Dugar,J.</Authors_Primary><Authors_Primary>Powell,R.J.</Authors_Primary><Authors_Primary>Lowe,J.</Authors_Primary><Date_Primary>1998/12</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Biopsy</Keywords><Keywords>complications</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Otorhinolaryngologic Diseases</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Wegener's Granulomatosis</Keywords><Reprint>Not in File</Reprint><Start_Page>188</Start_Page><End_Page>191</End_Page><Periodical>Rhinology</Periodical><Volume>36</Volume><Issue>4</Issue><Address>Department of Otorhinolaryngology, Queen's Medical Centre, Nottingham</Address><Web_URL>PM:9923063</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rhinology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Jennings and others 1998), nose picking, granulomatous polyangiitis, sarcoidosis or other vasculitides, (particularly if crusting is associated with bleeding), cocaine abuse, ozaena (wasting away of the bony ridges and mucous membranes inside the nose), non-invasive ventilation. 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ADDIN EN.CITE.DATA (Laitinen 1974; Laitinen and Kokkola 1974; Townley and others 1965).Disorders of the upper and lower respiratory tract often coexist:80% of asthmatics have rhinitis – see section on rhinitis and asthma8.7 Other SymptomsSnoring, sleep problems, repeated sniffing, nasal intonation of the voice Pollen food syndrome is triggered by ingestion of cross-reacting antigens in some fruits, vegetables and nuts ADDIN REFMGR.CITE <Refman><Cite><Author>Ortolani</Author><Year>1988</Year><RecNum>547</RecNum><IDText>The oral allergy syndrome</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>547</Ref_ID><Title_Primary>The oral allergy syndrome</Title_Primary><Authors_Primary>Ortolani,C.</Authors_Primary><Authors_Primary>Ispano,M.</Authors_Primary><Authors_Primary>Pastorello,E.</Authors_Primary><Authors_Primary>Bigi,A.</Authors_Primary><Authors_Primary>Ansaloni,R.</Authors_Primary><Date_Primary>1988/12</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Age of Onset</Keywords><Keywords>Allergy and Immunology</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>complications</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Female</Keywords><Keywords>Food Hypersensitivity</Keywords><Keywords>Fruit</Keywords><Keywords>Hay Fever</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Italy</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Mouth</Keywords><Keywords>Pollen</Keywords><Keywords>Pruritus</Keywords><Keywords>Radioallergosorbent Test</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Skin</Keywords><Keywords>Skin Tests</Keywords><Keywords>Syndrome</Keywords><Keywords>Vegetables</Keywords><Reprint>Not in File</Reprint><Start_Page>47</Start_Page><End_Page>52</End_Page><Periodical>Ann.Allergy</Periodical><Volume>61</Volume><Issue>6 Pt 2</Issue><Address>Bizzozero Medical Division Allergy and Immunology Center, Ospedale Niguarda Ca Granda, Milan, Italy</Address><Web_URL>PM:3264668</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Ortolani and others 1988) A proportion of patients suffering from allergic (mainly seasonal) rhinitis have an associated nasal hyper-reactivity which is generally not recognised/ treated8.8 Family historyA diagnosis of allergic rhinitis is more likely when rhinitis is seasonal, or with a family history of AR.However it can arise de novo.8.9 Social historyConsider pets or other contact with animals, occupation or schooling. 9.10 DrugsA number of drugs can cause or aggravate rhinitis symptoms and therefore a drug history should include details of the use of alpha- and beta-blockers and other anti-hypertensives, aspirin and other non-steroidal anti-inflammatory drugs, oral contraceptives as well as topical sympathomimetics (see table 1). It is also important to enquire about the efficacy of previous treatments for rhinitis and details of how they were used and for how long.EXAMINATION9.1 Visual assessmentAllergic salute and/or horizontal nasal crease across dorsum of nose and/ or eye involvement supports a diagnosis of allergic rhinitisChronic mouth breathingAllergic shinersAn assessment of nasal airflow – (e.g. metal spatula misting in young children)Depressed nasal bridge – post surgery, granulomatous polyangiitis or cocaine misuseWidened bridge; polyps (see also BSACI guideline on rhinosinusitis and nasal polyposis; PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNjYWRkaW5nPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE.DATA (Scadding and others 2008)Purple nasal tip due to sarcoidosis9.2 Anterior rhinoscopyHypertrophic, pale and boggy inferior or middle turbinates suggest inflammation, but nasal appearance may be normal in ARPresence or absence of clear, coloured or purulent secretionsA deviated septum does not usually cause rhinitisPresence or absence of nasal polyps, but it may not be possible to see small ones or if they are confined to the sinuses. Larger polyps can be seen in the nasal vestibule sometimes extending as low as the nares and can be distinguished from the inferior turbinate by their lack of sensitivity, yellow/ grey colour and the ability to get between them and the side wall of the nose.Yellow sub-mucosal nodules with a cobblestone appearance suggest sarcoidosis ADDIN REFMGR.CITE <Refman><Cite><Author>Fergie</Author><Year>1999</Year><RecNum>256</RecNum><IDText>The nasal manifestations of sarcoidosis: a review and report of eight cases</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>256</Ref_ID><Title_Primary>The nasal manifestations of sarcoidosis: a review and report of eight cases</Title_Primary><Authors_Primary>Fergie,N.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Authors_Primary>Havlat,M.F.</Authors_Primary><Date_Primary>1999/10</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Biopsy</Keywords><Keywords>complications</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Nasal Septum</Keywords><Keywords>Nose</Keywords><Keywords>Nose Diseases</Keywords><Keywords>pathology</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Sarcoidosis</Keywords><Keywords>Steroids</Keywords><Reprint>Not in File</Reprint><Start_Page>893</Start_Page><End_Page>898</End_Page><Periodical>J.Laryngol.Otol.</Periodical><Volume>113</Volume><Issue>10</Issue><Address>Department of Otorhinolaryngology, Queen's Medical Centre, Nottingham, UK</Address><Web_URL>PM:10664703</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Laryngol.Otol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Fergie and others 1999).Crusting and granulations raise the possibility of vasculitisSeptal perforation may occur after septal surgery or due to chronic vasoconstriction (cocaine, alpha agonists), granulomatous polyangiitis, anti-phospholipid antibody syndrome and nose pickingThroat examination- cobblestoned lymphoid hyperplasia, post nasal drip9.3 Nasal endoscopyUsed in specialist centres to examine both the anterior and posterior parts of the nasal cavity this is more specific than rhinoscopy and alters the diagnosis in up to a fifth of patients with nasal disease ADDIN REFMGR.CITE <Refman><Cite><Author>Hughes</Author><Year>1998</Year><RecNum>19</RecNum><IDText>The role of nasal endoscopy in outpatient management</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>19</Ref_ID><Title_Primary>The role of nasal endoscopy in outpatient management</Title_Primary><Authors_Primary>Hughes,R.G.</Authors_Primary><Authors_Primary>Jones,N.S.</Authors_Primary><Date_Primary>1998/6</Date_Primary><Keywords>Ambulatory Care</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>Endoscopy</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Nasal Polyps</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>Sinusitis</Keywords><Keywords>statistics & numerical data</Keywords><Keywords>surgery</Keywords><Keywords>Tomography,X-Ray Computed</Keywords><Keywords>utilization</Keywords><Reprint>Not in File</Reprint><Start_Page>224</Start_Page><End_Page>226</End_Page><Periodical>Clin.Otolaryngol.Allied Sci.</Periodical><Volume>23</Volume><Issue>3</Issue><Address>Department of Otorhinolaryngology/Head and Neck Surgery, Queen's Medical Centre, Nottingham, UK</Address><Web_URL>PM:9669070</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Otolaryngol.Allied Sci.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Hughes and Jones 1998). INVESTIGATIONSAllergen specific IgE can be detected with skin prick tests (SPTs) or by serum immunoassay.10.1 Skin prick tests (SPT)Should be carried out routinely in order to determine if the rhinitis is allergic or non-allergic, and have a high negative predictive value. They should be interpreted in the light of the clinical history At least 15% of people with a positive skin prick test do not develop symptoms on exposure to the relevant allergen PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRyb3N0ZTwvQXV0aG9yPjxZZWFyPjE5OTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Droste and others 1996)Prick to Prick tests with fresh food can be used to diagnose oral allergy syndrome10.2 Serum total and specific IgESerum specific IgE may be requested when skin tests are not possible or when the SPT together with the clinical history give equivocal results. Total IgE alone can be misleading but may aid interpretation of specific IgE. Currently available SPTs and allergen specific IgE show similar sensitivity for house dust mite (HDM), but SPTs are more sensitive to other inhalant allergens such as cat epithelium, mould and grass pollen ADDIN REFMGR.CITE <Refman><Cite><Author>Gleeson</Author><Year>1996</Year><RecNum>538</RecNum><IDText>A clinical evaluation in children of the Pharmacia ImmunoCAP system for inhalant allergens</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>538</Ref_ID><Title_Primary>A clinical evaluation in children of the Pharmacia ImmunoCAP system for inhalant allergens</Title_Primary><Authors_Primary>Gleeson,M.</Authors_Primary><Authors_Primary>Cripps,A.W.</Authors_Primary><Authors_Primary>Hensley,M.J.</Authors_Primary><Authors_Primary>Wlodarczyk,J.H.</Authors_Primary><Authors_Primary>Henry,R.L.</Authors_Primary><Authors_Primary>Clancy,R.L.</Authors_Primary><Date_Primary>1996/6</Date_Primary><Keywords>Aged</Keywords><Keywords>Allergens</Keywords><Keywords>analysis</Keywords><Keywords>Animals</Keywords><Keywords>Antibodies</Keywords><Keywords>Antigens,Dermatophagoides</Keywords><Keywords>Cats</Keywords><Keywords>Child</Keywords><Keywords>Disease</Keywords><Keywords>Dust</Keywords><Keywords>Epithelium</Keywords><Keywords>etiology</Keywords><Keywords>Glycoproteins</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>immunology</Keywords><Keywords>methods</Keywords><Keywords>Mites</Keywords><Keywords>pathology</Keywords><Keywords>Reagent Kits,Diagnostic</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Respiratory Hypersensitivity</Keywords><Keywords>Sensitivity and Specificity</Keywords><Reprint>Not in File</Reprint><Start_Page>697</Start_Page><End_Page>702</End_Page><Periodical>Clin Exp.Allergy</Periodical><Volume>26</Volume><Issue>6</Issue><Address>Hunter Immunology Unit, Hunter Area Pathology Service, Royal Newcastle Hospital, New South Wales, Australia</Address><Web_URL>PM:8809427</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Gleeson and others 1996). 10.3 Laboratory investigations Usually unnecessary, their use is guided by the history, examination and results of skin prick tests. Examples include:Full blood count (FBC) and differential white cell count, C-reactive protein (CRP), , immunoglobulin profile, microbiological examination of sputum and sinus swabs when chronic infection is suspectedThyroid function tests in unexplained nasal obstructionNasal secretions - asialotransferrin for CSF identificationUrine toxicology when cocaine abuse is suspected 10.4 Olfactory testsThe University of Pennsylvania Smell Identification Test (UPSIT) is well validated, and can be helpful when there is suspicion of malingering ADDIN REFMGR.CITE <Refman><Cite><Author>Doty</Author><Year>1984</Year><RecNum>16</RecNum><IDText>University of Pennsylvania Smell Identification Test: a rapid quantitative olfactory function test for the clinic</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>16</Ref_ID><Title_Primary>University of Pennsylvania Smell Identification Test: a rapid quantitative olfactory function test for the clinic</Title_Primary><Authors_Primary>Doty,R.L.</Authors_Primary><Authors_Primary>Shaman,P.</Authors_Primary><Authors_Primary>Kimmelman,C.P.</Authors_Primary><Authors_Primary>Dann,M.S.</Authors_Primary><Date_Primary>1984/2</Date_Primary><Keywords>diagnosis</Keywords><Keywords>Humans</Keywords><Keywords>Olfaction Disorders</Keywords><Keywords>Research</Keywords><Keywords>Research Support,U.'t,P.H.S.</Keywords><Keywords>Smell</Keywords><Keywords>Smoking</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>176</Start_Page><End_Page>178</End_Page><Periodical>Laryngoscope</Periodical><Volume>94</Volume><Issue>2 Pt 1</Issue><Web_URL>PM:6694486</Web_URL><ZZ_JournalStdAbbrev><f name="System">Laryngoscope</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Doty and others 1984), it is accepted for legal cases. 10.5 CytologyThe techniques for obtaining cells for cytology in secretions, lavage, scraping, cotton buds or brushings has not been standardised, nor have the criteria for evaluating cell counts ADDIN REFMGR.CITE <Refman><Cite><Author>Romero</Author><Year>1992</Year><RecNum>257</RecNum><IDText>Eosinophilia in nasal secretions compared to skin prick test and nasal challenge test in the diagnosis of nasal allergy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>257</Ref_ID><Title_Primary>Eosinophilia in nasal secretions compared to skin prick test and nasal challenge test in the diagnosis of nasal allergy</Title_Primary><Authors_Primary>Romero,J.N.</Authors_Primary><Authors_Primary>Scadding,G.</Authors_Primary><Date_Primary>1992/9</Date_Primary><Keywords>Adult</Keywords><Keywords>Comparative Study</Keywords><Keywords>diagnosis</Keywords><Keywords>Eosinophilia</Keywords><Keywords>Eosinophils</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>London</Keywords><Keywords>Male</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nasal Provocation Tests</Keywords><Keywords>Nose</Keywords><Keywords>pathology</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>secretion</Keywords><Keywords>Skin Tests</Keywords><Keywords>ultrastructure</Keywords><Reprint>Not in File</Reprint><Start_Page>169</Start_Page><End_Page>175</End_Page><Periodical>Rhinology</Periodical><Volume>30</Volume><Issue>3</Issue><Address>Royal National Throat, Nose and Ear Hospital, London, United Kingdom</Address><Web_URL>PM:1448673</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rhinology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Romero and Scadding 1992). 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ADDIN EN.CITE.DATA (Nielsen and others 1988; Nielsen and others 1998)10.6 Exhaled nitric oxide (eNO)Exhaled nitric oxide (FeNO = fractional exhaled nitric oxide) measurement can be useful clinically in the diagnosis and monitoring of asthma. Normal levels are less than 20ppb, but become elevated in eosinophilic lower respiratory tract inflammation ADDIN REFMGR.CITE <Refman><Cite><Author>Prieto</Author><Year>1994</Year><RecNum>23</RecNum><IDText>Effect of inhaled budesonide on seasonal changes in sensitivity and maximal response to methacholine in pollen-sensitive asthmatic subjects</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>23</Ref_ID><Title_Primary>Effect of inhaled budesonide on seasonal changes in sensitivity and maximal response to methacholine in pollen-sensitive asthmatic subjects</Title_Primary><Authors_Primary>Prieto,L.</Authors_Primary><Authors_Primary>Berto,J.M.</Authors_Primary><Authors_Primary>Gutierrez,V.</Authors_Primary><Authors_Primary>Tornero,C.</Authors_Primary><Date_Primary>1994/10</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Inhalation</Keywords><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>Bronchial Provocation Tests</Keywords><Keywords>Bronchodilator Agents</Keywords><Keywords>Budesonide</Keywords><Keywords>diagnostic use</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>Female</Keywords><Keywords>Forced Expiratory Volume</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>Methacholine Chloride</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>Pollen</Keywords><Keywords>Pregnenediones</Keywords><Keywords>Seasons</Keywords><Keywords>Sensitivity and Specificity</Keywords><Reprint>Not in File</Reprint><Start_Page>1845</Start_Page><End_Page>1851</End_Page><Periodical>Eur.Respir.J.</Periodical><Volume>7</Volume><Issue>10</Issue><Address>Unidad de Alergia, Hospital Dr. Peset, Valencia, Spain</Address><Web_URL>PM:7828695</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Respir.J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Prieto and others 1994).10.7 Nasal NO Levels are complex since there are two sources of NO: sinuses and nasal epithelium. However very low levels (<100 ppb) indicate the likelihood of primary ciliary dyskinesia, but can also be observed in cystic fibrosis and in sinus obstruction caused by large polyps. NO measurements are restricted to specialist centres.10.8 RadiologyRadiology is not routinely recommended for simple rhinitis. However, when rhinosinusitis or nasal polyposis is suspected, especially non-responsive to medical therapy, CT scan is helpful.10.9 Nasal challengeIt is not routinely available outside specialist centres, there is no standardised methodology and asthmatic reactions can occur. It may be useful to confirm aspirin sensitivity or in occupational allergic rhinitis, where there is discrepancy between history and when there are potentially important occupational implications.10.10 Objective measures of nasal airway Objective measurements of the nasal airway are not made in routine clinical practice but can be useful when allergen or aspirin challenges are undertaken and may be helpful when septal surgery or turbinate reduction are being contemplated.10.11 Tests for asthmaMeasurements of lung function should be considered in all patients with persistent rhinitis.10.12 ENT referralPatients with unilateral symptoms, heavily blood stained discharge or pain, require ENT referral. Those with nasal blockage unrelieved by pharmacotherapy or structural abnormalities, such as septal deviation, sufficient to render nasal therapy difficult, should be seen by a surgeon.treatment (see figure 2)11.1 Allergen avoidance Allergen avoidance clearly works in seasonal allergic rhino-conjunctivitis: hay fever sufferers are symptom-free outside the pollen season. For patients with house dust mite- sensitive AR the situation is complicated by the difficulties of reducing exposure to mites in the home. A systematic review of trials of mite allergen avoidance in rhinitis concluded that trials are generally small and of poor methodological quality and meta-analysis could not be performed ADDIN REFMGR.CITE <Refman><Cite><Author>Nurmatov</Author><Year>2012</Year><RecNum>703</RecNum><IDText>House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>703</Ref_ID><Title_Primary>House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review</Title_Primary><Authors_Primary>Nurmatov,U.</Authors_Primary><Authors_Primary>van Schayck,C.P.</Authors_Primary><Authors_Primary>Hurwitz,B.</Authors_Primary><Authors_Primary>Sheikh,A.</Authors_Primary><Date_Primary>2012/2</Date_Primary><Keywords>Animals</Keywords><Keywords>Antigens,Dermatophagoides</Keywords><Keywords>Dust</Keywords><Keywords>Health</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>methods</Keywords><Keywords>prevention & control</Keywords><Keywords>Pyroglyphidae</Keywords><Keywords>Randomized Controlled Trials</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Tick Control</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>158</Start_Page><End_Page>165</End_Page><Periodical>Allergy</Periodical><Volume>67</Volume><Issue>2</Issue><Misc_3>10.1111/j.1398-9995.2011.02752.x [doi]</Misc_3><Address>Allergy & Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, UK</Address><Web_URL>PM:22103686</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Nurmatov and others 2012). 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ADDIN EN.CITE.DATA (Raulf and others 2014). Irritants such as smoke, traffic pollution, etc. can worsen rhinitis symptoms and should be avoided, where possible.In a DBRPC study the application of a cellulose powder (Nasaleze?) three times daily resulted in significant reductions in severity scores for sneezing, runny nose, stuffy nose and symptoms from eyes and lower airways with no clinically significant adverse effects (Grade B) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkFiZXJnPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Aberg and others 2014).Interventions that may help to reduce symptoms during the pollen season include patients wearing sunglasses (PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk96dHVyazwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (O'Meara and others 2005), balms and ointments applied to the nose ADDIN REFMGR.CITE <Refman><Cite><Author>Kennedy</Author><Year>2012</Year><RecNum>1579</RecNum><IDText>Haymax - confidential report</IDText><MDL Ref_Type="Report"><Ref_Type>Report</Ref_Type><Ref_ID>1579</Ref_ID><Title_Primary>Haymax - confidential report</Title_Primary><Authors_Primary>Kennedy,R.</Authors_Primary><Authors_Primary>Robertson,L.</Authors_Primary><Authors_Primary>Lewis,M.</Authors_Primary><Date_Primary>2012</Date_Primary><Reprint>Not in File</Reprint><Start_Page>1</Start_Page><End_Page>14</End_Page><Pub_Place>Worcester</Pub_Place><Publisher>The National Pollen and Aerobiology Research Unit (NPARU)</Publisher><Availability>online</Availability><Web_URL><u>;(Kennedy and others 2012). Other practical/common sense measures that may reduce exposure to pollen are summarised in Table 3 but have not been tested in studies.11.2 Pet allergens For patients with AR sensitized to and symptomatic on contact with pets such as cats, dogs and horses, avoidance of the animal should be advised. For those who wish to keep pets to which they are sensitized, there is limited information from randomized studies on which to base recommendations ADDIN REFMGR.CITE <Refman><Cite><Author>Bjornsdottir</Author><Year>2003</Year><RecNum>707</RecNum><IDText>The effect of reducing levels of cat allergen (Fel d 1) on clinical symptoms in patients with cat allergy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>707</Ref_ID><Title_Primary>The effect of reducing levels of cat allergen (Fel d 1) on clinical symptoms in patients with cat allergy</Title_Primary><Authors_Primary>Bjornsdottir,U.S.</Authors_Primary><Authors_Primary>Jakobinudottir,S.</Authors_Primary><Authors_Primary>Runarsdottir,V.</Authors_Primary><Authors_Primary>Juliusson,S.</Authors_Primary><Date_Primary>2003/8</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Air Pollution,Indoor</Keywords><Keywords>Animals</Keywords><Keywords>Animals,Domestic</Keywords><Keywords>Cats</Keywords><Keywords>Dust</Keywords><Keywords>Environment</Keywords><Keywords>Environment,Controlled</Keywords><Keywords>Environmental Exposure</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Glycoproteins</Keywords><Keywords>Health</Keywords><Keywords>Housekeeping</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>prevention & control</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Ventilation</Keywords><Reprint>Not in File</Reprint><Start_Page>189</Start_Page><End_Page>194</End_Page><Periodical>Ann.Allergy Asthma Immunol.</Periodical><Volume>91</Volume><Issue>2</Issue><Address>Health Care Center, Reykjavik, Iceland. usb@landspitali.is</Address><Web_URL>PM:12952114</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Allergy Asthma Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bjornsdottir and others 2003) HEPA filters alone do not seem useful for cat allergic patients with cats. Cat allergen exposure can be reduced using temperature-controlled laminar airflow treatment ADDIN REFMGR.CITE <Refman><Cite><Author>Gore</Author><Year>2015</Year><RecNum>1603</RecNum><IDText>Effect of a novel temperature-controlled laminar airflow device on personal breathing zone aeroallergen exposure</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1603</Ref_ID><Title_Primary>Effect of a novel temperature-controlled laminar airflow device on personal breathing zone aeroallergen exposure</Title_Primary><Authors_Primary>Gore,R.B.</Authors_Primary><Authors_Primary>Boyle,R.J.</Authors_Primary><Authors_Primary>Gore,C.</Authors_Primary><Authors_Primary>Custovic,A.</Authors_Primary><Authors_Primary>Hanna,H.</Authors_Primary><Authors_Primary>Svensson,P.</Authors_Primary><Authors_Primary>Warner,J.O.</Authors_Primary><Date_Primary>2015/2</Date_Primary><Keywords>Environment</Keywords><Keywords>Health</Keywords><Keywords>Immunoassay</Keywords><Keywords>Research</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>36</Start_Page><End_Page>44</End_Page><Periodical>Indoor.Air</Periodical><Volume>25</Volume><Issue>1</Issue><Misc_3>10.1111/ina.12122 [doi]</Misc_3><Address>Manchester Academic Health Science Centre, University Hospitals of South Manchester, University of Manchester, Manchester, UK; East and North Herts NHS Trust, Stevenage, UK</Address><Web_URL>PM:24750266</Web_URL><ZZ_JournalStdAbbrev><f name="System">Indoor.Air</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Gore and others 2015), and although this treatment has shown to improve asthma – related quality of life, this has not been tested for rhinitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJveWxlPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Boyle and others 2012). 11.3 Saline irrigationIsotonic saline irrigation in both adults and children with allergic rhinitis, was well tolerated ADDIN REFMGR.CITE <Refman><Cite><Author>Jeffe</Author><Year>2012</Year><RecNum>710</RecNum><IDText>Nasal saline irrigation in children: a study of compliance and tolerance</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>710</Ref_ID><Title_Primary>Nasal saline irrigation in children: a study of compliance and tolerance</Title_Primary><Authors_Primary>Jeffe,J.S.</Authors_Primary><Authors_Primary>Bhushan,B.</Authors_Primary><Authors_Primary>Schroeder,J.W.,Jr.</Authors_Primary><Date_Primary>2012/3</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Adolescent</Keywords><Keywords>Age Factors</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>Cohort Studies</Keywords><Keywords>complications</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Health</Keywords><Keywords>Health Care Surveys</Keywords><Keywords>Humans</Keywords><Keywords>Irrigation</Keywords><Keywords>Isotonic Solutions</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Nasal Lavage</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Parents</Keywords><Keywords>Patient Compliance</Keywords><Keywords>Physicians</Keywords><Keywords>psychology</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sinusitis</Keywords><Keywords>Sodium</Keywords><Keywords>Sodium Chloride</Keywords><Keywords>Solutions</Keywords><Keywords>surgery</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>409</Start_Page><End_Page>413</End_Page><Periodical>Int.J.Pediatr.Otorhinolaryngol.</Periodical><Volume>76</Volume><Issue>3</Issue><Misc_3>S0165-5876(11)00649-5 [pii];10.1016/j.ijporl.2011.12.022 [doi]</Misc_3><Address>Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA</Address><Web_URL>PM:22266167</Web_URL><ZZ_JournalStdAbbrev><f name="System">Int.J.Pediatr.Otorhinolaryngol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Jeffe and others 2012), inexpensive, easy to use with no evidence of adverse effect to health with regular use PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1hcmNoaXNpbzwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA (Chen and others 2014; Marchisio and others 2012). It has a small beneficial effect in symptom reduction and may reduce the amount of pharmacotherapy needed (Grade B).11.4 Carbon dioxide washingThe use of a ten second burst of carbon dioxide from a pressurized container into the nasal airway, with the mouth open, reduces all the symptoms of rhinitis within minutes. It is now available over the counter for rescue treatment as Serenz ADDIN REFMGR.CITE <Refman><Cite><Author>Casale</Author><Year>2008</Year><RecNum>1801</RecNum><IDText>Intranasal noninhaled carbon dioxide for the symptomatic treatment of seasonal allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1801</Ref_ID><Title_Primary>Intranasal noninhaled carbon dioxide for the symptomatic treatment of seasonal allergic rhinitis</Title_Primary><Authors_Primary>Casale,T.B.</Authors_Primary><Authors_Primary>Romero,F.A.</Authors_Primary><Authors_Primary>Spierings,E.L.</Authors_Primary><Date_Primary>2008/1</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Allergy and Immunology</Keywords><Keywords>Carbon Dioxide</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Headache</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Inhalation</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Sneezing</Keywords><Keywords>therapeutic use</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>105</Start_Page><End_Page>109</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>121</Volume><Issue>1</Issue><Misc_3>S0091-6749(07)01657-0 [pii];10.1016/j.jaci.2007.08.056 [doi]</Misc_3><Address>Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, NE 68131, USA. tbcasale@creighton.edu</Address><Web_URL>PM:18028997</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Casale and others 2008) ADDIN REFMGR.CITE <Refman><Cite><Author>Casale</Author><Year>2011</Year><RecNum>1802</RecNum><IDText>Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1802</Ref_ID><Title_Primary>Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis</Title_Primary><Authors_Primary>Casale,T.B.</Authors_Primary><Authors_Primary>Korenblat,P.E.</Authors_Primary><Authors_Primary>Meltzer,E.O.</Authors_Primary><Authors_Primary>Yen,K.</Authors_Primary><Authors_Primary>Bhatnagar,A.</Authors_Primary><Date_Primary>2011/10</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Inhalation</Keywords><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Allergy and Immunology</Keywords><Keywords>Carbon Dioxide</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Headache</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Multicenter Studies</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Safety</Keywords><Keywords>Universities</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>364</Start_Page><End_Page>370</End_Page><Periodical>Ann.Allergy Asthma Immunol.</Periodical><Volume>107</Volume><Issue>4</Issue><Misc_3>S1081-1206(11)00560-6 [pii];10.1016/j.anai.2011.07.014 [doi]</Misc_3><Address>Division of Allergy and Immunology, Creighton University, Omaha, Nebraska, USA. tbcasale@creighton.edu</Address><Web_URL>PM:21962098</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Allergy Asthma Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Casale and others 2011). PHARMACOTHERAPYAllergen and irritant avoidance is difficult and many rhinitis sufferers continue to have persistent symptoms, the nature of which should help determine the selection of medication. Available treatments and their effects upon individual symptoms are detailed in Table 4. All have Grade A level of recommendation. Following diagnosis and classification according to disease severity, therapy using a stepwise pharmacotherapeutic approach should be undertaken. A combination of treatments is often needed for more severe disease and it is here that the option of immunotherapy should also be considered (Figure 3).12.1 AntihistaminesAntihistamines are available as oral, intranasal and ocular preparations.All demonstrate clinical efficacy. It is important to use a drug with the least adverse effect and that is considered safe for the current situation (i.e. such as pregnancy, breast feeding). Second generation antihistamines are long acting, and are largely non-sedating and have no clinically significant anti-cholinergic activity at therapeutic doses, although there is variation in individual susceptibility to such effects ADDIN REFMGR.CITE <Refman><Cite><Author>Shamsi</Author><Year>2000</Year><RecNum>652</RecNum><IDText>Sedation and antihistamines: a review of inter-drug differences using proportional impairment ratios</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>652</Ref_ID><Title_Primary>Sedation and antihistamines: a review of inter-drug differences using proportional impairment ratios</Title_Primary><Authors_Primary>Shamsi,Z.</Authors_Primary><Authors_Primary>Hindmarch,I.</Authors_Primary><Date_Primary>2000/10</Date_Primary><Reprint>Not in File</Reprint><Start_Page>S3</Start_Page><End_Page>S30</End_Page><Periodical>Hum.Psychopharmacol.</Periodical><Volume>15</Volume><Issue>S1</Issue><Misc_3>10.1002/1099-1077(200010)15:1+<::AID-HUP247>3.0.CO;2-S [doi]</Misc_3><Address>HPRU Medical Research Centre, University of Surrey, Egerton Road, Guildford GU2 5XP, Surrey, UK</Address><Web_URL>PM:12404608</Web_URL><ZZ_JournalStdAbbrev><f name="System">Hum.Psychopharmacol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Shamsi and Hindmarch 2000). 12.2 Oral H1- antihistamines Reduce mean daily rhinitis symptom scores (in absolute terms) by an estimated 7% versus placebo ADDIN REFMGR.CITE <Refman><Cite><Author>Wilson</Author><Year>2004</Year><RecNum>606</RecNum><IDText>Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>606</Ref_ID><Title_Primary>Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis</Title_Primary><Authors_Primary>Wilson,A.M.</Authors_Primary><Authors_Primary>O'Byrne,P.M.</Authors_Primary><Authors_Primary>Parameswaran,K.</Authors_Primary><Date_Primary>2004/3/1</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>analysis</Keywords><Keywords>Canada</Keywords><Keywords>drug therapy</Keywords><Keywords>Drug Therapy,Combination</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Leukotriene Antagonists</Keywords><Keywords>methods</Keywords><Keywords>Quality of Life</Keywords><Keywords>Randomized Controlled Trials</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>therapeutic use</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>338</Start_Page><End_Page>344</End_Page><Periodical>Am J Med.</Periodical><Volume>116</Volume><Issue>5</Issue><Address>Firestone Institute for Respiratory Health, St. Joseph's Healthcare, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada</Address><Web_URL>PM:14984820</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am J Med.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Wilson and others 2004) and can significantly improve quality of life PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBhcmllbnRlPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48
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ADDIN EN.CITE.DATA (Canonica and others 2007; Ciprandi and others 2004; Ciprandi and others 2001; Hore and others 2005; Nayak and Schenkel 2001; Patou and others 2006; van Steekelenburg J. and others 2002). Additionally, they reduce histamine driven symptoms such as itch ADDIN REFMGR.CITE <Refman><Cite><Author>Dhand</Author><Year>2014</Year><RecNum>636</RecNum><IDText>The neurology of itch</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>636</Ref_ID><Title_Primary>The neurology of itch</Title_Primary><Authors_Primary>Dhand,A.</Authors_Primary><Authors_Primary>Aminoff,M.J.</Authors_Primary><Date_Primary>2014/2</Date_Primary><Keywords>Animals</Keywords><Keywords>Anti-Inflammatory Agents</Keywords><Keywords>Anti-Inflammatory Agents,Non-Steroidal</Keywords><Keywords>Brain</Keywords><Keywords>Capsaicin</Keywords><Keywords>Central Nervous System</Keywords><Keywords>diagnosis</Keywords><Keywords>drug effects</Keywords><Keywords>Guanidines</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Nerve Fibers,Unmyelinated</Keywords><Keywords>Nervous System Diseases</Keywords><Keywords>pharmacology</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Pruritus</Keywords><Keywords>Quality of Life</Keywords><Keywords>Research</Keywords><Keywords>Skin</Keywords><Keywords>Spinothalamic Tracts</Keywords><Keywords>Syndrome</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>313</Start_Page><End_Page>322</End_Page><Periodical>Brain</Periodical><Volume>137</Volume><Issue>Pt 2</Issue><Misc_3>awt158 [pii];10.1093/brain/awt158 [doi]</Misc_3><Address>Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0114, USA</Address><Web_URL>PM:23794605</Web_URL><ZZ_JournalStdAbbrev><f name="System">Brain</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Dhand and Aminoff 2014) at sites other than just the nose such as conjunctiva, palate and skin PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk5lbHNvbjwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Nelson 2003; Portnoy and Dinakar 2004; Schwarzer and others 2004). They should be used regularly rather than ‘as needed’ use in persistent rhinitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNpcHJhbmRpPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48
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ADDIN EN.CITE.DATA (Ciprandi and others 1997a; Leurs and others 2002). Acrivastine has the fastest onset of action, but needs to be used 8 hourly; fexofenadine is the least sedating oral antihistamine with a wide therapeutic index. 12.3 Adverse EffectsFirst generation anti-histamines are less useful due to sedation and cognitive impairment which can worsen driving and examination results already impaired by rhinitis ADDIN REFMGR.CITE <Refman><Cite><Author>Walker</Author><Year>2007</Year><RecNum>2</RecNum><IDText>Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study</Title_Primary><Authors_Primary>Walker,S.</Authors_Primary><Authors_Primary>Khan-Wasti,S.</Authors_Primary><Authors_Primary>Fletcher,M.</Authors_Primary><Authors_Primary>Cullinan,P.</Authors_Primary><Authors_Primary>Harris,J.</Authors_Primary><Authors_Primary>Sheikh,A.</Authors_Primary><Date_Primary>2007/8</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Anti-Allergic Agents</Keywords><Keywords>adverse effects</Keywords><Keywords>therapeutic use</Keywords><Keywords>Case-Control Studies</Keywords><Keywords>Educational Measurement</Keywords><Keywords>Female</Keywords><Keywords>Great Britain</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Hypnotics and Sedatives</Keywords><Keywords>Male</Keywords><Keywords>Regression Analysis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>drug therapy</Keywords><Keywords>physiopathology</Keywords><Keywords>psychology</Keywords><Keywords>Surveys and Questionnaires</Keywords><Keywords>Task Performance and Analysis</Keywords><Reprint>Not in File</Reprint><Start_Page>381</Start_Page><End_Page>387</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>120</Volume><Issue>2</Issue><Misc_3>S0091-6749(07)00632-X [pii];10.1016/j.jaci.2007.03.034 [doi]</Misc_3><Address>Education for Health, Warwick, United Kingdom. s.walker@.uk</Address><Web_URL>PM:17560637</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Walker and others 2007a), PFJlZm1hbj48Q2l0ZT48QXV0aG9yPldlaWxlcjwvQXV0aG9yPjxZZWFyPjIwMDA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Gray and others 2015).Second generation antihistamines Terfenadine and astemizole were implicated in deaths from ventricular fibrillation via QT interval prolongation ADDIN REFMGR.CITE <Refman><Cite><Author>Olasinska-Wisniewska</Author><Year>2014</Year><RecNum>1810</RecNum><IDText>Cardiovascular safety of antihistamines</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1810</Ref_ID><Title_Primary>Cardiovascular safety of antihistamines</Title_Primary><Authors_Primary>Olasinska-Wisniewska,A.</Authors_Primary><Authors_Primary>Olasinski,J.</Authors_Primary><Authors_Primary>Grajek,S.</Authors_Primary><Date_Primary>2014/6</Date_Primary><Keywords>Anaphylaxis</Keywords><Keywords>Astemizole</Keywords><Keywords>Bronchi</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Disease</Keywords><Keywords>Histamine</Keywords><Keywords>Muscle Contraction</Keywords><Keywords>Nasal Cavity</Keywords><Keywords>Permeability</Keywords><Keywords>Poland</Keywords><Keywords>Potassium</Keywords><Keywords>Potassium Channels</Keywords><Keywords>Rhinitis</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>Terfenadine</Keywords><Keywords>Universities</Keywords><Keywords>Urticaria</Keywords><Reprint>Not in File</Reprint><Start_Page>182</Start_Page><End_Page>186</End_Page><Periodical>Postepy Dermatol.Alergol.</Periodical><Volume>31</Volume><Issue>3</Issue><User_Def_5>PMC4112269</User_Def_5><Misc_3>10.5114/pdia.2014.43191 [doi];22874 [pii]</Misc_3><Address>1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland. Head of Department: Prof. Stefan Grajek MD, PhD
Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland. Head of Department: Prof. Zbigniew Adamski MD, PhD
1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland. Head of Department: Prof. Stefan Grajek MD, PhD</Address><Web_URL>PM:25097491</Web_URL><ZZ_JournalStdAbbrev><f name="System">Postepy Dermatol.Alergol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Olasinska-Wisniewska and others 2014). Ebastine and mizolastine also need to be used with caution in those with cardiac risk factors ADDIN REFMGR.CITE <Refman><Cite><Author>Davila</Author><Year>2006</Year><RecNum>634</RecNum><IDText>Effect of H1 antihistamines upon the cardiovascular system</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>634</Ref_ID><Title_Primary>Effect of H1 antihistamines upon the cardiovascular system</Title_Primary><Authors_Primary>Davila,I.</Authors_Primary><Authors_Primary>Sastre,J.</Authors_Primary><Authors_Primary>Bartra,J.</Authors_Primary><Authors_Primary>Del,Cuvillo A.</Authors_Primary><Authors_Primary>Jauregui,I.</Authors_Primary><Authors_Primary>Montoro,J.</Authors_Primary><Authors_Primary>Mullol,J.</Authors_Primary><Authors_Primary>Valero,A.L.</Authors_Primary><Date_Primary>2006</Date_Primary><Keywords>Action Potentials</Keywords><Keywords>adverse effects</Keywords><Keywords>Animals</Keywords><Keywords>Cardiovascular System</Keywords><Keywords>contraindications</Keywords><Keywords>drug effects</Keywords><Keywords>Electrocardiography</Keywords><Keywords>genetics</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Long QT Syndrome</Keywords><Keywords>Potassium</Keywords><Keywords>Potassium Channel Blockers</Keywords><Keywords>Spain</Keywords><Reprint>Not in File</Reprint><Start_Page>13</Start_Page><End_Page>23</End_Page><Periodical>J.Investig.Allergol Clin.Immunol.</Periodical><Volume>16 Suppl 1</Volume><Address>Servicio de Alergia, Hospital Clinico, Salamanca, Spain</Address><Web_URL>PM:17357373</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Investig.Allergol Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Davila and others 2006), but even cetirizine, desloratadine, diphenhydramine, fexofenadine, loratadine were possibly associated with cardiac arrhythmias in a single large European pharmacovigilance study PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBvbHV6emk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Poluzzi and others 2015). Interaction with other medications is rare other than for mizolastine with certain anti-arrhythmics, antibiotics and beta-blockers leading to an increased risk of arrhythmia. Rupatadine should not be co-prescribed with known CYP3A4 inhibitors ADDIN REFMGR.CITE <Refman><Cite><Author>Picado</Author><Year>2006</Year><RecNum>654</RecNum><IDText>Rupatadine: pharmacological profile and its use in the treatment of allergic disorders</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>654</Ref_ID><Title_Primary>Rupatadine: pharmacological profile and its use in the treatment of allergic disorders</Title_Primary><Authors_Primary>Picado,C.</Authors_Primary><Date_Primary>2006/10</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>analogs & derivatives</Keywords><Keywords>Animals</Keywords><Keywords>Cetirizine</Keywords><Keywords>Cyproheptadine</Keywords><Keywords>drug effects</Keywords><Keywords>drug therapy</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Loratadine</Keywords><Keywords>pharmacology</Keywords><Keywords>Platelet Activating Factor</Keywords><Keywords>Psychomotor Performance</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>therapeutic use</Keywords><Keywords>Urticaria</Keywords><Reprint>Not in File</Reprint><Start_Page>1989</Start_Page><End_Page>2001</End_Page><Periodical>Expert.Opin.Pharmacother.</Periodical><Volume>7</Volume><Issue>14</Issue><Misc_3>10.1517/14656566.7.14.1989 [doi]</Misc_3><Address>University of Barcelona, Servei de Pneumologia i Allergia Respiratoria, Hospital Clinic, c/Villarroel 170, 08036 Barcelona, Spain. cpicado@ub.edu</Address><Web_URL>PM:17020424</Web_URL><ZZ_JournalStdAbbrev><f name="System">Expert.Opin.Pharmacother.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Picado 2006). 12.4 Place in therapy First line therapy for mild to moderate intermittent and mild persistent rhinitis Addition to intranasal steroids for moderate/severe persistent rhinitis uncontrolled on topical intranasal corticosteroids alone, particularly when eye symptoms are present PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkp1bmlwZXI8L0F1dGhvcj48WWVhcj4xOTg5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Juniper and others 1989; Ratner and others 1998; Simpson 1994). Evidence for this combination is less good than for the addition of intranasal antihistamine to topical intranasal corticosteroids in a guinea pig model ADDIN REFMGR.CITE <Refman><Cite><Author>Takahashi</Author><Year>2012</Year><RecNum>8</RecNum><IDText>The potential role of prostaglandin D2 in nasal congestion observed in a guinea pig model of allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>8</Ref_ID><Title_Primary>The potential role of prostaglandin D2 in nasal congestion observed in a guinea pig model of allergic rhinitis</Title_Primary><Authors_Primary>Takahashi,G.</Authors_Primary><Authors_Primary>Tanaka,H.</Authors_Primary><Authors_Primary>Higuchi,N.</Authors_Primary><Authors_Primary>Ikeda,M.</Authors_Primary><Authors_Primary>Inagaki,N.</Authors_Primary><Authors_Primary>Shichijo,M.</Authors_Primary><Date_Primary>2012</Date_Primary><Keywords>Animals</Keywords><Keywords>Cyclic AMP</Keywords><Keywords>analysis</Keywords><Keywords>Disease Models,Animal</Keywords><Keywords>Guinea Pigs</Keywords><Keywords>Male</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>blood supply</Keywords><Keywords>immunology</Keywords><Keywords>metabolism</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Prostaglandin D2</Keywords><Keywords>Receptors,Prostaglandin</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Reprint>Not in File</Reprint><Start_Page>359</Start_Page><End_Page>368</End_Page><Periodical>Int.Arch.Allergy Immunol.</Periodical><Volume>158</Volume><Issue>4</Issue><Misc_3>000334555 [pii];10.1159/000334555 [doi]</Misc_3><Address>United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University, Gifu, Japan</Address><Web_URL>PM:22472859</Web_URL><ZZ_JournalStdAbbrev><f name="System">Int.Arch.Allergy Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Takahashi and others 2012). 12.5 Topical H1- antihistamines12.5.1 Nasal These are superior to oral antihistamines in attenuating rhinitis symptoms ADDIN REFMGR.CITE <Refman><Cite><Author>Lee</Author><Year>2007</Year><RecNum>629</RecNum><IDText>Meta-analysis of azelastine nasal spray for the treatment of allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>629</Ref_ID><Title_Primary>Meta-analysis of azelastine nasal spray for the treatment of allergic rhinitis</Title_Primary><Authors_Primary>Lee,T.A.</Authors_Primary><Authors_Primary>Pickard,A.S.</Authors_Primary><Date_Primary>2007/6</Date_Primary><Keywords>Administration,Intranasal</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Anti-Allergic Agents</Keywords><Keywords>Cost-Benefit Analysis</Keywords><Keywords>drug therapy</Keywords><Keywords>Europe</Keywords><Keywords>Humans</Keywords><Keywords>Patient Satisfaction</Keywords><Keywords>Phthalazines</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>therapeutic use</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>852</Start_Page><End_Page>859</End_Page><Periodical>Pharmacotherapy</Periodical><Volume>27</Volume><Issue>6</Issue><Misc_3>10.1592/phco.27.6.852 [doi]</Misc_3><Address>Midwest Center for Health Services and Policy Research, Hines Veterans Affairs Hospital, Hines, Illinois, USA</Address><Web_URL>PM:17542768</Web_URL><ZZ_JournalStdAbbrev><f name="System">Pharmacotherapy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Lee and Pickard 2007), and in decreasing nasal obstruction PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpZWJlcm1hbjwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+
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ADDIN EN.CITE.DATA (Horak 2008; Lieberman and others 2005), though they do not improve symptoms due to histamine at other sites, such as skin. There is a rapid onset of action (15 minutes), faster than oral antihistamines PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkhvcmFrPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Horak and others 2006), thus the drug can be used on demand as rescue therapy for symptom breakthrough. Continuous treatment is however more clinically effective than on-demand use PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNpcHJhbmRpPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48
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ADDIN EN.CITE.DATA (Ciprandi and others 1997b). They can be effective in patients who have previously failed oral anti-histamines PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxhRm9yY2U8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Yanez and Rodrigo 2002). Adverse effects include local nasal irritation and taste disturbance with Azelastine (dysgeusia). Azelastine nasal spray is the only available intranasal antihistamine in the UK. 12.5.2 Place in therapy This is the first line of therapy for mild to moderate intermittent and mild persistent rhinitis. Intranasal steroids used for moderate/severe persistent rhinitis which are not controlled on topical intranasal corticosteroids alone. CORTICOSTEROID THERAPY13.1 Intranasal corticosteroids (INS) Topical corticosteroids are the mainstay of anti-inflammatory intervention in AR. Factors which need consideration are systemic drug bioavailability, safety and cost ADDIN REFMGR.CITE <Refman><Cite><Author>Bielory</Author><Year>2014</Year><RecNum>1587</RecNum><IDText>Over-the-counter migration of steroid use: impact on the eye</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1587</Ref_ID><Title_Primary>Over-the-counter migration of steroid use: impact on the eye</Title_Primary><Authors_Primary>Bielory,B.</Authors_Primary><Authors_Primary>Bielory,L.</Authors_Primary><Date_Primary>2014/10</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Comorbidity</Keywords><Keywords>Glaucoma</Keywords><Keywords>Intraocular Pressure</Keywords><Keywords>Pressure</Keywords><Keywords>Risk</Keywords><Keywords>Smoking</Keywords><Keywords>Steroids</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>471</Start_Page><End_Page>476</End_Page><Periodical>Curr.Opin.Allergy Clin.Immunol.</Periodical><Volume>14</Volume><Issue>5</Issue><Misc_3>10.1097/ACI.0000000000000099 [doi]</Misc_3><Address>aDepartment of Ophthalmology, New York Medical College, Valhalla, New York bDepartment of Medicine, Robert Wood Johnson University Hospital, Rutgers University, New Brunswick, New Jersey, USA</Address><Web_URL>PM:25102105</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bielory and Bielory 2014). Ease of device use may influence concordance. INS reduces all symptoms of rhinitis by about 17% more than placebo, with a variable effect on associated allergic conjunctivitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPktlaXRoPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Hong and others 2011; Keith and Scadding 2009). Meta-analysis shows that INS is superior to oral antihistamines or leukotriene receptor antagonist alone on all aspects of allergic rhinitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPldlaW5lcjwvQXV0aG9yPjxZZWFyPjE5OTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Weiner and others 1998; Wilson and others 2004) (Grade Ia). Unlike other treatments, INS reduce nasal congestion ADDIN REFMGR.CITE <Refman><Cite><Author>Weiner</Author><Year>1998</Year><RecNum>33</RecNum><IDText>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>33</Ref_ID><Title_Primary>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</Title_Primary><Authors_Primary>Weiner,J.M.</Authors_Primary><Authors_Primary>Abramson,M.J.</Authors_Primary><Authors_Primary>Puy,R.M.</Authors_Primary><Date_Primary>1998/12/12</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Administration,Oral</Keywords><Keywords>Adrenal Cortex Hormones</Keywords><Keywords>analysis</Keywords><Keywords>Australia</Keywords><Keywords>drug therapy</Keywords><Keywords>Eye</Keywords><Keywords>Female</Keywords><Keywords>Histamine</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Receptors,Histamine H1</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sneezing</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>1624</Start_Page><End_Page>1629</End_Page><Periodical>BMJ</Periodical><Volume>317</Volume><Issue>7173</Issue><User_Def_5>PMC28740</User_Def_5><Address>Department of Medicine, Monash University, Melbourne, Victoria, 3181, Australia. jmwiener@.au</Address><Web_URL>PM:9848901</Web_URL><ZZ_JournalStdAbbrev><f name="System">BMJ</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Weiner and others 1998). Onset of action is 6-8 hours after the first dose, clinical improvement may not be apparent for a few days and maximal effect may not be apparent until after two weeks ADDIN REFMGR.CITE <Refman><Cite><Author>Weiner</Author><Year>1998</Year><RecNum>33</RecNum><IDText>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>33</Ref_ID><Title_Primary>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</Title_Primary><Authors_Primary>Weiner,J.M.</Authors_Primary><Authors_Primary>Abramson,M.J.</Authors_Primary><Authors_Primary>Puy,R.M.</Authors_Primary><Date_Primary>1998/12/12</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Administration,Oral</Keywords><Keywords>Adrenal Cortex Hormones</Keywords><Keywords>analysis</Keywords><Keywords>Australia</Keywords><Keywords>drug therapy</Keywords><Keywords>Eye</Keywords><Keywords>Female</Keywords><Keywords>Histamine</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Receptors,Histamine H1</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sneezing</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>1624</Start_Page><End_Page>1629</End_Page><Periodical>BMJ</Periodical><Volume>317</Volume><Issue>7173</Issue><User_Def_5>PMC28740</User_Def_5><Address>Department of Medicine, Monash University, Melbourne, Victoria, 3181, Australia. jmwiener@.au</Address><Web_URL>PM:9848901</Web_URL><ZZ_JournalStdAbbrev><f name="System">BMJ</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Weiner and others 1998). Starting treatment two weeks prior to a known allergen season improves efficacy PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkdyYWZ0PC9BdXRob3I+PFllYXI+MTk5NjwvWWVhcj48UmVj
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Pm==
ADDIN EN.CITE.DATA (Graft and others 1996). Similar clinical efficacy for all INS, but bioavailability varies considerably (see Figure 3).Systemic absorption negligible with mometasone furoate, fluticasone furoate and fluticasone propionate and these preparations are favoured for children. Systemic absorption is modest for the remainder, and high for betamethasone which should be used short term only PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRlcmVuZG9yZjwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+
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ADDIN EN.CITE.DATA (Derendorf and Meltzer 2008; Homer and Gazis 1999).13.2 Adverse eventsLocal nasal irritation, sore throat and epistaxis affect around 10% of users. Benzalkonium chloride is used as a preservative in several topical corticosteroids, and may irritate the nose, but does not adversely affect mucociliary clearance ADDIN REFMGR.CITE <Refman><Cite><Author>McMahon</Author><Year>1997</Year><RecNum>667</RecNum><IDText>Immediate and short-term effects of benzalkonium chloride on the human nasal mucosa in vivo</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>667</Ref_ID><Title_Primary>Immediate and short-term effects of benzalkonium chloride on the human nasal mucosa in vivo</Title_Primary><Authors_Primary>McMahon,C.</Authors_Primary><Authors_Primary>Darby,Y.</Authors_Primary><Authors_Primary>Ryan,R.</Authors_Primary><Authors_Primary>Scadding,G.</Authors_Primary><Date_Primary>1997/8</Date_Primary><Keywords>Adult</Keywords><Keywords>Anti-Infective Agents</Keywords><Keywords>Anti-Infective Agents,Local</Keywords><Keywords>Benzalkonium Compounds</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug effects</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Mucociliary Clearance</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nasal Sprays</Keywords><Keywords>Nose</Keywords><Keywords>pharmacology</Keywords><Keywords>Time</Keywords><Keywords>Time Factors</Keywords><Reprint>Not in File</Reprint><Start_Page>318</Start_Page><End_Page>322</End_Page><Periodical>Clin.Otolaryngol.Allied Sci.</Periodical><Volume>22</Volume><Issue>4</Issue><Address>Royal National Throat, Nose and Ear Hospital, London, UK</Address><Web_URL>PM:9298605</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Otolaryngol.Allied Sci.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(McMahon and others 1997). In patients with nasal irritation symptoms such as burning for example, a trial with a benzalkonium- free preparation, e.g. Rhinocort, Flixonase nasules is suggested. Reduction of local adverse effects such as nasal crusting, bleeding and pain can be achieved in many cases by correct use of the intranasal device, see figure 4a; (Grade of recommendation=D). Nasal drops are useful for severe obstruction and should be used in the ‘head upside down’ position in order to reach the ostiomeatal complex (OMC), see figure 4b.Hypothalamic-pituitary axis suppression may occur when multiple sites are treated with topical corticosteroids in the same person (e.g. skin, nose and chest) ADDIN REFMGR.CITE <Refman><Cite><Author>Allen</Author><Year>2000</Year><RecNum>357</RecNum><IDText>Systemic effects of intranasal steroids: an endocrinologist's perspective</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>357</Ref_ID><Title_Primary>Systemic effects of intranasal steroids: an endocrinologist's perspective</Title_Primary><Authors_Primary>Allen,D.B.</Authors_Primary><Date_Primary>2000/10</Date_Primary><Keywords>Absorption</Keywords><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>adverse effects</Keywords><Keywords>analogs & derivatives</Keywords><Keywords>Androstadienes</Keywords><Keywords>Beclomethasone</Keywords><Keywords>Budesonide</Keywords><Keywords>drug therapy</Keywords><Keywords>Efficiency</Keywords><Keywords>Endocrinology</Keywords><Keywords>Fluocinolone Acetonide</Keywords><Keywords>Growth</Keywords><Keywords>Hay Fever</Keywords><Keywords>Humans</Keywords><Keywords>metabolism</Keywords><Keywords>methods</Keywords><Keywords>physiology</Keywords><Keywords>Pregnadienediols</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>Steroids</Keywords><Keywords>therapy</Keywords><Keywords>Triamcinolone</Keywords><Keywords>Triamcinolone Acetonide</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>S179</Start_Page><End_Page>S190</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>106</Volume><Issue>4 Suppl</Issue><Address>Department of Pediatrics, Division of Endocrinology, University of Wisconsin Children's Hospital, USA.</Address><Web_URL>PM:11032642</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Allen 2000). If corticosteroids are used in multiple sites, then a low bioavailability preparation should be favoured.Raised intra-ocular pressure has been described with INS ADDIN REFMGR.CITE <Refman><Cite><Author>Bui</Author><Year>2005</Year><RecNum>669</RecNum><IDText>Discontinuing nasal steroids might lower intraocular pressure in glaucoma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>669</Ref_ID><Title_Primary>Discontinuing nasal steroids might lower intraocular pressure in glaucoma</Title_Primary><Authors_Primary>Bui,C.M.</Authors_Primary><Authors_Primary>Chen,H.</Authors_Primary><Authors_Primary>Shyr,Y.</Authors_Primary><Authors_Primary>Joos,K.M.</Authors_Primary><Date_Primary>2005/11</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Drug Administration Schedule</Keywords><Keywords>drug effects</Keywords><Keywords>Eye</Keywords><Keywords>Female</Keywords><Keywords>Glaucoma</Keywords><Keywords>Humans</Keywords><Keywords>Intraocular Pressure</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Ocular Hypertension</Keywords><Keywords>physiopathology</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Steroids</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>1042</Start_Page><End_Page>1047</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>116</Volume><Issue>5</Issue><Misc_3>S0091-6749(05)01724-0 [pii];10.1016/j.jaci.2005.07.031 [doi]</Misc_3><Address>Vanderbilt Eye Institute, Nashville, TN, 37232-8808, USA</Address><Web_URL>PM:16275373</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bui and others 2005) thus limiting its use in patients with predisposition to high ocular pressure/glaucoma is important. 13.3 Place in TherapyFirst line therapy for moderate to severe persistent symptoms ADDIN REFMGR.CITE <Refman><Cite><Author>Bousquet</Author><Year>2001</Year><RecNum>41</RecNum><IDText>Allergic rhinitis and its impact on asthma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>41</Ref_ID><Title_Primary>Allergic rhinitis and its impact on asthma</Title_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Authors_Primary>Van,Cauwenberge P.</Authors_Primary><Authors_Primary>Khaltaev,N.</Authors_Primary><Date_Primary>2001/11</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>complications</Keywords><Keywords>Developing Countries</Keywords><Keywords>Disease</Keywords><Keywords>Disease Management</Keywords><Keywords>France</Keywords><Keywords>genetics</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>immunology</Keywords><Keywords>Patient Education</Keywords><Keywords>Quality of Life</Keywords><Keywords>Research</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>S147</Start_Page><End_Page>S334</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>108</Volume><Issue>5 Suppl</Issue><Address>Department of Allergy and Respiratory Diseases, University Hospital and INSERM, Montpellier, France</Address><Web_URL>PM:11707753</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Bousquet and others 2001).First line of therapy if presenting with severe nasal obstruction ADDIN REFMGR.CITE <Refman><Cite><Author>Weiner</Author><Year>1998</Year><RecNum>33</RecNum><IDText>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>33</Ref_ID><Title_Primary>Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials</Title_Primary><Authors_Primary>Weiner,J.M.</Authors_Primary><Authors_Primary>Abramson,M.J.</Authors_Primary><Authors_Primary>Puy,R.M.</Authors_Primary><Date_Primary>1998/12/12</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Administration,Oral</Keywords><Keywords>Adrenal Cortex Hormones</Keywords><Keywords>analysis</Keywords><Keywords>Australia</Keywords><Keywords>drug therapy</Keywords><Keywords>Eye</Keywords><Keywords>Female</Keywords><Keywords>Histamine</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Receptors,Histamine H1</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sneezing</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>1624</Start_Page><End_Page>1629</End_Page><Periodical>BMJ</Periodical><Volume>317</Volume><Issue>7173</Issue><User_Def_5>PMC28740</User_Def_5><Address>Department of Medicine, Monash University, Melbourne, Victoria, 3181, Australia. jmwiener@.au</Address><Web_URL>PM:9848901</Web_URL><ZZ_JournalStdAbbrev><f name="System">BMJ</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Weiner and others 1998), possibly combined with a short term nasal decongestant. 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ADDIN EN.CITE.DATA (Pullerits and others 2002a; Wilson and others 2001b). 14.2 INS and topical H1-antihistamine combination Currently available as a combination spray containing azelastine and fluticasone propionate (FP), Dymista leads to greater symptom improvement than using either agent alone in SAR PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhcnI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Carr and others 2012a) (Grade A ). All symptoms of allergic rhinitis were significantly improved with onset of action by 30 minutes PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1lbHR6ZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Meltzer and others 2012). The combination approach leads to clinical improvement of symptoms days earlier than seen with azelastine or FP monotherapy PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhcnI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Meltzer and others 2012). Efficacy over FP is demonstrated in perennial allergic rhinitis ADDIN REFMGR.CITE <Refman><Cite><Author>Price</Author><Year>2013</Year><RecNum>641</RecNum><IDText>A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>641</Ref_ID><Title_Primary>A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis</Title_Primary><Authors_Primary>Price,D.</Authors_Primary><Authors_Primary>Shah,S.</Authors_Primary><Authors_Primary>Bhatia,S.</Authors_Primary><Authors_Primary>Bachert,C.</Authors_Primary><Authors_Primary>Berger,W.</Authors_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Authors_Primary>Carr,W.</Authors_Primary><Authors_Primary>Hellings,P.</Authors_Primary><Authors_Primary>Munzel,U.</Authors_Primary><Authors_Primary>Scadding,G.</Authors_Primary><Authors_Primary>Lieberman,P.</Authors_Primary><Date_Primary>2013</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Androstadienes</Keywords><Keywords>Child</Keywords><Keywords>Chronic Disease</Keywords><Keywords>Drug Combinations</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Phthalazines</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Keywords>Time</Keywords><Reprint>Not in File</Reprint><Start_Page>495</Start_Page><End_Page>503</End_Page><Periodical>J.Investig.Allergol.Clin.Immunol.</Periodical><Volume>23</Volume><Issue>7</Issue><Web_URL>PM:24654314</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Investig.Allergol.Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Price and others 2013).14.3 Adverse effectsThe main side effect is the bitter taste of azelastine, which is experienced by a small proportion of users.14.4 Place in therapyCombination of topical AH with INS should be used in patients when symptoms remain uncontrolled on AH or INS monotherapy or on a combination of oral AH plus INS.14.5 Systemic glucocorticoidsThere are no trials of oral steroid use and efficacy in AR, though there is grade A evidence in chronic rhinosinusitis with nasal polyposis where inflammation is more severe. Use is rarely indicated in the management of allergic rhinitis except for: SEVERE NASAL OBSTRUCTIONIn order to obtain control, short term rescue medication is used during severe exacerbation despite compliance on conventional pharmacotherapy. It is important to ensure intranasal steroid therapy is co-administered alongside oral steroids with or without a short term decongestant spray to allow intranasal drug penetration (see below). There is no definite consensus on the dose and duration of systemic steroid therapy. A suggested regime for adults is 0.5mg per kg for 5-10 days. Oral preparations of steroids as a short course are recommended over depot injectable preparations which cannot be removed if adverse effects occur. Frequent oral steroid rescue should prompt immunotherapy as a treatment option.15.1 Injectable corticosteroidsInjected preparations are not recommended since compared to other available treatments the risk-benefit profile for intramuscular corticosteroids is poor PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk5hc3NlcjwvQXV0aG9yPjxZZWFyPjIwMDE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Barnes and others 2005; Baroody and others 2011a). A decongestant spray may allow delivery of intranasal drugs beyond the inferior turbinates. For example oxymetazoline and fluticasone furoate when used together further improved nasal congestion more than either alone ADDIN REFMGR.CITE <Refman><Cite><Author>Baroody</Author><Year>2011</Year><RecNum>448</RecNum><IDText>Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>448</Ref_ID><Title_Primary>Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis</Title_Primary><Authors_Primary>Baroody,F.M.</Authors_Primary><Authors_Primary>Brown,D.</Authors_Primary><Authors_Primary>Gavanescu,L.</Authors_Primary><Authors_Primary>deTineo,M.</Authors_Primary><Authors_Primary>Naclerio,R.M.</Authors_Primary><Date_Primary>2011/4</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Androstadienes</Keywords><Keywords>Anti-Inflammatory Agents</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Drug Therapy,Combination</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Oxymetazoline</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Steroids</Keywords><Keywords>surgery</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>927</Start_Page><End_Page>934</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>127</Volume><Issue>4</Issue><Misc_3>S0091-6749(11)00126-6 [pii];10.1016/j.jaci.2011.01.037 [doi]</Misc_3><Address>Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medical Center, and Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA</Address><Web_URL>PM:21377716</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Baroody and others 2011b). There is no licensed INS plus decongestant combination preparation in the UK at present.15.3 Adverse events Only short term use (generally fewer than 10 days) is recommended as a paradoxical increase in nasal congestion secondary to rebound vasodilatation (rhinitis medicamentosa) can occur ADDIN REFMGR.CITE <Refman><Cite><Author>Scadding</Author><Year>1995</Year><RecNum>205</RecNum><IDText>Rhinitis medicamentosa</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>205</Ref_ID><Title_Primary>Rhinitis medicamentosa</Title_Primary><Authors_Primary>Scadding,G.K.</Authors_Primary><Date_Primary>1995/5</Date_Primary><Keywords>Administration,Inhalation</Keywords><Keywords>adverse effects</Keywords><Keywords>chemically induced</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapeutic use</Keywords><Reprint>Not in File</Reprint><Start_Page>391</Start_Page><End_Page>394</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>25</Volume><Issue>5</Issue><Web_URL>PM:7553240</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Scadding 1995). The risk of this occurrence increases with duration of 3 -5 days maximum PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1vcnJpczwvQXV0aG9yPjxZZWFyPjE5OTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Morris and others 1997; Yoo and others 1997). Intranasal decongestants are less likely to lead to rhinitis medicamentosa when used short term and alongside an intranasal steroid ADDIN REFMGR.CITE <Refman><Cite><Author>Baroody</Author><Year>2011</Year><RecNum>448</RecNum><IDText>Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>448</Ref_ID><Title_Primary>Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis</Title_Primary><Authors_Primary>Baroody,F.M.</Authors_Primary><Authors_Primary>Brown,D.</Authors_Primary><Authors_Primary>Gavanescu,L.</Authors_Primary><Authors_Primary>deTineo,M.</Authors_Primary><Authors_Primary>Naclerio,R.M.</Authors_Primary><Date_Primary>2011/4</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Androstadienes</Keywords><Keywords>Anti-Inflammatory Agents</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Drug Therapy,Combination</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Oxymetazoline</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Steroids</Keywords><Keywords>surgery</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>927</Start_Page><End_Page>934</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>127</Volume><Issue>4</Issue><Misc_3>S0091-6749(11)00126-6 [pii];10.1016/j.jaci.2011.01.037 [doi]</Misc_3><Address>Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medical Center, and Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA</Address><Web_URL>PM:21377716</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Baroody and others 2011b). They can also cause nasal irritation and may increase rhinitis.15.4 Place in TherapyEustachian tube dysfunction when flying (evidence level D)To increase nasal patency before douching (Grade D) or intranasal administration of nasal steroids ADDIN REFMGR.CITE <Refman><Cite><Author>Baroody</Author><Year>2011</Year><RecNum>1798</RecNum><IDText>Nasal-ocular reflexes and their role in the management of allergic rhinoconjunctivitis with intranasal steroids</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1798</Ref_ID><Title_Primary>Nasal-ocular reflexes and their role in the management of allergic rhinoconjunctivitis with intranasal steroids</Title_Primary><Authors_Primary>Baroody,F.M.</Authors_Primary><Authors_Primary>Naclerio,R.M.</Authors_Primary><Date_Primary>2011/1</Date_Primary><Keywords>Allergens</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Eye</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Reflex</Keywords><Keywords>Rhinitis</Keywords><Keywords>Steroids</Keywords><Keywords>surgery</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>S1</Start_Page><End_Page>S5</End_Page><Periodical>World Allergy Organ J.</Periodical><Volume>4</Volume><Issue>1 Suppl</Issue><User_Def_5>PMC3666181</User_Def_5><Misc_3>10.1097/WOX.0b013e3181f32dcd [doi];01312070-201101001-00001 [pii]</Misc_3><Address>From the Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, The University of Chicago Medical Center, Chicago, IL</Address><Web_URL>PM:23283068</Web_URL><ZZ_JournalStdAbbrev><f name="System">World Allergy Organ J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Baroody and Naclerio 2011)15.5 Oral decongestants (pseudoephedrine)Weakly effective in reducing nasal obstruction ADDIN REFMGR.CITE <Refman><Cite><Author>Malm</Author><Year>1994</Year><RecNum>674</RecNum><IDText>Pharmacological background to decongesting and anti-inflammatory treatment of rhinitis and sinusitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>674</Ref_ID><Title_Primary>Pharmacological background to decongesting and anti-inflammatory treatment of rhinitis and sinusitis</Title_Primary><Authors_Primary>Malm,L.</Authors_Primary><Date_Primary>1994</Date_Primary><Keywords>Anti-Inflammatory Agents</Keywords><Keywords>Clinical Trials as Topic</Keywords><Keywords>drug effects</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sinusitis</Keywords><Keywords>Sweden</Keywords><Keywords>therapeutic use</Keywords><Reprint>Not in File</Reprint><Start_Page>53</Start_Page><End_Page>55</End_Page><Periodical>Acta Otolaryngol.Suppl</Periodical><Volume>515</Volume><Address>Department of Otorhinolaryngology, Malmo General Hospital, University of Lund, Sweden</Address><Web_URL>PM:7520660</Web_URL><ZZ_JournalStdAbbrev><f name="System">Acta Otolaryngol.Suppl</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Malm 1994) and have many side effects, so are not recommended ADDIN REFMGR.CITE <Refman><Cite><Author>Naclerio</Author><Year>1998</Year><RecNum>675</RecNum><IDText>Optimizing treatment options</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>675</Ref_ID><Title_Primary>Optimizing treatment options</Title_Primary><Authors_Primary>Naclerio,R.M.</Authors_Primary><Date_Primary>1998/12</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Age Factors</Keywords><Keywords>Aged</Keywords><Keywords>Allergens</Keywords><Keywords>Beclomethasone</Keywords><Keywords>Child</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>diagnosis</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Ipratropium</Keywords><Keywords>Leukotriene Antagonists</Keywords><Keywords>Male</Keywords><Keywords>metabolism</Keywords><Keywords>Middle Aged</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>pharmacokinetics</Keywords><Keywords>Pregnancy</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>secretion</Keywords><Keywords>Steroids</Keywords><Keywords>therapeutic use</Keywords><Keywords>Triamcinolone</Keywords><Keywords>Triamcinolone Acetonide</Keywords><Reprint>Not in File</Reprint><Start_Page>54</Start_Page><End_Page>59</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>28 Suppl 6</Volume><Address>University of Chicago, Illinois 60637, USA</Address><Web_URL>PM:9988437</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Naclerio 1998). 15.6 Anti-leukotrienesThese have a therapeutic profile similar to antihistamines, with efficacy comparable to loratadine in seasonal allergic rhinitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBoaWxpcDwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Philip and others 2002), and are less effective than topical nasal corticosteroids PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBoaWxpcDwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Philip and others 2002; Pullerits and others 1999; Ratner and others 2003; Wilson and others 2001a). The response is less consistent than that observed with antihistamines PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkZvd2xlcjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Fowler and others 2002; Mastalerz and others 2002; Sampson and others 2000). LTRAs reduce the mean daily rhinitis symptom scores by 5% more than placebo ADDIN REFMGR.CITE <Refman><Cite><Author>Wilson</Author><Year>2004</Year><RecNum>632</RecNum><IDText>Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>632</Ref_ID><Title_Primary>Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis</Title_Primary><Authors_Primary>Wilson,A.M.</Authors_Primary><Authors_Primary>O'Byrne,P.M.</Authors_Primary><Authors_Primary>Parameswaran,K.</Authors_Primary><Date_Primary>2004/3/1</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>analysis</Keywords><Keywords>drug therapy</Keywords><Keywords>Drug Therapy,Combination</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Leukotriene Antagonists</Keywords><Keywords>methods</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>therapeutic use</Keywords><Reprint>Not in File</Reprint><Start_Page>338</Start_Page><End_Page>344</End_Page><Periodical>Am.J.Med.</Periodical><Volume>116</Volume><Issue>5</Issue><Misc_3>10.1016/j.amjmed.2003.10.030 [doi];S0002934303007514 [pii]</Misc_3><Address>Firestone Institute for Respiratory Health, St. Joseph's Healthcare, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada</Address><Web_URL>PM:14984820</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Med.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Wilson and others 2001a).Combination of anti-leukotriene plus antihistamine has no advantage over either drug used alone PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1lbHR6ZXI8L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Di Lorenzo G. and others 2004; Pullerits and others 2002b). Antileukotrienes may have a place in asthma patients with seasonal allergic rhinitis ADDIN REFMGR.CITE <Refman><Cite><Author>Philip</Author><Year>2004</Year><RecNum>689</RecNum><IDText>The effect of montelukast on rhinitis symptoms in patients with asthma and seasonal allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>689</Ref_ID><Title_Primary>The effect of montelukast on rhinitis symptoms in patients with asthma and seasonal allergic rhinitis</Title_Primary><Authors_Primary>Philip,G.</Authors_Primary><Authors_Primary>Nayak,A.S.</Authors_Primary><Authors_Primary>Berger,W.E.</Authors_Primary><Authors_Primary>Leynadier,F.</Authors_Primary><Authors_Primary>Vrijens,F.</Authors_Primary><Authors_Primary>Dass,S.B.</Authors_Primary><Authors_Primary>Reiss,T.F.</Authors_Primary><Date_Primary>2004/10</Date_Primary><Keywords>Acetates</Keywords><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Anti-Asthmatic Agents</Keywords><Keywords>Asthma</Keywords><Keywords>complications</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Eye</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Quality of Life</Keywords><Keywords>Quinolines</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Single-Blind Method</Keywords><Keywords>therapeutic use</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>1549</Start_Page><End_Page>1558</End_Page><Periodical>Curr.Med.Res.Opin.</Periodical><Volume>20</Volume><Issue>10</Issue><Misc_3>10.1185/030079904X3348 [doi]</Misc_3><Address>Merck Research Laboratories, Rahway, NJ, USA</Address><Web_URL>PM:15462688</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Med.Res.Opin.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Philip and others 2004).15.7 Adverse eventsThey are usually well tolerated; occasional headache, gastrointestinal symptoms or rashes. Neuropsychiatric manifestations have been reported in children, especially adolescents. There is a possible causal link between LTRA use and eosinophilic polyangiitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk5hdGhhbmk8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Hauser and others 2008; Nathani and others 2008). 15.8 Place in TherapyMontelukast is licensed in the UK for those with seasonal allergic rhinitis who also have concomitant asthma (UK licence for age > 6 months; Zafirlukast UK license>12 years). TOPICAL ANTI-CHOLINERGIC16.1 Ipratropium bromide Used three times daily it decreases rhinorrhoea (particularly if neurogenic rather than inflammatory origin) but has no effect on other nasal symptoms PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1lbHR6ZXI8L0F1dGhvcj48WWVhcj4xOTkyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Grossman and others 1995; Kaiser and others 1998; Meltzer and others 1992; Tan and Corren 1995). Regular use may be effective as an ‘add on’ for allergic rhinitis when watery rhinorrhoea persists despite topical steroids and antihistamines PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRvY2tob3JuPC9BdXRob3I+PFllYXI+MTk5OTwvWWVhcj48
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ADDIN EN.CITE.DATA (Dockhorn and others 1999; Grossman and others 1995)16.2 Adverse EventsDry nose and epistaxis ADDIN REFMGR.CITE <Refman><Cite><Author>Wood</Author><Year>1995</Year><RecNum>700</RecNum><IDText>Product characteristics and pharmacokinetics of intranasal ipratropium bromide</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>700</Ref_ID><Title_Primary>Product characteristics and pharmacokinetics of intranasal ipratropium bromide</Title_Primary><Authors_Primary>Wood,C.C.</Authors_Primary><Authors_Primary>Fireman,P.</Authors_Primary><Authors_Primary>Grossman,J.</Authors_Primary><Authors_Primary>Wecker,M.</Authors_Primary><Authors_Primary>MacGregor,T.</Authors_Primary><Date_Primary>1995/5</Date_Primary><Keywords>Absorption</Keywords><Keywords>Administration,Oral</Keywords><Keywords>Common Cold</Keywords><Keywords>Cross-Over Studies</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug effects</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Hemodynamics</Keywords><Keywords>Humans</Keywords><Keywords>Injections,Intravenous</Keywords><Keywords>Ipratropium</Keywords><Keywords>Male</Keywords><Keywords>metabolism</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Nebulizers and Vaporizers</Keywords><Keywords>pharmacokinetics</Keywords><Keywords>Pupil</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>therapeutic use</Keywords><Reprint>Not in File</Reprint><Start_Page>1111</Start_Page><End_Page>1116</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>95</Volume><Issue>5 Pt 2</Issue><Misc_3>a63460 [pii]</Misc_3><Address>Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Conn. 06877-0368, USA</Address><Web_URL>PM:7751527</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Wood and others 1995), systemic anti-cholinergic effects are unusual ADDIN REFMGR.CITE <Refman><Cite><Author>Pras</Author><Year>1991</Year><RecNum>702</RecNum><IDText>Urinary retention associated with ipratropium bromide</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>702</Ref_ID><Title_Primary>Urinary retention associated with ipratropium bromide</Title_Primary><Authors_Primary>Pras,E.</Authors_Primary><Authors_Primary>Stienlauf,S.</Authors_Primary><Authors_Primary>Pinkhas,J.</Authors_Primary><Authors_Primary>Sidi,Y.</Authors_Primary><Date_Primary>1991/9</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Inhalation</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>chemically induced</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy</Keywords><Keywords>Ipratropium</Keywords><Keywords>Lung</Keywords><Keywords>Lung Diseases,Obstructive</Keywords><Keywords>Male</Keywords><Keywords>Urinary Retention</Keywords><Reprint>Not in File</Reprint><Start_Page>939</Start_Page><End_Page>940</End_Page><Periodical>DICP.</Periodical><Volume>25</Volume><Issue>9</Issue><Address>Department of Medicine D, Beilinson Medical Center, Petah Tiqva, Israel</Address><Web_URL>PM:1835224</Web_URL><ZZ_JournalStdAbbrev><f name="System">DICP.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Pras and others 1991). Caution is advised in the elderly in whom periodic revisions of its requirement may have to be instigated.16.3 Place in therapyPatients with watery rhinorrhoea despite compliance with INS or INS plus antihistamineCHROMONES (Sodium cromoglicate (=cromolyn) and nedocromil sodium)Sodium cromoglicate and nedocromil sodium inhibit the degranulation of sensitized mast cells, inhibiting the release of mediators ADDIN REFMGR.CITE <Refman><Cite><Author>Ratner</Author><Year>2002</Year><RecNum>704</RecNum><IDText>Use of intranasal cromolyn sodium for allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>704</Ref_ID><Title_Primary>Use of intranasal cromolyn sodium for allergic rhinitis</Title_Primary><Authors_Primary>Ratner,P.H.</Authors_Primary><Authors_Primary>Ehrlich,P.M.</Authors_Primary><Authors_Primary>Fineman,S.M.</Authors_Primary><Authors_Primary>Meltzer,E.O.</Authors_Primary><Authors_Primary>Skoner,D.P.</Authors_Primary><Date_Primary>2002/4</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Anti-Asthmatic Agents</Keywords><Keywords>Asthma</Keywords><Keywords>Child,Preschool</Keywords><Keywords>Clinical Trials as Topic</Keywords><Keywords>Comorbidity</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Cromolyn Sodium</Keywords><Keywords>Drug Interactions</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Mast Cells</Keywords><Keywords>Nonprescription Drugs</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Sinusitis</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>350</Start_Page><End_Page>354</End_Page><Periodical>Mayo Clin.Proc.</Periodical><Volume>77</Volume><Issue>4</Issue><Misc_3>S0025-6196(11)61788-6 [pii];10.1016/S0025-6196(11)61788-6 [doi]</Misc_3><Address>Sylvana Research Associates and Department of Pediatrics, University of Texas Health Science Center, San Antonio, USA. ratnermd@</Address><Web_URL>PM:11936930</Web_URL><ZZ_JournalStdAbbrev><f name="System">Mayo Clin.Proc.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Ratner and others 2002). 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ADDIN EN.CITE.DATA (James and others 2003; Meltzer 2002). The spray needs to be used several times (3-4x up to 6x) per day.17.1 Adverse eventsGenerally very well tolerated (including in pregnancy) but these include local irritation, taste disturbance and headache.17.2 Place in therapyChildren and adults with mild symptoms only and sporadic problems in season or on limited allergen exposure ADDIN REFMGR.CITE <Refman><Cite><Author>Hadley</Author><Year>2003</Year><RecNum>708</RecNum><IDText>Cost-effective pharmacotherapy for inhalant allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>708</Ref_ID><Title_Primary>Cost-effective pharmacotherapy for inhalant allergic rhinitis</Title_Primary><Authors_Primary>Hadley,J.A.</Authors_Primary><Date_Primary>2003/10</Date_Primary><Keywords>Adrenal Cortex Hormones</Keywords><Keywords>Anti-Asthmatic Agents</Keywords><Keywords>Cholinergic Antagonists</Keywords><Keywords>Cost-Benefit Analysis</Keywords><Keywords>Cromolyn Sodium</Keywords><Keywords>drug therapy</Keywords><Keywords>economics</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Leukotriene Antagonists</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>surgery</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>825</Start_Page><End_Page>836</End_Page><Periodical>Otolaryngol.Clin.North Am.</Periodical><Volume>36</Volume><Issue>5</Issue><Address>Division of Otolaryngology Head and Neck Surgery, University of Rochester Medical Center, Rochester, NY 14618, USA. enthadley@</Address><Web_URL>PM:14743775</Web_URL><ZZ_JournalStdAbbrev><f name="System">Otolaryngol.Clin.North Am.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Hadley 2003). Useful for individuals unable to take other medications, e.g. pregnant females.Cromoglicate and nedocromil eye drops are useful in conjunctivitis as topical therapy PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkphbWVzPC9BdXRob3I+PFllYXI+MjAwMzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ozturk and others 2013), but since these can occur reflexively secondary to nasal inflammation complete protection is impossible. The ocular manifestations of seasonal rhinoconjunctivitis can often be suppressed by oral antihistamines, usually H1 receptor antagonists, and by intra-nasal agents, including corticosteroids, antihistamines and combination products. However they are often better treated using topical eye drops. Mast cell stabilisers such as sodium cromoglicate, nedocromil sodium and lodoxamide are generally effective and safe ADDIN REFMGR.CITE <Refman><Cite><Author>Owen</Author><Year>2004</Year><RecNum>608</RecNum><IDText>Topical treatments for seasonal allergic conjunctivitis: systematic review and meta-analysis of efficacy and effectiveness</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>608</Ref_ID><Title_Primary>Topical treatments for seasonal allergic conjunctivitis: systematic review and meta-analysis of efficacy and effectiveness</Title_Primary><Authors_Primary>Owen,C.G.</Authors_Primary><Authors_Primary>Shah,A.</Authors_Primary><Authors_Primary>Henshaw,K.</Authors_Primary><Authors_Primary>Smeeth,L.</Authors_Primary><Authors_Primary>Sheikh,A.</Authors_Primary><Date_Primary>2004/6</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Topical</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Conjunctivitis,Allergic</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>drug effects</Keywords><Keywords>drug therapy</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>London</Keywords><Keywords>Mast Cells</Keywords><Keywords>Nedocromil</Keywords><Keywords>Randomized Controlled Trials</Keywords><Keywords>Respiratory System</Keywords><Keywords>Respiratory System Agents</Keywords><Keywords>Seasons</Keywords><Keywords>Sodium</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>451</Start_Page><End_Page>456</End_Page><Periodical>Br.J Gen.Pract.</Periodical><Volume>54</Volume><Issue>503</Issue><Address>Department of Community Health Sciences, St George's Hospital Medical School, London. c.woen@sghms.ac.uk</Address><Web_URL>PM:15186569</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J Gen.Pract.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Owen and others 2004). Antihistamines such as azelastine, emedastine and epinastine may be preferred by some patients ADDIN REFMGR.CITE <Refman><Cite><Author>Glacy.J</Author><Year>2013</Year><RecNum>1585</RecNum><IDText>Treatment for Seasonal Allergic Rhinitis</IDText><MDL Ref_Type="Report"><Ref_Type>Report</Ref_Type><Ref_ID>1585</Ref_ID><Title_Primary>Treatment for Seasonal Allergic Rhinitis</Title_Primary><Authors_Primary>Glacy.J</Authors_Primary><Authors_Primary>Putnam,K.</Authors_Primary><Authors_Primary>Godfrey,S.</Authors_Primary><Authors_Primary>Falzon,L.</Authors_Primary><Authors_Primary>Mauger,B.</Authors_Primary><Authors_Primary>Samson,D.</Authors_Primary><Authors_Primary>Aronson,N.</Authors_Primary><Date_Primary>2013/7</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>Consensus</Keywords><Keywords>Ipratropium</Keywords><Keywords>methods</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Risk</Keywords><Reprint>Not in File</Reprint><Start_Page>online</Start_Page><Volume>120</Volume><Authors_Secondary>Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No.290-2007-10058-I</Authors_Secondary><Pub_Place>Rockville, MD</Pub_Place><Publisher>AHRQ Publication No. 13-EHC098-EF - Agency for Healthcare Research and Quality</Publisher><Title_Series>Comparative Effectiveness Review</Title_Series><Web_URL><u>effectivehealthcare.reports/final.cfm</u></Web_URL><Web_URL_Link2><u>;(Glacy.J and others 2013). A drug with both mast cell stabilising and antihistaminic properties, olopatadine, is often effective and well tolerated, and has the advantage of twice daily application, which particularly suits contact lens wearers. Some patients find that tear supplement drops (‘artificial tears’) provide a good measure of symptomatic relief. Topical steroids are effective in suppressing inflammation but can have potentially sight-threatening adverse effects including ocular hypertension / glaucoma, cataract, and the enhancement of infection. If indicated, e.g. for vernal conjunctivitis1, use should be supervised by an ophthalmologist. Immnotherapy, where indicated, is effective for ocular symptoms. IMMUNOTHERAPYAllergen immunotherapy can improve symptoms, reduce medication requirements and improve quality of life PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJvdXNxdWV0PC9BdXRob3I+PFllYXI+MTk5ODwvWWVhcj48
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ADDIN EN.CITE.DATA (Bousquet and others 1998; Canonica and others 2014; Passalacqua and Durham 2007). Vernal keratoconjunctivitis is a rare allergic disorder of children, especially atopic boys.?Its complex immunopathology involves raised IgE levels in tears, mast cells, eosinophils and other inflammatory cells in the conjunctival epithelium.? Seasonal exacerbations are common (hence the name) but if severe the disease can be active year-round.? The condition is sight-threatening because the corneal epithelium is under attack from the products of immune reactions in the conjunctiva. ?Topical steroid therapy is usually needed and this too has sight-threatening aspects.19.1 Subcutaneous injection immunotherapy (SCIT)This is effective for both seasonal rhinitis due to pollens (Cochrane meta-analysis ADDIN REFMGR.CITE <Refman><Cite><Author>Calderon</Author><Year>2007</Year><RecNum>1591</RecNum><IDText>Allergen injection immunotherapy for seasonal allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1591</Ref_ID><Title_Primary>Allergen injection immunotherapy for seasonal allergic rhinitis</Title_Primary><Authors_Primary>Calderon,M.A.</Authors_Primary><Authors_Primary>Alves,B.</Authors_Primary><Authors_Primary>Jacobson,M.</Authors_Primary><Authors_Primary>Hurwitz,B.</Authors_Primary><Authors_Primary>Sheikh,A.</Authors_Primary><Authors_Primary>Durham,S.</Authors_Primary><Date_Primary>2007</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>analysis</Keywords><Keywords>Data Collection</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>Disease</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Injections,Subcutaneous</Keywords><Keywords>London</Keywords><Keywords>Lung</Keywords><Keywords>methods</Keywords><Keywords>Nose</Keywords><Keywords>Pollen</Keywords><Keywords>Prevalence</Keywords><Keywords>Quality of Life</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>CD001936</Start_Page><Periodical>Cochrane.Database.Syst.Rev.</Periodical><Issue>1</Issue><Misc_3>10.1002/14651858.CD001936.pub2 [doi]</Misc_3><Address>Royal Brompton Hospital, Department of Allergy and Respiratory Medicine, Imperial College School of Medicine at the National Heart and Lung Institute, London, UK, SW3 6LY. m.calderon@imperial.ac.uk</Address><Web_URL>PM:17253469</Web_URL><ZZ_JournalStdAbbrev><f name="System">Cochrane.Database.Syst.Rev.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Calderon and others 2007) evidence level 1++) and perennial rhinitis due to house dust mite PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVpZmFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Alvarez-Cuesta and others 1994; Varney and others 1997), (level 1) SCIT requires weekly up-dosing regimens followed by 4-6 weekly maintenance injections for 3-5 yr. Pre-seasonal SCIT is effective for pollen allergy. In view of the risk of systemic side effects SCIT should only be given in specialist clinics by trained personnel with immediate access to adrenaline and resuscitation facilities ADDIN REFMGR.CITE <Refman><Cite><Author>Alvarez-Cuesta</Author><Year>2006</Year><RecNum>586</RecNum><IDText>Standards for practical allergen-specific immunotherapy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>586</Ref_ID><Title_Primary>Standards for practical allergen-specific immunotherapy</Title_Primary><Authors_Primary>Alvarez-Cuesta,O.</Authors_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Authors_Primary>Canonica,G.W.</Authors_Primary><Authors_Primary>Durham,S.R.</Authors_Primary><Authors_Primary>Malling,H.J.</Authors_Primary><Authors_Primary>Valovirta,E.</Authors_Primary><Date_Primary>2006</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>Dose-Response Relationship,Immunologic</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Reference Standards</Keywords><Keywords>Risk Factors</Keywords><Keywords>standards</Keywords><Reprint>Not in File</Reprint><Start_Page>1</Start_Page><End_Page>20</End_Page><Periodical>Allergy</Periodical><Volume>61 Suppl 82</Volume><Web_URL>PM:16930249</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Alvarez-Cuesta and others 2006). 19.2 Sublingual Immunotherapy (SLIT)SLIT has emerged as an effective and safe alternative for the treatment of allergic rhinitis with/without seasonal asthma PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhbm9uaWNhPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Canonica and others 2014) due to grass pollen ADDIN REFMGR.CITE <Refman><Cite><Author>Radulovic</Author><Year>2010</Year><RecNum>1596</RecNum><IDText>Sublingual immunotherapy for allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1596</Ref_ID><Title_Primary>Sublingual immunotherapy for allergic rhinitis</Title_Primary><Authors_Primary>Radulovic,S.</Authors_Primary><Authors_Primary>Calderon,M.A.</Authors_Primary><Authors_Primary>Wilson,D.</Authors_Primary><Authors_Primary>Durham,S.</Authors_Primary><Date_Primary>2010</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Sublingual</Keywords><Keywords>Adult</Keywords><Keywords>Allergens</Keywords><Keywords>analysis</Keywords><Keywords>Anaphylaxis</Keywords><Keywords>Child</Keywords><Keywords>Data Collection</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>London</Keywords><Keywords>methods</Keywords><Keywords>Quality of Life</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>CD002893</Start_Page><Periodical>Cochrane.Database.Syst.Rev.</Periodical><Issue>12</Issue><Misc_3>10.1002/14651858.CD002893 [doi]</Misc_3><Address>LEAP Study Team, Paediatric Allergy Research Department, St. Thomas' Hospital, Lambeth Palace Road, London, UK, SE1 7EH</Address><Web_URL>PM:21154351</Web_URL><ZZ_JournalStdAbbrev><f name="System">Cochrane.Database.Syst.Rev.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Radulovic and others 2010) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRhaGw8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Calderon and others 2015) ADDIN REFMGR.CITE <Refman><Cite><Author>Radulovic</Author><Year>2010</Year><RecNum>1596</RecNum><IDText>Sublingual immunotherapy for allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1596</Ref_ID><Title_Primary>Sublingual immunotherapy for allergic rhinitis</Title_Primary><Authors_Primary>Radulovic,S.</Authors_Primary><Authors_Primary>Calderon,M.A.</Authors_Primary><Authors_Primary>Wilson,D.</Authors_Primary><Authors_Primary>Durham,S.</Authors_Primary><Date_Primary>2010</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Sublingual</Keywords><Keywords>Adult</Keywords><Keywords>Allergens</Keywords><Keywords>analysis</Keywords><Keywords>Anaphylaxis</Keywords><Keywords>Child</Keywords><Keywords>Data Collection</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>London</Keywords><Keywords>methods</Keywords><Keywords>Quality of Life</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>CD002893</Start_Page><Periodical>Cochrane.Database.Syst.Rev.</Periodical><Issue>12</Issue><Misc_3>10.1002/14651858.CD002893 [doi]</Misc_3><Address>LEAP Study Team, Paediatric Allergy Research Department, St. Thomas' Hospital, Lambeth Palace Road, London, UK, SE1 7EH</Address><Web_URL>PM:21154351</Web_URL><ZZ_JournalStdAbbrev><f name="System">Cochrane.Database.Syst.Rev.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Radulovic and others 2010). Sublingual immunotherapy is well-tolerated, with side effects largely confined to local itching and swelling in the mouth and throat. After supervision of the first dose by the prescribing physician with a one hour period of observation, SLIT is self-administered daily at home. SLIT has an excellent safety record, although there are case reports of systemic reactions and of eosinophilic oesophagitis, but no deaths have been reported. Oral anti- histamine given prior to SLIT initiation and for the first two weeks of the course of therapy can reduce local oral irritation (level D). 19.3 Long term benefitsImmunotherapy is the only treatment that can modify the course of allergic rhinitis, with long term remission following discontinuation PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkR1cmhhbTwvQXV0aG9yPjxZZWFyPjE5OTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Didier and others 2013; Durham and others 2012). Subcutaneous immunotherapy in children with seasonal rhinitis reduces progression to asthma, an effect that persisted for 10 years PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkphY29ic2VuPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Des and others 1997; Pajno and others 2001) 19.4 Place in rhinitis therapyAllergen immunotherapy within the United Kingdom is recommended in patients with a history of symptoms on allergen exposure and objective confirmation of IgE sensitivity (skin prick test positive and/or elevated allergen-specific IgE) in the following circumstances PFJlZm1hbj48Q2l0ZT48QXV0aG9yPldhbGtlcjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Walker and others 2011):Seasonal pollen induced rhinoconjunctivitis in patients whose symptoms persist despite maximal drug therapy (combinations of intranasal corticosteroid and antihistamine taken regularly) (Evidence level 1++, category A). The choice of SCIT or SLIT is based largely on patient preference since there are no adequately powered head-to-head comparative trials Perennial allergic rhinoconjunctivitis in patients with an allergy to house dust mite who respond inadequately to anti-allergic drugs and where the allergen is not easily avoided (for example veterinary surgeons and public sector workers) COMPLEMENTARY THERAPIESThe levels of evidence for all complementary therapies, including acupuncture, herbal medicine, phototherapy and homeopathy are not considered sufficient for recommendation for clinical use at present. TREATMENT OF NAREvidence quality from trials is reduced by inadequate patient selection which is often based solely on negative skin prick tests, without elucidation of NAR phenotypes. A search to identify knowledge gaps and research needs in a database is being undertaken by a working party of the American Academy of Asthma, Allergy and Clinical Immunology and their full report are awaited. Present conclusions, based on a search of literature from 1960-2010 and using 40% of 2000 articles, personal communication) suggests the following:21.1 Intranasal ipratropium This is effective for watery rhinorrhoea (level 1b) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJvbmFkb25uYTwvQXV0aG9yPjxZZWFyPjIwMDE8L1llYXI+
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ADDIN EN.CITE.DATA (Becker and others 1997; Bonadonna and others 2001; Bronsky and others 1995; Dolovich and others 1987; Druce and others 1992; Georgitis and others 1994; Jessen and Bylander 1990; Jokinen and Sipila 1983; Kirkegaard and others 1987; O'Dwyer and others 1988; Purello-D'Ambrosio and others 1999; Sanwikarja and others 1986; Sapci and others 2008; Sjogren and others 1988).21.2 Topical capsaicin Desensitisation reduced symptoms for several months in non- allergic, non- infectious rhinitis, NINAR PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJsb208L0F1dGhvcj48WWVhcj4xOTk3PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Blom and others 1997b; Ciabatti and D'Ascanio 2009; van Rijswijk and others 2003). 21.3 Topical corticosteroids have an effect in skin prick test negative rhinitis patients (level 1b), probably on those with underlying inflammation, since studies give variable results PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlZhcnJpY2NoaW88L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Blom and others 1997a; Jacobs and others 2009; Lofkvist and Svensson 1976; Lundblad and others 2001; Varricchio and others 2011), and relief was limited in subjects with low levels of nasal eosinophils in a recent study ADDIN REFMGR.CITE <Refman><Cite><Author>Tantilipikorn</Author><Year>2010</Year><RecNum>1811</RecNum><IDText>Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1811</Ref_ID><Title_Primary>Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis</Title_Primary><Authors_Primary>Tantilipikorn,P.</Authors_Primary><Authors_Primary>Thanaviratananich,S.</Authors_Primary><Authors_Primary>Chusakul,S.</Authors_Primary><Authors_Primary>Benjaponpitak,S.</Authors_Primary><Authors_Primary>Fooanant,S.</Authors_Primary><Authors_Primary>Chintrakarn,C.</Authors_Primary><Authors_Primary>Jirapongsananuruk,O.</Authors_Primary><Authors_Primary>Visitsunthorn,N.</Authors_Primary><Authors_Primary>Toler,T.</Authors_Primary><Authors_Primary>Sutton,L.</Authors_Primary><Authors_Primary>Wu,W.</Authors_Primary><Authors_Primary>Lee,L.</Authors_Primary><Date_Primary>2010/11/3</Date_Primary><Keywords>Air Pollution</Keywords><Keywords>Allergens</Keywords><Keywords>cytology</Keywords><Keywords>Eosinophilia</Keywords><Keywords>Eosinophils</Keywords><Keywords>Fluticasone</Keywords><Keywords>Histamine</Keywords><Keywords>methods</Keywords><Keywords>Rhinitis</Keywords><Keywords>Safety</Keywords><Keywords>Skin</Keywords><Keywords>Thailand</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>92</Start_Page><End_Page>99</End_Page><Periodical>Open.Respir.Med.J</Periodical><Volume>4</Volume><User_Def_5>PMC3023068</User_Def_5><Misc_3>10.2174/1874306401004010092 [doi]</Misc_3><Address>Department of Otorhinolaryngology, Siriraj Hospital, Mahidol University, Bangkok, Thailand</Address><Web_URL>PM:21253453</Web_URL><ZZ_JournalStdAbbrev><f name="System">Open.Respir.Med.J</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Tantilipikorn and others 2010). 21.4 Topical nasal antihistaminesAzelastine and olopatadine PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpZWJlcm1hbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Banov and Lieberman 2001; Gehanno and others 2001; Kalpaklioglu and Kavut 2010; Lieberman and others 2011) (level 1b) and a combination of azelastine with fluticasone (level 3) reduced symptoms in skin prick test negative patients over one year ADDIN REFMGR.CITE <Refman><Cite><Author>Price</Author><Year>2013</Year><RecNum>652</RecNum><IDText>A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>652</Ref_ID><Title_Primary>A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis</Title_Primary><Authors_Primary>Price,D.</Authors_Primary><Authors_Primary>Shah,S.</Authors_Primary><Authors_Primary>Bhatia,S.</Authors_Primary><Authors_Primary>Bachert,C.</Authors_Primary><Authors_Primary>Berger,W.</Authors_Primary><Authors_Primary>Bousquet,J.</Authors_Primary><Authors_Primary>Carr,W.</Authors_Primary><Authors_Primary>Hellings,P.</Authors_Primary><Authors_Primary>Munzel,U.</Authors_Primary><Authors_Primary>Scadding,G.</Authors_Primary><Authors_Primary>Lieberman,P.</Authors_Primary><Date_Primary>2013</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Androstadienes</Keywords><Keywords>Child</Keywords><Keywords>Chronic Disease</Keywords><Keywords>Drug Combinations</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Phthalazines</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>495</Start_Page><End_Page>503</End_Page><Periodical>J.Investig.Allergol Clin.Immunol.</Periodical><Volume>23</Volume><Issue>7</Issue><Web_URL>PM:24654314</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Investig.Allergol Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Price and others 2013). Decongestants and oral antihistamines are ineffective. 21.5 Montelukast has not been formally trialled in NAR but low quality studies ADDIN REFMGR.CITE <Refman><Cite><Author>Wilson</Author><Year>2001</Year><RecNum>715</RecNum><IDText>Effects of leukotriene receptor antagonist therapy in patients with chronic rhinosinusitis in a real life rhinology clinic setting</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>715</Ref_ID><Title_Primary>Effects of leukotriene receptor antagonist therapy in patients with chronic rhinosinusitis in a real life rhinology clinic setting</Title_Primary><Authors_Primary>Wilson,A.M.</Authors_Primary><Authors_Primary>White,P.S.</Authors_Primary><Authors_Primary>Gardiner,Q.</Authors_Primary><Authors_Primary>Nassif,R.</Authors_Primary><Authors_Primary>Lipworth,B.J.</Authors_Primary><Date_Primary>2001/9</Date_Primary><Keywords>Acetates</Keywords><Keywords>analysis</Keywords><Keywords>Asthma</Keywords><Keywords>Chronic Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>Facial Pain</Keywords><Keywords>Headache</Keywords><Keywords>Humans</Keywords><Keywords>Leukotriene Antagonists</Keywords><Keywords>pharmacology</Keywords><Keywords>physiopathology</Keywords><Keywords>Quinolines</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Scotland</Keywords><Keywords>Sinusitis</Keywords><Keywords>Smell</Keywords><Keywords>Spirometry</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>142</Start_Page><End_Page>146</End_Page><Periodical>Rhinology</Periodical><Volume>39</Volume><Issue>3</Issue><Address>Asthma & Allergy Research Group, Department of Clinical Pharmacology & Therapeutics, University of Dundee, Dundee, Scotland, UK</Address><Web_URL>PM:11721504</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rhinology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Wilson and others 2001d) suggest a possible effect in SPT negative patients.TRPV1 was considered a prime target for neurogenic rhinitis therapy, but a recent study proved negative when cold dry air challenges were used ADDIN REFMGR.CITE <Refman><Cite><Author>Murdoch</Author><Year>2014</Year><RecNum>716</RecNum><IDText>TRPV1 inhibition does not prevent cold dry air-elicited symptoms in non-allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>716</Ref_ID><Title_Primary>TRPV1 inhibition does not prevent cold dry air-elicited symptoms in non-allergic rhinitis</Title_Primary><Authors_Primary>Murdoch,R.D.</Authors_Primary><Authors_Primary>Bareille,P.</Authors_Primary><Authors_Primary>Denyer,J.</Authors_Primary><Authors_Primary>Newlands,A.</Authors_Primary><Authors_Primary>Bentley,J.</Authors_Primary><Authors_Primary>Smart,K.</Authors_Primary><Authors_Primary>Yarnall,K.</Authors_Primary><Authors_Primary>Patel,D.</Authors_Primary><Date_Primary>2014/4</Date_Primary><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>analogs & derivatives</Keywords><Keywords>antagonists & inhibitors</Keywords><Keywords>Cold</Keywords><Keywords>Cold Temperature</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>Environmental Exposure</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>pharmacokinetics</Keywords><Keywords>prevention & control</Keywords><Keywords>Pyrrolidines</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapeutic use</Keywords><Keywords>TRPV Cation Channels</Keywords><Keywords>Urea</Keywords><Reprint>Not in File</Reprint><Start_Page>267</Start_Page><End_Page>276</End_Page><Periodical>Int.J.Clin.Pharmacol.Ther.</Periodical><Volume>52</Volume><Issue>4</Issue><Misc_3>11213 [pii];10.5414/CP202013 [doi]</Misc_3><Web_URL>PM:24472402</Web_URL><ZZ_JournalStdAbbrev><f name="System">Int.J.Clin.Pharmacol.Ther.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Murdoch and others 2014), but antagonism did reduce the response to capsaicin PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkhvbGxhbmQ8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Fruth and others 2013; Howe and others 2014; Miller and others 2013; Xu and others 2013). A suggestion for NAR therapy is given in Figure 5.SURGERYSurgery is offered?in only a?minority of cases. The indications for surgical intervention are:Anatomical variations of the septum with functional relevance PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBhc3NhbGk8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Passali and others 2003). Drug-resistant inferior turbinate hypertrophy [Poor objective evidence to support this indication other than in the short term]. There are no well conducted (prospective and randomised) studies supporting the use of coblation, laser or surgery to the inferior turbinates in patients with rhinitis which demonstrate benefit, supported by objective measurements, other than in the short term. Studies of this nature show that surgery to the inferior turbinate does not confer any lasting benefit PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxhdmluc2t5LVdvbGZmPC9BdXRob3I+PFllYXI+MjAxMzwv
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ADDIN EN.CITE.DATA (Lavinsky-Wolff and others 2013). If in future trials of surgery are to be done it would seem that, in the first instance,?they should be limited to patients who have failed to respond to medical treatment given the evidence that is currently available for the benefit that concordant medical treatment provides in the majority of patients.? ASSESSMENT OF RHINITIS CONTROLSince 2001 the ARIA patient classification system for allergic rhinitis has been used in both clinical and research settings. It focuses on patient symptoms, their time patterns (either ‘intermittent’ or ‘persistent’) and their severity (mild’ vs ‘moderate/severe’) and is a simple and quick to administer tool. In response to a World Health Organisation endorsed trend, disease control rather than severity is considered a preferable metric to measure and monitor. Three rigorously developed and validated assessments are available (Control of Allergic Rhinitis and Asthma Test (CARAT) ADDIN REFMGR.CITE <Refman><Cite><Author>Nogueira-Silva</Author><Year>2009</Year><RecNum>720</RecNum><IDText>Control of allergic rhinitis and asthma test--a formal approach to the development of a measuring tool</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>720</Ref_ID><Title_Primary>Control of allergic rhinitis and asthma test--a formal approach to the development of a measuring tool</Title_Primary><Authors_Primary>Nogueira-Silva,L.</Authors_Primary><Authors_Primary>Martins,S.V.</Authors_Primary><Authors_Primary>Cruz-Correia,R.</Authors_Primary><Authors_Primary>Azevedo,L.F.</Authors_Primary><Authors_Primary>Morais-Almeida,M.</Authors_Primary><Authors_Primary>Bugalho-Almeida,A.</Authors_Primary><Authors_Primary>Vaz,M.</Authors_Primary><Authors_Primary>Costa-Pereira,A.</Authors_Primary><Authors_Primary>Fonseca,J.A.</Authors_Primary><Date_Primary>2009</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Asthma</Keywords><Keywords>Consensus</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>Feasibility Studies</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Physicians</Keywords><Keywords>Portugal</Keywords><Keywords>Questionnaires</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>therapy</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>52</Start_Page><Periodical>Respir.Res.</Periodical><Volume>10</Volume><User_Def_5>PMC2706215</User_Def_5><Misc_3>1465-9921-10-52 [pii];10.1186/1465-9921-10-52 [doi]</Misc_3><Address>Faculdade de Medicina da Universidade do Porto, Porto, Portugal. luis.nsilva@netcabo.pt</Address><Web_URL>PM:19534774</Web_URL><ZZ_JournalStdAbbrev><f name="System">Respir.Res.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Nogueira-Silva and others 2009), Rhinitis Control Assessment Test (RCAT) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk5hdGhhbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Nathan and others 2010; Schatz and others 2010) and Allergic Rhinitis Control Test (ARCT) ADDIN REFMGR.CITE <Refman><Cite><Author>Demoly</Author><Year>2011</Year><RecNum>722</RecNum><IDText>Validation of a self-questionnaire for assessing the control of allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>722</Ref_ID><Title_Primary>Validation of a self-questionnaire for assessing the control of allergic rhinitis</Title_Primary><Authors_Primary>Demoly,P.</Authors_Primary><Authors_Primary>Jankowski,R.</Authors_Primary><Authors_Primary>Chassany,O.</Authors_Primary><Authors_Primary>Bessah,Y.</Authors_Primary><Authors_Primary>Allaert,F.A.</Authors_Primary><Date_Primary>2011/6</Date_Primary><Keywords>Adult</Keywords><Keywords>Female</Keywords><Keywords>France</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Models,Statistical</Keywords><Keywords>prevention & control</Keywords><Keywords>psychology</Keywords><Keywords>Psychometrics</Keywords><Keywords>Questionnaires</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Self-Assessment</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>standards</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>860</Start_Page><End_Page>868</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>41</Volume><Issue>6</Issue><Misc_3>10.1111/j.1365-2222.2011.03734.x [doi]</Misc_3><Address>Allergy Department, Inserm U657, Hopital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France. pascal.demoly@inserm.fr</Address><Web_URL>PM:21518040</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Demoly and others 2011). More recently the simple and quick MACVIA visual analogue scale has been developed ZXMsIEd1YW5nemhvdSBJbnN0aXR1dGUgb2YgUmVzcGlyYXRvcnkgRGlzZWFzZSwgdGhlIEZpcnN0
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ADDIN EN.CITE.DATA (Bousquet and others 2009). Severe uncontrolled allergic rhinitis, of whatever aetiology, can be classified as SCUAD which affects 18.5% of allergic rhinitis patients. It is important to differentiate between this situation and those patients who are symptomatic because they are incorrectly treated or have poor adherence. The pathophysiology, genotype-phenotype relationships and natural history of SCUAD are currently poorly understood.IMPROVING PATIENT ADHERENCE IN RHINITIS Poor adherence is a challenge in the management of allergic and non-allergic rhinitis, just as it is in other chronic diseases where generic estimates of non-adherence range from 30-60% and from 50 to 80% for preventive measures ADDIN REFMGR.CITE <Refman><Cite><Author>Christensen</Author><Year>2004</Year><RecNum>724</RecNum><IDText>Patient adhernece to medical treatment regimens: challenges for behavioral science and biomedicine.</IDText><MDL Ref_Type="Book, Whole"><Ref_Type>Book, Whole</Ref_Type><Ref_ID>724</Ref_ID><Title_Primary>Patient adhernece to medical treatment regimens: challenges for behavioral science and biomedicine.</Title_Primary><Authors_Primary>Christensen,A.J.</Authors_Primary><Date_Primary>2004</Date_Primary><Reprint>Not in File</Reprint><Pub_Place>New Haven</Pub_Place><Publisher>Yale University Press</Publisher><ZZ_WorkformID>2</ZZ_WorkformID></MDL></Cite></Refman>(Christensen 2004). There are few ‘real life’ studies of adherence in rhinitis to antihistamines and nasal corticosteroids and there are no data available for adherence with intranasal anticholinergics and cromolyn ADDIN REFMGR.CITE <Refman><Cite><Author>Passalacqua</Author><Year>2013</Year><RecNum>725</RecNum><IDText>Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>725</Ref_ID><Title_Primary>Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis</Title_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Authors_Primary>Baiardini,I.</Authors_Primary><Authors_Primary>Senna,G.</Authors_Primary><Authors_Primary>Canonica,G.W.</Authors_Primary><Date_Primary>2013/1</Date_Primary><Keywords>Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Italy</Keywords><Keywords>methods</Keywords><Keywords>Patient Compliance</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Steroids</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>22</Start_Page><End_Page>28</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>43</Volume><Issue>1</Issue><Misc_3>10.1111/j.1365-2222.2012.04052.x [doi]</Misc_3><Address>Allergy and Respiratory Diseases, DIMI, University of Genoa, Genoa, Italy. passalacqua@unige.it</Address><Web_URL>PM:23278877</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Passalacqua and others 2013). Adherence to Specific Immunotherapy (SIT) has been documented in greater detail with estimates for compliance with subcutaneous (SCIT) regimes ranging from 33-89%, and the reasons for discontinuation being time taken. Sublingual therapy adherence rates range from 44-97% initially, but discontinuation rates are high with fewer than 20% of patients progressing to the third year of therapy. The frequency of follow up visits, perception of poor efficacy and cost contribute to these high rates of attrition ADDIN REFMGR.CITE <Refman><Cite><Author>Passalacqua</Author><Year>2013</Year><RecNum>725</RecNum><IDText>Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>725</Ref_ID><Title_Primary>Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis</Title_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Authors_Primary>Baiardini,I.</Authors_Primary><Authors_Primary>Senna,G.</Authors_Primary><Authors_Primary>Canonica,G.W.</Authors_Primary><Date_Primary>2013/1</Date_Primary><Keywords>Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Italy</Keywords><Keywords>methods</Keywords><Keywords>Patient Compliance</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Steroids</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>22</Start_Page><End_Page>28</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>43</Volume><Issue>1</Issue><Misc_3>10.1111/j.1365-2222.2012.04052.x [doi]</Misc_3><Address>Allergy and Respiratory Diseases, DIMI, University of Genoa, Genoa, Italy. passalacqua@unige.it</Address><Web_URL>PM:23278877</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Passalacqua and others 2013). Unlike some chronic disorders, there has been little effort expended to date in understanding and improving adherence in rhinitis, however there is evidence to support the importance of:25.1 Frequent monitoring visits for SLIT Paediatric patients who were reviewed at three monthly intervals were significantly more adherent than those reviewed twice or once a year ADDIN REFMGR.CITE <Refman><Cite><Author>Vita</Author><Year>2010</Year><RecNum>726</RecNum><IDText>Sublingual immunotherapy: adherence based on timing and monitoring control visits</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>726</Ref_ID><Title_Primary>Sublingual immunotherapy: adherence based on timing and monitoring control visits</Title_Primary><Authors_Primary>Vita,D.</Authors_Primary><Authors_Primary>Caminiti,L.</Authors_Primary><Authors_Primary>Ruggeri,P.</Authors_Primary><Authors_Primary>Pajno,G.B.</Authors_Primary><Date_Primary>2010/5</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Sublingual</Keywords><Keywords>Allergens</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>Drug Administration Schedule</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Italy</Keywords><Keywords>methods</Keywords><Keywords>Patient Compliance</Keywords><Keywords>Time</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>668</Start_Page><End_Page>669</End_Page><Periodical>Allergy</Periodical><Volume>65</Volume><Issue>5</Issue><Misc_3>ALL2223 [pii];10.1111/j.1398-9995.2009.02223.x [doi]</Misc_3><Address>Department of Pediatrics, University of Messina, Italy. Giovanni.Pajno@unime.it <Giovanni.Pajno@unime.it></Address><Web_URL>PM:19845569</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Vita and others 2010).25.2 Enhanced patient education A 3 hour educational program together with written information achieved greater compliance than standard oral instruction ADDIN REFMGR.CITE <Refman><Cite><Author>Incorvaia</Author><Year>2010</Year><RecNum>727</RecNum><IDText>Importance of patient's education in favouring compliance with sublingual immunotherapy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>727</Ref_ID><Title_Primary>Importance of patient's education in favouring compliance with sublingual immunotherapy</Title_Primary><Authors_Primary>Incorvaia,C.</Authors_Primary><Authors_Primary>Rapetti,A.</Authors_Primary><Authors_Primary>Scurati,S.</Authors_Primary><Authors_Primary>Puccinelli,P.</Authors_Primary><Authors_Primary>Capecce,M.</Authors_Primary><Authors_Primary>Frati,F.</Authors_Primary><Date_Primary>2010/10</Date_Primary><Keywords>Administration,Sublingual</Keywords><Keywords>Adult</Keywords><Keywords>Comparative Study</Keywords><Keywords>complications</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Italy</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Patient Compliance</Keywords><Keywords>Patient Education as Topic</Keywords><Keywords>psychology</Keywords><Keywords>therapy</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>1341</Start_Page><End_Page>1342</End_Page><Periodical>Allergy</Periodical><Volume>65</Volume><Issue>10</Issue><Misc_3>ALL2347 [pii];10.1111/j.1398-9995.2010.02347.x [doi]</Misc_3><Address>Allergy/Pulmonary rehabilitation, ICP Hospital, Milan, Italy. cristoforo.incorvaia@</Address><Web_URL>PM:20192941</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Incorvaia and others 2010). rhinitis in pregnancy and during breastfeedingRhinitis affects at least 20% of pregnancies PFJlZm1hbj48Q2l0ZT48QXV0aG9yPktlbGVzPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ellegard 2003; Incaudo 2004). Rhinitis patients have higher levels of oestrogen and IGF1 during the third trimester. Rhinitis in pregnancy may not be adequately treated during routine antenatal care, and patients benefit from a multidisciplinary approach ADDIN REFMGR.CITE <Refman><Cite><Author>Soares dos Reis</Author><Year>2009</Year><RecNum>740</RecNum><IDText>Rhinitis in pregnancy: knowledge and attitudes among obstetricians</IDText><MDL Ref_Type="Abstract"><Ref_Type>Abstract</Ref_Type><Ref_ID>740</Ref_ID><Title_Primary><f name="AdvPSUnv-B">Rhinitis in pregnancy: knowledge and attitudes among obstetricians</f></Title_Primary><Authors_Primary>Soares dos Reis,A.</Authors_Primary><Authors_Primary>Carvalho,S.</Authors_Primary><Authors_Primary>Romeiro,A.</Authors_Primary><Authors_Primary>Prates,S.</Authors_Primary><Authors_Primary>Leiria Pinto,P.</Authors_Primary><Date_Primary>2009</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Asthma</Keywords><Keywords>diagnosis</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Pregnancy</Keywords><Keywords>Prevalence</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>130</Start_Page><End_Page>130</End_Page><Periodical>Allergy</Periodical><Volume>64</Volume><Issue>Supplement 90</Issue><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>4</ZZ_WorkformID></MDL></Cite></Refman>(Dzieciolowska-Baran, 2013). Rhinitis in pregnancy impacts negatively on quality of life, especially during the third trimester and women with pre-existing allergic rhinitis are more severely affected ADDIN REFMGR.CITE <Refman><Cite><Author>Gilbey</Author><Year>2012</Year><RecNum>729</RecNum><IDText>Rhinosinusitis-related quality of life during pregnancy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>729</Ref_ID><Title_Primary>Rhinosinusitis-related quality of life during pregnancy</Title_Primary><Authors_Primary>Gilbey,P.</Authors_Primary><Authors_Primary>McGruthers,L.</Authors_Primary><Authors_Primary>Morency,A.M.</Authors_Primary><Authors_Primary>Shrim,A.</Authors_Primary><Date_Primary>2012/7</Date_Primary><Keywords>Adult</Keywords><Keywords>Awareness</Keywords><Keywords>Canada</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Female</Keywords><Keywords>Health</Keywords><Keywords>Humans</Keywords><Keywords>Israel</Keywords><Keywords>methods</Keywords><Keywords>Pregnancy</Keywords><Keywords>Pregnancy Complications</Keywords><Keywords>Prevalence</Keywords><Keywords>psychology</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Risk</Keywords><Keywords>Sinusitis</Keywords><Keywords>Sleep</Keywords><Keywords>surgery</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>283</Start_Page><End_Page>286</End_Page><Periodical>Am.J.Rhinol.Allergy</Periodical><Volume>26</Volume><Issue>4</Issue><Misc_3>10.2500/ajra.2012.26.3776 [doi]</Misc_3><Address>Otolaryngology, Head and Neck Surgery Unit, Ziv Medical Center, Zefat, Israel. peter.g@ziv..il</Address><Web_URL>PM:22801015</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Rhinol.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Gilbey and others 2012). Informing the patient that pregnancy-induced rhinitis is a self-limiting condition is often reassuring. Women developing rhinitis during pregnancy are more likely to deliver female babies ADDIN REFMGR.CITE <Refman><Cite><Author>Indirani</Author><Year>2013</Year><RecNum>731</RecNum><IDText>Hormonal changes causing rhinitis in pregnancy among Malaysian women</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>731</Ref_ID><Title_Primary>Hormonal changes causing rhinitis in pregnancy among Malaysian women</Title_Primary><Authors_Primary>Indirani,B.</Authors_Primary><Authors_Primary>Raman,R.</Authors_Primary><Authors_Primary>Omar,S.Z.</Authors_Primary><Date_Primary>2013/9</Date_Primary><Keywords>Female</Keywords><Keywords>Growth</Keywords><Keywords>methods</Keywords><Keywords>Pregnancy</Keywords><Keywords>Prevalence</Keywords><Keywords>Progesterone</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>876</Start_Page><End_Page>881</End_Page><Periodical>J.Laryngol.Otol.</Periodical><Volume>127</Volume><Issue>9</Issue><Misc_3>S0022215113001692 [pii];10.1017/S0022215113001692 [doi]</Misc_3><Address>Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia</Address><Web_URL>PM:23954035</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Laryngol.Otol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Indirani and others 2013) and children of mothers developing rhinitis in early pregnancy are more likely to develop rhinitis themselves ADDIN REFMGR.CITE <Refman><Cite><Author>Shinohara</Author><Year>2007</Year><RecNum>730</RecNum><IDText>Symptoms of allergic rhinitis in women during early pregnancy are associated with higher prevalence of allergic rhinitis in their offspring</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>730</Ref_ID><Title_Primary>Symptoms of allergic rhinitis in women during early pregnancy are associated with higher prevalence of allergic rhinitis in their offspring</Title_Primary><Authors_Primary>Shinohara,M.</Authors_Primary><Authors_Primary>Wakiguchi,H.</Authors_Primary><Authors_Primary>Saito,H.</Authors_Primary><Authors_Primary>Matsumoto,K.</Authors_Primary><Date_Primary>2007/12</Date_Primary><Keywords>Asthma</Keywords><Keywords>Cell Differentiation</Keywords><Keywords>Cohort Studies</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Epigenesis,Genetic</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>Infant</Keywords><Keywords>methods</Keywords><Keywords>Mothers</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Pregnancy</Keywords><Keywords>Pregnancy Complications</Keywords><Keywords>Pregnancy Outcome</Keywords><Keywords>Prevalence</Keywords><Keywords>Research</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Reprint>Not in File</Reprint><Start_Page>411</Start_Page><End_Page>417</End_Page><Periodical>Allergol Int.</Periodical><Volume>56</Volume><Issue>4</Issue><Misc_3>056040411 [pii];10.2332/allergolint.O-06-471 [doi]</Misc_3><Address>Department of Pediatrics, Kochi Medical School, Kochi, Japan</Address><Web_URL>PM:17713362</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergol Int.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Shinohara and others 2007). During pregnancy, most medications cross the placenta, and should only be prescribed when the apparent benefit is greater than the risk to the foetus ADDIN REFMGR.CITE <Refman><Cite><Author>Gani</Author><Year>2003</Year><RecNum>206</RecNum><IDText>Rhinitis in pregnancy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>206</Ref_ID><Title_Primary>Rhinitis in pregnancy</Title_Primary><Authors_Primary>Gani,F.</Authors_Primary><Authors_Primary>Braida,A.</Authors_Primary><Authors_Primary>Lombardi,C.</Authors_Primary><Authors_Primary>Del,Giudice A.</Authors_Primary><Authors_Primary>Senna,G.E.</Authors_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Date_Primary>2003/10</Date_Primary><Keywords>Abnormalities,Drug-Induced</Keywords><Keywords>Adult</Keywords><Keywords>Anti-Allergic Agents</Keywords><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>contraindications</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>drug therapy</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Gonadal Steroid Hormones</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Immunotherapy</Keywords><Keywords>physiology</Keywords><Keywords>Pregnancy</Keywords><Keywords>Pregnancy Complications</Keywords><Keywords>prevention & control</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Vasomotor</Keywords><Keywords>Safety</Keywords><Keywords>Steroids</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>306</Start_Page><End_Page>313</End_Page><Periodical>Allerg.Immunol.(Paris)</Periodical><Volume>35</Volume><Issue>8</Issue><Address>Clinica di Malattie Apparato Respiratorio, Servizio di Allergologia, Universita' di Torino, Azienda San Luigi, Orbassano</Address><Web_URL>PM:14653050</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allerg.Immunol.(Paris)</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Gani and others 2003). 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ADDIN EN.CITE.DATA (Garavello and others 2010). Chromones have not shown teratogenic effects in animals and are the safest drug recommended in the first 3 months of pregnancy although they require multiple daily administrations. The safety of nasal steroids in pregnancy has not been established through clinical trials. Only minimal amounts of steroid pass into the bloodstream after using a nasal spray and it is good practice to treat with ‘tried and tested’ drugs ADDIN REFMGR.CITE <Refman><Cite><Author>Gani</Author><Year>2003</Year><RecNum>206</RecNum><IDText>Rhinitis in pregnancy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>206</Ref_ID><Title_Primary>Rhinitis in pregnancy</Title_Primary><Authors_Primary>Gani,F.</Authors_Primary><Authors_Primary>Braida,A.</Authors_Primary><Authors_Primary>Lombardi,C.</Authors_Primary><Authors_Primary>Del,Giudice A.</Authors_Primary><Authors_Primary>Senna,G.E.</Authors_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Date_Primary>2003/10</Date_Primary><Keywords>Abnormalities,Drug-Induced</Keywords><Keywords>Adult</Keywords><Keywords>Anti-Allergic Agents</Keywords><Keywords>Asthma</Keywords><Keywords>classification</Keywords><Keywords>contraindications</Keywords><Keywords>Desensitization,Immunologic</Keywords><Keywords>drug therapy</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Gonadal Steroid Hormones</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Immunotherapy</Keywords><Keywords>physiology</Keywords><Keywords>Pregnancy</Keywords><Keywords>Pregnancy Complications</Keywords><Keywords>prevention & control</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Vasomotor</Keywords><Keywords>Safety</Keywords><Keywords>Steroids</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>306</Start_Page><End_Page>313</End_Page><Periodical>Allerg.Immunol.(Paris)</Periodical><Volume>35</Volume><Issue>8</Issue><Address>Clinica di Malattie Apparato Respiratorio, Servizio di Allergologia, Universita' di Torino, Azienda San Luigi, Orbassano</Address><Web_URL>PM:14653050</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allerg.Immunol.(Paris)</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Gani and others 2003). Beclamethasone, FP and budesonide have good safety records and are widely used in pregnant asthmatic women of these fluticasone has least systemic bioavailability when used nasally PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRlbW9seTwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Demoly and others 2003b; Ellegard and others 2001; Mazzotta and others 1999). There is considerable clinical experience with chlorphenamine, loratadine and cetirizine in pregnancy, which may be used in addition, but decongestants should be avoided PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRpYXYtQ2l0cmluPC9BdXRob3I+PFllYXI+MjAwMzwvWWVh
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ADDIN EN.CITE.DATA (Diav-Citrin and others 2003; Moretti and others 2003). Patients already on immunotherapy may continue if they have already reached the maintenance phase but each case must be considered individually. The initiation of immunotherapy and up-dosing is contraindicated ADDIN REFMGR.CITE <Refman><Cite><Author>Keles</Author><Year>2004</Year><RecNum>440</RecNum><IDText>Treatment of allergic rhinitis during pregnancy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>440</Ref_ID><Title_Primary>Treatment of allergic rhinitis during pregnancy</Title_Primary><Authors_Primary>Keles,N.</Authors_Primary><Date_Primary>2004/1</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Oral</Keywords><Keywords>Administration,Topical</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>Anti-Asthmatic Agents</Keywords><Keywords>Beclomethasone</Keywords><Keywords>Budesonide</Keywords><Keywords>Cetirizine</Keywords><Keywords>Chlorpheniramine</Keywords><Keywords>Cromolyn Sodium</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Health Behavior</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine H1 Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Loratadine</Keywords><Keywords>Nasal Decongestants</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Pregnancy</Keywords><Keywords>Pregnancy Complications</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Safety</Keywords><Keywords>Sneezing</Keywords><Keywords>Steroids</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Keywords>Triamcinolone</Keywords><Keywords>Triamcinolone Acetonide</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>23</Start_Page><End_Page>28</End_Page><Periodical>Am.J.Rhinol.</Periodical><Volume>18</Volume><Issue>1</Issue><Address>Department of Otorhinolaryngology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey</Address><Web_URL>PM:15035567</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Rhinol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Keles 2004). Similar recommendations can be made about the treatment of AR during lactation. Nasal lavage is safe to use whilst breastfeeding. Nasal administration of sodium cromoglicate is not known to have any harmful effects when used by breastfeeding mothers. Antihistamines and nasal steroids should only be used when the clinical imperative outweighs the potential harm to the child. Antihistamines are excreted in breast milk and, although not known to be harmful, the manufacturers of most antihistamines advise avoidance whilst breastfeeding. Chlorphenamine may cause drowsiness and poor feeding in the baby. Both loratadine ADDIN REFMGR.CITE <Refman><Cite><Author>Hilbert</Author><Year>1988</Year><RecNum>733</RecNum><IDText>Excretion of loratadine in human breast milk</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>733</Ref_ID><Title_Primary>Excretion of loratadine in human breast milk</Title_Primary><Authors_Primary>Hilbert,J.</Authors_Primary><Authors_Primary>Radwanski,E.</Authors_Primary><Authors_Primary>Affrime,M.B.</Authors_Primary><Authors_Primary>Perentesis,G.</Authors_Primary><Authors_Primary>Symchowicz,S.</Authors_Primary><Authors_Primary>Zampaglione,N.</Authors_Primary><Date_Primary>1988/3</Date_Primary><Keywords>Adult</Keywords><Keywords>analogs & derivatives</Keywords><Keywords>analysis</Keywords><Keywords>blood</Keywords><Keywords>Cyproheptadine</Keywords><Keywords>Female</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Infant</Keywords><Keywords>Loratadine</Keywords><Keywords>metabolism</Keywords><Keywords>Milk,Human</Keywords><Keywords>pharmacokinetics</Keywords><Keywords>Piperidines</Keywords><Keywords>Pyridines</Keywords><Keywords>Radioimmunoassay</Keywords><Keywords>Research</Keywords><Keywords>Time</Keywords><Reprint>Not in File</Reprint><Start_Page>234</Start_Page><End_Page>239</End_Page><Periodical>J.Clin.Pharmacol.</Periodical><Volume>28</Volume><Issue>3</Issue><Address>Pharmaceutical Research Division, Schering Corporation, Bloomfield, New Jersey 07003</Address><Web_URL>PM:2966185</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Clin.Pharmacol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Hilbert and others 1988) and cetirizine appear safer with low levels found in breast milk ADDIN REFMGR.CITE <Refman><Cite><Author>Briggs</Author><Year>2001</Year><RecNum>734</RecNum><IDText>Drugs in Pregnacy and Lactation</IDText><MDL Ref_Type="Book, Whole"><Ref_Type>Book, Whole</Ref_Type><Ref_ID>734</Ref_ID><Title_Primary><b>Drugs in Pregnacy and Lactation</b></Title_Primary><Authors_Primary>Briggs,G.G</Authors_Primary><Authors_Primary>Freeman,R.K.</Authors_Primary><Authors_Primary>Jaffe,S.J</Authors_Primary><Date_Primary>2001/11/1</Date_Primary><Keywords>Lactation</Keywords><Reprint>Not in File</Reprint><Volume>6</Volume><Pub_Place>Philadelphia</Pub_Place><Publisher>Lippincott Williams & Wilkins</Publisher><ZZ_WorkformID>2</ZZ_WorkformID></MDL></Cite></Refman>(Briggs and others 2001). The lowest dose should be used for the shortest duration.rhinitis in childrenAcute viral rhinitis is common and usually easy to distinguish. It peaks during the winter. The frequency of episodes varies with age, birth order and degree of day-care exposure. Between 1 and 10 episodes per year is usual, with a peak between 6 months and 6 years of age. Thereafter, 1-2 episodes per year, occurring mainly during the winter ADDIN REFMGR.CITE <Refman><Cite><Author>RCPCH</Author><Year>2016</Year><RecNum>1800</RecNum><IDText>Manual of childhood infections</IDText><MDL Ref_Type="Generic"><Ref_Type>Generic</Ref_Type><Ref_ID>1800</Ref_ID><Title_Primary>Manual of childhood infections</Title_Primary><Authors_Primary>RCPCH</Authors_Primary><Date_Primary>2016</Date_Primary><Keywords>Infection</Keywords><Reprint>Not in File</Reprint><Start_Page>373</Start_Page><ZZ_WorkformID>33</ZZ_WorkformID></MDL></Cite></Refman>(RCPCH 2016) retained foreign body, nasal septum deviation, unilateral choanal atresia, cerebro-spinal fluid leak, and nasal polyposis can all present with rhinitis. Chronic infective rhinitis (rhinosinusitis) (>3 months), particularly if severe, can be a manifestation of underlining pathologies such as primary ciliary dyskinesia, cystic fibrosis, or antibody deficiency. Allergic rhinitis affects 3% of 4 year olds, increasing to 27% of 18 year olds ADDIN REFMGR.CITE <Refman><Cite><Author>Kurukulaaratchy</Author><Year>2011</Year><RecNum>1784</RecNum><IDText>The influence of gender and atopy on the natural history of rhinitis in the first 18 years of life</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1784</Ref_ID><Title_Primary>The influence of gender and atopy on the natural history of rhinitis in the first 18 years of life</Title_Primary><Authors_Primary>Kurukulaaratchy,R.J.</Authors_Primary><Authors_Primary>Karmaus,W.</Authors_Primary><Authors_Primary>Raza,A.</Authors_Primary><Authors_Primary>Matthews,S.</Authors_Primary><Authors_Primary>Roberts,G.</Authors_Primary><Authors_Primary>Arshad,S.H.</Authors_Primary><Date_Primary>2011/6</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Age Factors</Keywords><Keywords>Asthma</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>complications</Keywords><Keywords>Disease</Keywords><Keywords>Disease Progression</Keywords><Keywords>Eczema</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Incidence</Keywords><Keywords>Infant</Keywords><Keywords>Longitudinal Studies</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Prevalence</Keywords><Keywords>Prognosis</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Sex Factors</Keywords><Keywords>Skin</Keywords><Reprint>Not in File</Reprint><Start_Page>851</Start_Page><End_Page>859</End_Page><Periodical>Clin.Exp.Allergy</Periodical><Volume>41</Volume><Issue>6</Issue><Misc_3>10.1111/j.1365-2222.2011.03765.x [doi]</Misc_3><Address>The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK</Address><Web_URL>PM:21561494</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.Exp.Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Kurukulaaratchy and others 2011) (figure 6).Allergic rhinitis in early childhood is a risk factor for developing asthma in later childhood and adulthood PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJvY2hhdDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ZWZtYW4+
ADDIN EN.CITE.DATA (Walker and others 2007b). It often presents alongside other atopic disorders, asthma, and eczema and food allergy. Its presentation may be influenced by co-morbidities, such as conjunctivitis, impaired hearing, rhinosinusitis, sleep problems and pollen-food syndrome PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJvYmVydHM8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS
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PgB=
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PgB=
ADDIN EN.CITE.DATA (Roberts and others 2013) (figure 7). Entopy (local allergic rhinitis), diagnosed by nasal allergen challenge, is found in children (level D) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkZvcmVzdGVyPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE.DATA (Forester and Calabria 2010; Payne 2009).The approach to diagnosis in children is similar to that in adults: history, skin prick test and anterior rhinoscopyEntopy (local allergic rhinitis), diagnosed by nasal allergen challenge is found in this age group (level D) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlBheW5lPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Forester and Calabria 2010; Payne and others 2011)Therapy of rhinitis in children is based on the same principles as in adults, however it should take into account specific paediatric needs, such as acceptability, practicality for both children and parents, and concern for potential side effects (figure 8)Nasal saline irrigation is effective in the treatment of AR in children PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNoZW48L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Chen and others 2014; Garavello and others 2003)Brief concomitant use (3 days) of topical decongestants can be helpful in children with significant nasal blockage to aid introduction of topical nasal steroid therapyRecommendation for continuous use of intranasal steroids can often create anxiety in parents; Intranasal steroids with low bio-availability have a better safety profile at recommended doses and should be used in preference (Figure 4) PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkFsbGVuPC9BdXRob3I+PFllYXI+MjAwMjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Allen and others 2002b) (see also table 3)A short course (3 to 7 days) of oral corticosteroids may be required in severe cases. Intramuscular steroids have no role in the treatment of ARImmunotherapy is recommended in subjects who have not adequately responded to maximal pharmacotherapy; the potential added benefit in disease prevention should be considered when treating children PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1vbGxlcjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Moller and others 2002; Niggemann and others 2006) Education on therapy plays an important role on treatment outcome. Both children and carers should be provided with the relevant information and appropriate training PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkluZHJhZGF0PC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Indradat and others 2014)Otitis media with effusion and/or adenoidal hypertrophy may be associated with AR; the mechanistic link is unknown. Some studies suggest benefit to these common paediatric conditions from rhinitis treatment ADDIN REFMGR.CITE <Refman><Cite><Author>Scadding</Author><Year>2014</Year><RecNum>1676</RecNum><IDText>Double-blind, placebo controlled randomised trial of medical therapy in otitis media with effusion</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1676</Ref_ID><Title_Primary>Double-blind, placebo controlled randomised trial of medical therapy in otitis media with effusion</Title_Primary><Authors_Primary>Scadding,G.K.</Authors_Primary><Authors_Primary>Darby,Y.C.</Authors_Primary><Authors_Primary>Jansz,A.J.</Authors_Primary><Authors_Primary>Richards,D.</Authors_Primary><Authors_Primary>Tate,H.</Authors_Primary><Authors_Primary>Gane,S.</Authors_Primary><Authors_Primary>Hills,S.</Authors_Primary><Authors_Primary>Rajput,K.</Authors_Primary><Authors_Primary>Parikh,A.</Authors_Primary><Date_Primary>2014</Date_Primary><Keywords>Otitis Media</Keywords><Keywords>Otitis Media with Effusion</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>58</Start_Page><End_Page>68</End_Page><Periodical>Advances in Life Sciences and Health</Periodical><Volume>1</Volume><Issue>2</Issue><Web_URL><u> name="System">Advances in Life Sciences and Health</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Scadding and others 2014)QUALITY OF LIFE QUESTIONNAIRES FOR RHINITISThe burden of rhinitis for an individual patient can be estimated using Patient-Reported Outcome Measures (PROMs). Generic PROMs such as the EQ-5D allow a comparison between different diseases and are particularly useful when calculating the incremental cost of new treatments. However, a disease-specific validated Quality of life (QoL) questionnaire is more sensitive when assessing severity of disease and response to treatment. In routine clinical practice the use of such tools allows greater focus on symptoms important to the patient. Commonly used and validated quality of life disease specific scoring systems include the RQLQ for allergic rhinitis and rhino-conjunctivitis, the SNOT-22 or RSOM-31in chronic rhinosinusitis and a modified SNOT-16 in acute rhinosinusitis.FUTURE RESEARCH29.1 ARPrevention of AR development: e.g. environmental changes, use of synbioticsAdoption of single unified scheme for assessing rhinitis controlPrevention of progression from AR to asthma: confirmation of effect of immunotherapy, investigation of AR well-controlled by pharmacotherapyReduction of proportion of SCUAD sufferers by combination therapies29.2 NARPrevalence- accurate figures needed29.3 EndotypesTrials of therapy in well – selected endotypesAcknowledgementsThe preparation of this document has benefited from extensive discussions within the Standards of Care Committee of the BSACI and we would like to acknowledge all the members of this committee for their valuable contribution. 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Mixed forms of rhinitis, allergic plus non- allergic, also occur.Table 2: Co- morbidities of Allergic RhinitisSome co- morbidities appear as consequences of AR, e.g. concentration and sleep problems, others co- exist with it as a consequence of underlying allergy, e.g. atopic dermatitis .The mechanism of the association between asthma and rhinitis is uncertain, but the tendency for asthma to succeed rhinitis, the demonstration that nasal allergen challenge in AR gives lower respiratory tract inflammation and the prevention of progression of AR to asthma by allergen immunotherapy suggest that the asthma is consequential in individuals in whom rhinitis is the initial manifestation of atopic disease. Table 3: Allergen Avoidance measures and their effectivenessTable 4: Pharmacotherapy- effects upon individual symptoms of rhinitisFigure 1: Immunological mechanisms of Allergic Rhinitis Sensitised patients with allergic rhinitis have IgE antibodies for specific allergen(s) bound to receptors on the surface of mast cells. On re-exposure to the specific allergen(s), cross-linking of adjacent IgE molecules occurs, and mast cell degranulation results. Pre-formed mediators such as histamine stimulate sensory nerve endings within seconds, causing itch and sneezing, and promote dilatation of local vasculature and glandular secretion, causing obstruction and rhinorrhoea, respectively. Newly-synthesised mediators, including leukotrienes, as wells as chemokines and cytokines contribute to a delayed eosinophil and Th2 T-cell predominant inflammation, the late phase response, characterised by nasal obstruction and hyper-reactivity ADDIN REFMGR.CITE <Refman><Cite><Author>Hansen</Author><Year>2004</Year><RecNum>40</RecNum><IDText>Mediators of inflammation in the early and the late phase of allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>40</Ref_ID><Title_Primary>Mediators of inflammation in the early and the late phase of allergic rhinitis</Title_Primary><Authors_Primary>Hansen,I.</Authors_Primary><Authors_Primary>Klimek,L.</Authors_Primary><Authors_Primary>Mosges,R.</Authors_Primary><Authors_Primary>Hormann,K.</Authors_Primary><Date_Primary>2004/6</Date_Primary><Keywords>Attention</Keywords><Keywords>Chemokines</Keywords><Keywords>Cytokines</Keywords><Keywords>Germany</Keywords><Keywords>Growth</Keywords><Keywords>Hay Fever</Keywords><Keywords>Humans</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>immunology</Keywords><Keywords>Inflammation</Keywords><Keywords>Inflammation Mediators</Keywords><Keywords>Interleukin-3</Keywords><Keywords>Interleukin-4</Keywords><Keywords>Interleukin-5</Keywords><Keywords>Lymphocytes</Keywords><Keywords>Nerve Growth Factor</Keywords><Keywords>Nitric Oxide</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sneezing</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>159</Start_Page><End_Page>163</End_Page><Periodical>Curr.Opin.Allergy Clin.Immunol.</Periodical><Volume>4</Volume><Issue>3</Issue><Address>ENT Department, Mannheim University Hospital, Germany</Address><Web_URL>PM:15126935</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Hansen and others 2004). Additional mechanisms are likely to be relevant. These include neuro-immune interactions, such as release of neuropeptides (substance P, calcitonin gene-related peptide) and neurokinins from sensory nerve endings in response to inflammatory mediators ADDIN REFMGR.CITE <Refman><Cite><Author>Van Gerven L.</Author><Year>2012</Year><RecNum>681</RecNum><IDText>Up-date on neuro-immune mechanisms involved in allergic and non-allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>681</Ref_ID><Title_Primary>Up-date on neuro-immune mechanisms involved in allergic and non-allergic rhinitis</Title_Primary><Authors_Primary>Van Gerven L.</Authors_Primary><Authors_Primary>Boeckxstaens,G.</Authors_Primary><Authors_Primary>Hellings,P.</Authors_Primary><Date_Primary>2012/9</Date_Primary><Keywords>Belgium</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>etiology</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Inflammation</Keywords><Keywords>innervation</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>pathology</Keywords><Keywords>Rhinitis</Keywords><Keywords>Skin</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>227</Start_Page><End_Page>235</End_Page><Periodical>Rhinology</Periodical><Volume>50</Volume><Issue>3</Issue><Misc_3>1080 [pii];10.4193/Rhino11.152 [doi]</Misc_3><Address>Department of Otorhinolaryngology, University Hospitals, Leuven, Belgium</Address><Web_URL>PM:22888478</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rhinology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Van Gerven L. and others 2012). 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ADDIN EN.CITE.DATA (Saglani and others 2013; Ying and others 2008). Further research is needed to confirm the relevance epithelial-derived cytokines such as TSLP, IL-33 and IL-25 as well as ILC2 cells in allergic rhinitis ADDIN REFMGR.CITE <Refman><Cite><Author>Scadding</Author><Year>2014</Year><RecNum>684</RecNum><IDText>Cytokine profiles in allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>684</Ref_ID><Title_Primary>Cytokine profiles in allergic rhinitis</Title_Primary><Authors_Primary>Scadding,G.</Authors_Primary><Date_Primary>2014/5</Date_Primary><Keywords>Animals</Keywords><Keywords>Asthma</Keywords><Keywords>Chronic Disease</Keywords><Keywords>Cytokines</Keywords><Keywords>Disease</Keywords><Keywords>drug therapy</Keywords><Keywords>Epithelial Cells</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Inflammation</Keywords><Keywords>Interleukins</Keywords><Keywords>London</Keywords><Keywords>Nasal Polyps</Keywords><Keywords>Nose</Keywords><Keywords>pathology</Keywords><Keywords>Polyps</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>T-Lymphocytes,Helper-Inducer</Keywords><Reprint>Not in File</Reprint><Start_Page>435</Start_Page><Periodical>Curr.Allergy Asthma Rep.</Periodical><Volume>14</Volume><Issue>5</Issue><Misc_3>10.1007/s11882-014-0435-7 [doi]</Misc_3><Address>Allergy and Clinical Immunology, Imperial College, London, South Kensington Campus, London, SW7 2AZ, UK, g.scadding@imperial.ac.uk</Address><Web_URL>PM:24633619</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Allergy Asthma Rep.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Scadding 2014). Figure 2: Rhinitis Pharmacotherapy Treatment AlgorithmPharmacotherapy should be used when allergen and irritant avoidance, where possible, plus saline douching are insufficiently effective. Additional therapies, such as INS plus INAH, can be accomplished using two different medications, or a combination treatment in one device. There is, as yet, no comparative evidence on which to base this choice, however concordance appears more likely when the regime is simple.Figure 3: Bioavailability of intranasal corticosteroids The more recent molecules have little systemic uptake and are suitable for use in children and for long term therapy. (Grade A evidence)Figure 4a and b: How to use a nasal spray and nasal drops Evidence grade D Figure 5: Treatment of Non- Allergic RhinitisTherapy in NAR depends upon the phenotype. The division into those with and without nasal inflammation can be made on the basis of nasal smears. Those with inflammation may respond to anti-inflammatory therapy, though less well than in AR and higher INS doses and combinations of therapy may be needed. If these fail a nasal aspirin challenge could be undertaken, followed by desensitization if positive (Howe and others 2014; Miller and others 2013). Non inflammatory NAR may respond to anti- cholinergic therapy or to capsaicin. Some patients require both anti- inflammatory and anti-neurogenic treatments. (Grade D evidence)Figure 6: Rhinitis in Children, with permission from EAACIFigure 7: Recognition of Rhinitis in Children at different Ages, with permission from EAACIFigure 8: Approach to therapy for paediatric allergic rhinitisAppendicesA1.Levels of EvidenceA2.Local combination therapy in rhinitisTable 1: Triggers for non-allergic rhinitisTypeSuggested triggers/causeSigns/symptomsEosinophilic or NARES (non allergic rhinitis with eosinophilia syndrome)50% develop aspirin sensitive disease with asthma and nasal polyposis later in life PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxlb25lPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Leone and others 1997)Skin tests negative but nasal smears show eosinophilia. Perennial symptoms with paroxysmal episodes. About 50% have bronchial hyper-reactivity PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxlb25lPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48UmVj
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aW92YW5uaSwgSXRhbHk8L0FkZHJlc3M+PFdlYl9VUkw+UE06OTQzODQ4NjwvV2ViX1VSTD48Wlpf
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ADDIN EN.CITE.DATA (Leone and others 1997).Autonomic (formerly known as vasomotor)Triggered by physical/chemical agentsMore common in middle age with clear rhinorrhoea especially in the morning. Less favourable course than allergic. Possibly caused by parasympathetic hyperactivity ADDIN REFMGR.CITE <Refman><Cite><Author>Garay</Author><Year>2004</Year><RecNum>25</RecNum><IDText>Mechanisms of vasomotor rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>25</Ref_ID><Title_Primary>Mechanisms of vasomotor rhinitis</Title_Primary><Authors_Primary>Garay,R.</Authors_Primary><Date_Primary>2004</Date_Primary><Keywords>chemistry</Keywords><Keywords>Comparative Study</Keywords><Keywords>Drug-Related Side Effects and Adverse Reactions</Keywords><Keywords>Eosinophilia</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>France</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Inflammation</Keywords><Keywords>Male</Keywords><Keywords>Nasal Lavage Fluid</Keywords><Keywords>Nasal Mucosa</Keywords><Keywords>Parasympathetic Nervous System</Keywords><Keywords>physiopathology</Keywords><Keywords>Prognosis</Keywords><Keywords>Reflex</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Vasomotor</Keywords><Keywords>Risk Assessment</Keywords><Keywords>Severity of Illness Index</Keywords><Keywords>Syndrome</Keywords><Reprint>Not in File</Reprint><Start_Page>4</Start_Page><End_Page>9</End_Page><Periodical>Allergy</Periodical><Volume>59 Suppl 76</Volume><Misc_3>388 [pii]</Misc_3><Address>INSERM U400, Faculte de Medecine de Creteil, France. Garayperso@</Address><Web_URL>PM:14984550</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Garay 2004).Drugs?-adrenergic blockers, ACE inhibitors,Beta blockers,chlorpromazine Cocaine Nasal decongestants (with prolonged use) Aspirin/NSAIDs Nasal blockage Rhinorrhoea, crusting, pain and nasal septum perforation reduced olfaction ADDIN REFMGR.CITE <Refman><Cite><Author>Yewell</Author><Year>2002</Year><RecNum>204</RecNum><IDText>Complications of intranasal prescription narcotic abuse</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>204</Ref_ID><Title_Primary>Complications of intranasal prescription narcotic abuse</Title_Primary><Authors_Primary>Yewell,J.</Authors_Primary><Authors_Primary>Haydon,R.</Authors_Primary><Authors_Primary>Archer,S.</Authors_Primary><Authors_Primary>Manaligod,J.M.</Authors_Primary><Date_Primary>2002/2</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Adult</Keywords><Keywords>chemically induced</Keywords><Keywords>Cocaine</Keywords><Keywords>Cocaine-Related Disorders</Keywords><Keywords>complications</Keywords><Keywords>diagnosis</Keywords><Keywords>etiology</Keywords><Keywords>Facial Pain</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hydrocodone</Keywords><Keywords>Male</Keywords><Keywords>microbiology</Keywords><Keywords>Mycoses</Keywords><Keywords>Nasal Obstruction</Keywords><Keywords>Nasal Septum</Keywords><Keywords>Nose Diseases</Keywords><Keywords>Opioid-Related Disorders</Keywords><Keywords>pathology</Keywords><Keywords>Sinusitis</Keywords><Keywords>surgery</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>174</Start_Page><End_Page>177</End_Page><Periodical>Ann.Otol.Rhinol.Laryngol.</Periodical><Volume>111</Volume><Issue>2</Issue><Address>Division of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, Lexington, USA</Address><Web_URL>PM:11860072</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Otol.Rhinol.Laryngol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Yewell and others 2002) Rhinitis medicamentosa with chronic nasal blockage ADDIN REFMGR.CITE <Refman><Cite><Author>Tan</Author><Year>1995</Year><RecNum>430</RecNum><IDText>Optimum treatment of rhinitis in the elderly</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>430</Ref_ID><Title_Primary>Optimum treatment of rhinitis in the elderly</Title_Primary><Authors_Primary>Tan,R.</Authors_Primary><Authors_Primary>Corren,J.</Authors_Primary><Date_Primary>1995/9</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aging</Keywords><Keywords>Allergens</Keywords><Keywords>Arrhythmia</Keywords><Keywords>Cromolyn Sodium</Keywords><Keywords>Histamine</Keywords><Keywords>Histamine Antagonists</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>In Vitro</Keywords><Keywords>Ipratropium</Keywords><Keywords>Irritants</Keywords><Keywords>Nose</Keywords><Keywords>physiology</Keywords><Keywords>Rhinitis</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>168</Start_Page><End_Page>175</End_Page><Periodical>Drugs Aging</Periodical><Volume>7</Volume><Issue>3</Issue><Address>UCLA School of Medicine, Department of Medicine, USA</Address><Web_URL>PM:8535047</Web_URL><ZZ_JournalStdAbbrev><f name="System">Drugs Aging</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Tan and Corren 1995)Acute rhinitis symptoms +/- asthmaHormonalPregnancy ADDIN REFMGR.CITE <Refman><Cite><Author>Canonica</Author><Year>2003</Year><RecNum>387</RecNum><IDText>Noninjection routes for immunotherapy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>387</Ref_ID><Title_Primary>Noninjection routes for immunotherapy</Title_Primary><Authors_Primary>Canonica,G.W.</Authors_Primary><Authors_Primary>Passalacqua,G.</Authors_Primary><Date_Primary>2003/3</Date_Primary><Keywords>administration & dosage</Keywords><Keywords>Administration,Intranasal</Keywords><Keywords>Administration,Sublingual</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Allergens</Keywords><Keywords>Animals</Keywords><Keywords>Asthma</Keywords><Keywords>Clinical Trials</Keywords><Keywords>Disease</Keywords><Keywords>Dose-Response Relationship,Drug</Keywords><Keywords>Humans</Keywords><Keywords>Immunotherapy</Keywords><Keywords>Italy</Keywords><Keywords>methods</Keywords><Keywords>Preventive Medicine</Keywords><Keywords>Research Support,Non-U.'t</Keywords><Keywords>Rhinitis</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Universities</Keywords><Keywords>World Health Organization</Keywords><Reprint>Not in File</Reprint><Start_Page>437</Start_Page><End_Page>448</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>111</Volume><Issue>3</Issue><Address>Division of Allergy and Respiratory Diseases, Department of Internal Medicine, University of Genoa, Italy</Address><Web_URL>PM:12642818</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Canonica and Passalacqua 2003), puberty, HRT, contraceptive pill PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNodXN0ZXJtYW48L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFy
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ADDIN EN.CITE.DATA (Cullinan and others 1999; Petrick and Slavin 2003) All can cause nasal blockage and/or rhinorrhoeaFoodAlcohol, spicy foods, pepper, sulphitesRhinorrhoea, facial flushingGustatory rhinorrhoea AtrophicKlebsiella ozonae PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkdhdXRyaW48L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Gautrin and others 2001a)Primary mucus defectCystic fibrosis Children with polyps must be screened for cystic fibrosis ADDIN REFMGR.CITE <Refman><Cite><Author>Cartier</Author><Year>1984</Year><RecNum>520</RecNum><IDText>Occupational asthma in snow crab-processing workers</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>520</Ref_ID><Title_Primary>Occupational asthma in snow crab-processing workers</Title_Primary><Authors_Primary>Cartier,A.</Authors_Primary><Authors_Primary>Malo,J.L.</Authors_Primary><Authors_Primary>Forest,F.</Authors_Primary><Authors_Primary>Lafrance,M.</Authors_Primary><Authors_Primary>Pineau,L.</Authors_Primary><Authors_Primary>St-Aubin,J.J.</Authors_Primary><Authors_Primary>Dubois,J.Y.</Authors_Primary><Date_Primary>1984/9</Date_Primary><Keywords>Allergens</Keywords><Keywords>Asthma</Keywords><Keywords>Brachyura</Keywords><Keywords>Bronchi</Keywords><Keywords>Bronchial Provocation Tests</Keywords><Keywords>Canada</Keywords><Keywords>diagnosis</Keywords><Keywords>drug effects</Keywords><Keywords>epidemiology</Keywords><Keywords>Fish Products</Keywords><Keywords>Food-Processing Industry</Keywords><Keywords>Forced Expiratory Volume</Keywords><Keywords>Histamine</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity,Immediate</Keywords><Keywords>immunology</Keywords><Keywords>Nasal Provocation Tests</Keywords><Keywords>Occupational Diseases</Keywords><Keywords>Peak Expiratory Flow Rate</Keywords><Keywords>pharmacology</Keywords><Keywords>Prevalence</Keywords><Keywords>Seasons</Keywords><Keywords>Skin</Keywords><Keywords>Skin Tests</Keywords><Keywords>Smoking</Keywords><Keywords>Spirometry</Keywords><Keywords>Urticaria</Keywords><Reprint>Not in File</Reprint><Start_Page>261</Start_Page><End_Page>269</End_Page><Periodical>J.Allergy Clin Immunol</Periodical><Volume>74</Volume><Issue>3 Pt 1</Issue><Web_URL>PM:6470360</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin Immunol</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Cartier and others 1984)Primary ciliary dyskinesiasKartagener and Young syndromes Rhinosinusitis, bronchiectasis and reduced fertility.Systemic/InflammatorySjogren, SLE, rheumatoid arthritis Eosinophilic polyangiitis PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkhvdWJhPC9BdXRob3I+PFllYXI+MTk5ODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Gwaltney 2002; Johnston and others 1995; Wernfors and others 1986)Local ARAllergens as for AR (see table 1)Skin test negativeTable 2: Co-morbid associations with rhinitisAuthorsStudyNo patientsAge yrsAim of the study ResultsConjunctivitis ADDIN REFMGR.CITE <Refman><Cite><Author>Virchow</Author><Year>2011</Year><RecNum>1807</RecNum><IDText>Impact of ocular symptoms on quality of life (QoL), work productivity and resource utilisation in allergic rhinitis patients--an observational, cross sectional study in four countries in Europe</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1807</Ref_ID><Title_Primary>Impact of ocular symptoms on quality of life (QoL), work productivity and resource utilisation in allergic rhinitis patients--an observational, cross sectional study in four countries in Europe</Title_Primary><Authors_Primary>Virchow,J.C.</Authors_Primary><Authors_Primary>Kay,S.</Authors_Primary><Authors_Primary>Demoly,P.</Authors_Primary><Authors_Primary>Mullol,J.</Authors_Primary><Authors_Primary>Canonica,W.</Authors_Primary><Authors_Primary>Higgins,V.</Authors_Primary><Date_Primary>2011</Date_Primary><Keywords>Adult</Keywords><Keywords>analysis</Keywords><Keywords>Comorbidity</Keywords><Keywords>Conjunctivitis,Allergic</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Employment</Keywords><Keywords>Europe</Keywords><Keywords>Female</Keywords><Keywords>Germany</Keywords><Keywords>Health Resources</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>physiopathology</Keywords><Keywords>Population</Keywords><Keywords>Quality of Life</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Sleep</Keywords><Keywords>Smoking</Keywords><Keywords>Time</Keywords><Keywords>utilization</Keywords><Reprint>Not in File</Reprint><Start_Page>305</Start_Page><End_Page>314</End_Page><Periodical>J.Med.Econ.</Periodical><Volume>14</Volume><Issue>3</Issue><Misc_3>10.3111/13696998.2011.576039 [doi]</Misc_3><Address>Universitatsklinik Rostock, Germany</Address><Web_URL>PM:21488807</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Med.Econ.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Virchow and others 2011) Observational 1009Adultsstudy to assess extra burden associated with ocular symptomsOcular symptoms reduces quality of life and work productivityPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJvemt1cnQ8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Bertelsen and others 2010)Parental interviews of 1019 cohort 254 with rhinitis (=25%)childrenPrevalence of rhinitis co-morbidities 87.4% had at least one rhinitis co-morbidity. Conjunctivitis was present in 75.6% (11.8% of them also had asthma & eczema) ADDIN REFMGR.CITE <Refman><Cite><Author>Kim</Author><Year>2013</Year><RecNum>1724</RecNum><IDText>Prevalence and comorbidity of allergic diseases in preschool children</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1724</Ref_ID><Title_Primary>Prevalence and comorbidity of allergic diseases in preschool children</Title_Primary><Authors_Primary>Kim,H.Y.</Authors_Primary><Authors_Primary>Kwon,E.B.</Authors_Primary><Authors_Primary>Baek,J.H.</Authors_Primary><Authors_Primary>Shin,Y.H.</Authors_Primary><Authors_Primary>Yum,H.Y.</Authors_Primary><Authors_Primary>Jee,H.M.</Authors_Primary><Authors_Primary>Yoon,J.W.</Authors_Primary><Authors_Primary>Han,M.Y.</Authors_Primary><Date_Primary>2013/8</Date_Primary><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>Child</Keywords><Keywords>Comorbidity</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Dermatitis</Keywords><Keywords>Disease</Keywords><Keywords>Food</Keywords><Keywords>Health</Keywords><Keywords>methods</Keywords><Keywords>Prevalence</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Reprint>Not in File</Reprint><Start_Page>338</Start_Page><End_Page>342</End_Page><Periodical>Korean J.Pediatr.</Periodical><Volume>56</Volume><Issue>8</Issue><User_Def_5>PMC3764258</User_Def_5><Misc_3>10.3345/kjp.2013.56.8.338 [doi]</Misc_3><Address>Department of Pediatrics, Bundang Jesaeng General Hospital, Seongnam, Korea</Address><Web_URL>PM:24019844</Web_URL><ZZ_JournalStdAbbrev><f name="System">Korean J.Pediatr.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Kim and others 2013a) ISAAC Questionnaire(12 months evaluation)615 3-6Prevalence of rhinitis in children with conjunctivitis and conjunctivitis in children with rhinitisPrevalence of rhinitis in children with conjunctivitis was 64.8% .Prevalence of conjunctivitis in children with rhinitis was 23.6%Otitis media with effusionPFJlZm1hbj48Q2l0ZT48QXV0aG9yPlVtYXBhdGh5PC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Ibanez and others 2013) Multi centre prospective1275271 centres6-12Evaluation of ear co-morbidities in AR23.8% of AR had OME;17.3% of AR had adenoidal hypertrophyPFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNpbmdoPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Singh and others 2011)Prospective30patients 20controlsAdults Audiological and ontological status in ARAll patients had sensorineural hearing loss>high frequency& otoacoustic emission abnormalities PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJvemt1cnQ8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Chen and others 2013)Nationwide Prospective 167312-15Association AR and depression after 10 years FU Severe depression 2.5%vs 1.2%Any other depression 4.9% vs 2.8% ADDIN REFMGR.CITE <Refman><Cite><Author>Tsai</Author><Year>2011</Year><RecNum>1746</RecNum><IDText>Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1746</Ref_ID><Title_Primary>Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study</Title_Primary><Authors_Primary>Tsai,M.C.</Authors_Primary><Authors_Primary>Lin,H.K.</Authors_Primary><Authors_Primary>Lin,C.H.</Authors_Primary><Authors_Primary>Fu,L.S.</Authors_Primary><Date_Primary>2011/11</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Asthma</Keywords><Keywords>Attention</Keywords><Keywords>Attention Deficit Disorder with Hyperactivity</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>Comorbidity</Keywords><Keywords>complications</Keywords><Keywords>Dermatitis</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Health</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Prevalence</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk</Keywords><Keywords>Risk Factors</Keywords><Keywords>Sleep</Keywords><Keywords>Taiwan</Keywords><Reprint>Not in File</Reprint><Start_Page>41</Start_Page><End_Page>46</End_Page><Periodical>Allergy Asthma Proc.</Periodical><Volume>32</Volume><Issue>6</Issue><Misc_3>10.2500/aap.2011.32.3489 [doi]</Misc_3><Address>Department of Pediatrics, Taichung Veterans General Hospital, Taiwan</Address><Web_URL>PM:22221429</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy Asthma Proc.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Tsai and others 2011)Nationwide on Taiwan National Health Research Database226550<18Prevalence & risk of ADH in AR childrenIncreased ADH rate P<0.001(eczema & asthma do not carry the same risk)PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkthbHBha2xpb2dsdTwvQXV0aG9yPjxZZWFyPjIwMDk8L1ll
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ADDIN EN.CITE.DATA (Kalpaklioglu and others 2009)Observational study on sleeping symptoms48AdultsPrevalence of OSA in AR vs NAROSA 36% in AR vs 83% in NAR (OSA OR in NAR 6.4).AR & NAR subjects were snorersPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVtaW48L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Emin and others 2009)Prospective 82 vs 70 mothers of AR7-15Anxiety parameters scores in mothers of AR children vs controlsAnxiety scores significantly higher in mothers with AR childrenP<0.02PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxhdmlnbmU8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Lavigne and others 2013)Prospective for 12/weeks 34 AR21 NARAdultsEffects of mometasone on sleep parameters & upper airway inflammation on biopsiesSignificant improvement on sleeping parameters &reduction of eosinophils in AR only ADDIN REFMGR.CITE <Refman><Cite><Author>Messias</Author><Year>2010</Year><RecNum>1747</RecNum><IDText>Seasonal allergies and suicidality: results from the National Comorbidity Survey Replication</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1747</Ref_ID><Title_Primary>Seasonal allergies and suicidality: results from the National Comorbidity Survey Replication</Title_Primary><Authors_Primary>Messias,E.</Authors_Primary><Authors_Primary>Clarke,D.E.</Authors_Primary><Authors_Primary>Goodwin,R.D.</Authors_Primary><Date_Primary>2010/8</Date_Primary><Keywords>Adult</Keywords><Keywords>Age Factors</Keywords><Keywords>Aged</Keywords><Keywords>Asthma</Keywords><Keywords>Comorbidity</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Depressive Disorder</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Health Surveys</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Odds Ratio</Keywords><Keywords>psychology</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk Factors</Keywords><Keywords>Sex Factors</Keywords><Keywords>Smoking</Keywords><Keywords>statistics & numerical data</Keywords><Keywords>Suicide,Attempted</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>139</Start_Page><End_Page>142</End_Page><Periodical>Acta Psychiatr.Scand.</Periodical><Volume>122</Volume><Issue>2</Issue><Misc_3>ACP1518 [pii];10.1111/j.1600-0447.2009.01518.x [doi]</Misc_3><Address>Department of Psychiatry, Medical College of Georgia, Augusta, 30912, USA. emessias@</Address><Web_URL>PM:20003091</Web_URL><ZZ_JournalStdAbbrev><f name="System">Acta Psychiatr.Scand.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Messias and others 2010)National co-morbidity survey 5692AdultsAssociation of seasonal allergie with suicidal ideationSignificant association (OR 1.27) but not with suicide attempts ADDIN REFMGR.CITE <Refman><Cite><Author>Vuurman</Author><Year>2014</Year><RecNum>1728</RecNum><IDText>Allergic rhinitis is a risk factor for traffic safety</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1728</Ref_ID><Title_Primary>Allergic rhinitis is a risk factor for traffic safety</Title_Primary><Authors_Primary>Vuurman,E.F.</Authors_Primary><Authors_Primary>Vuurman,L.L.</Authors_Primary><Authors_Primary>Lutgens,I.</Authors_Primary><Authors_Primary>Kremer,B.</Authors_Primary><Date_Primary>2014/7</Date_Primary><Keywords>Adult</Keywords><Keywords>Androstadienes</Keywords><Keywords>Anti-Allergic Agents</Keywords><Keywords>Automobile Driving</Keywords><Keywords>blood</Keywords><Keywords>Cetirizine</Keywords><Keywords>complications</Keywords><Keywords>Cross-Over Studies</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Netherlands</Keywords><Keywords>Pollen</Keywords><Keywords>psychology</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Risk</Keywords><Keywords>Safety</Keywords><Keywords>therapeutic use</Keywords><Keywords>therapy</Keywords><Keywords>Universities</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>906</Start_Page><End_Page>912</End_Page><Periodical>Allergy</Periodical><Volume>69</Volume><Issue>7</Issue><Misc_3>10.1111/all.12418 [doi]</Misc_3><Address>Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands</Address><Web_URL>PM:24815889</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Vuurman and others 2014)Double blind randomized cross-over following nasal provocation with pollen extract and during the season19 (9 females/10men)AdultsEffect of untreated AR on driving performance compared with treated AR Magnitude of impairment (evaluated on standard deviation of lateral position of performance) comparable to that seen driving with 0.03% alcohol. Rx with anti H1 or steroids reduces the effects on driving performanceRhinosinusitis/anosmiaPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkliYW5lejwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Ibanez and others 2013)Multi centre prospective1275271 centresChildrenCo-morbidities in children with AR 26.1%of AR had rhinosinusitis ADDIN REFMGR.CITE <Refman><Cite><Author>Guss</Author><Year>2009</Year><RecNum>1730</RecNum><IDText>Olfactory dysfunction in allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1730</Ref_ID><Title_Primary>Olfactory dysfunction in allergic rhinitis</Title_Primary><Authors_Primary>Guss,J.</Authors_Primary><Authors_Primary>Doghramji,L.</Authors_Primary><Authors_Primary>Reger,C.</Authors_Primary><Authors_Primary>Chiu,A.G.</Authors_Primary><Date_Primary>2009</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Epithelium</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Olfaction Disorders</Keywords><Keywords>Olfactory Mucosa</Keywords><Keywords>Prevalence</Keywords><Keywords>Prospective Studies</Keywords><Keywords>radiography</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sinusitis</Keywords><Keywords>Smell</Keywords><Keywords>surgery</Keywords><Keywords>Tomography,X-Ray Computed</Keywords><Keywords>Universities</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>268</Start_Page><End_Page>272</End_Page><Periodical>ORL J.Otorhinolaryngol.Relat Spec.</Periodical><Volume>71</Volume><Issue>5</Issue><Misc_3>000242429 [pii];10.1159/000242429 [doi]</Misc_3><Address>Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA</Address><Web_URL>PM:19797935</Web_URL><ZZ_JournalStdAbbrev><f name="System">ORL J.Otorhinolaryngol.Relat Spec.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Guss and others 2009)Prospective 51 (80% allergic) AdultsInvestigate the olfactory function in AR (with Smell Identification Test and also CT scan)50% of AR with normal CT scored in the 30th percentile on olfactory test. 50% of allergic patients had hyposmiaAsthmaPFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNoYWFiYW48L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Shaaban and others 2008)Longitudinal population based study6461AdultsDevelopment of new asthmaRR of asthma development: 1.63 atopy, 2.71 NAR, 3.53 ARPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxleW5hZXJ0PC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Leynaert and others 2004)Cross sectional study3000 (1500 male and 1500 female)Young adultsIdentification of sensitization, BHR, asthma74-81% had asthma, BHR (OR 3.02) and asthma ( OR 6.63) more frequent in rhinitics. Asthma risk 2% without rhinitis, 6.7% with pollen rhinitis, 11.9% with animal rhinitis, 18.8% both. Strong association between asthma and rhinitis not fully explained by atopy ADDIN REFMGR.CITE <Refman><Cite><Author>Settipane</Author><Year>2000</Year><RecNum>1</RecNum><IDText>Natural history of asthma: a 23-year followup of college students</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1</Ref_ID><Title_Primary>Natural history of asthma: a 23-year followup of college students</Title_Primary><Authors_Primary>Settipane,G.A.</Authors_Primary><Authors_Primary>Greisner,W.A.,III</Authors_Primary><Authors_Primary>Settipane,R.J.</Authors_Primary><Date_Primary>2000/5</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>diagnosis</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Humans</Keywords><Keywords>Interviews as Topic</Keywords><Keywords>Male</Keywords><Keywords>Prevalence</Keywords><Keywords>Prognosis</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Rhinitis,Allergic,Seasonal</Keywords><Keywords>Skin Tests</Keywords><Keywords>Surveys and Questionnaires</Keywords><Reprint>Not in File</Reprint><Start_Page>499</Start_Page><End_Page>503</End_Page><Periodical>Ann.Allergy Asthma Immunol.</Periodical><Volume>84</Volume><Issue>5</Issue><Misc_3>S1081-1206(10)62512-4 [pii];10.1016/S1081-1206(10)62512-4 [doi]</Misc_3><Address>Brown University School of Medicine, USA</Address><Web_URL>PM:10831002</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Allergy Asthma Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Settipane and others 2000)Questionnaire1601AdultsAsthma and rhinitis/AR improvement associated with a resolution of asthma symptomsAsthma and rhinitis present in 85.7% of asthmatics, asthma in 21.3% of rhinitics. In 44.8% of those with both rhinitis appeared first, in 20.7% at the same time ADDIN REFMGR.CITE <Refman><Cite><Author>Williams</Author><Year>2013</Year><RecNum>1</RecNum><IDText>Recognition of allergic conjunctivitis in patients with allergic rhinitis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1</Ref_ID><Title_Primary>Recognition of allergic conjunctivitis in patients with allergic rhinitis</Title_Primary><Authors_Primary>Williams,D.C.</Authors_Primary><Authors_Primary>Edney,G.</Authors_Primary><Authors_Primary>Maiden,B.</Authors_Primary><Authors_Primary>Smith,P.K.</Authors_Primary><Date_Primary>2013</Date_Primary><Reprint>Not in File</Reprint><Start_Page>4</Start_Page><Periodical>World Allergy Organ J.</Periodical><Volume>6</Volume><Issue>1</Issue><User_Def_5>PMC3646537</User_Def_5><Misc_3>1939-4551-6-4 [pii];10.1186/1939-4551-6-4 [doi]</Misc_3><Address>Department, Institute, School of Medicine Gold Coast Campus, Griffith University, 16 High Street, Gold Coast 4222, Australia. daniel.c.r.williams@</Address><Web_URL>PM:23663473</Web_URL><ZZ_JournalStdAbbrev><f name="System">World Allergy Organ J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Williams and others 2013)MARYAM PL MOVE THIS TO CONJUNCTIVITIS SECTIONQuestionnaire and direct question187AdultsTo identify the incidence of allergic conjunctivitis in patients with allergic rhinitisFifty five percent of patients with AR were identified as having AC by direct questioning and the use of the TOSS questionnaire. A further 41% were identifiable by asking additional questions and performing therapeutic challenge with olopadatine.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1hZ25hbjwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Ciprandi and others 2011) Prospective89 AR940 controlsAdultsFollow up of patients with AR every 2 years for 8years to investigate spirometric abnormalities /BHR34/89 AR patients develop BHR after 8 yearsSensitization for mite, birch, parietaria as well as rhinitis duration are risk factors ADDIN REFMGR.CITE <Refman><Cite><Author>Yilmaz</Author><Year>2014</Year><RecNum>1750</RecNum><IDText>Allergic rhinitis may impact the recovery of pulmonary function tests after moderate/severe asthma exacerbation in children</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1750</Ref_ID><Title_Primary>Allergic rhinitis may impact the recovery of pulmonary function tests after moderate/severe asthma exacerbation in children</Title_Primary><Authors_Primary>Yilmaz,O.</Authors_Primary><Authors_Primary>Bakirtas,A.</Authors_Primary><Authors_Primary>Ertoy Karagol,H.I.</Authors_Primary><Authors_Primary>Topal,E.</Authors_Primary><Authors_Primary>Demirsoy,M.S.</Authors_Primary><Date_Primary>2014/5</Date_Primary><Keywords>analysis</Keywords><Keywords>Asthma</Keywords><Keywords>Child</Keywords><Keywords>complications</Keywords><Keywords>drug therapy</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>physiopathology</Keywords><Keywords>Regression Analysis</Keywords><Keywords>Respiratory Function Tests</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic</Keywords><Keywords>Risk</Keywords><Keywords>Risk Factors</Keywords><Keywords>Severity of Illness Index</Keywords><Keywords>Time</Keywords><Keywords>Time Factors</Keywords><Keywords>Turkey</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>652</Start_Page><End_Page>657</End_Page><Periodical>Allergy</Periodical><Volume>69</Volume><Issue>5</Issue><Misc_3>10.1111/all.12391 [doi]</Misc_3><Address>Department of Pediatric Allergy and Asthma, Gazi University, School of Medicine, Ankara, Turkey</Address><Web_URL>PM:24649828</Web_URL><ZZ_JournalStdAbbrev><f name="System">Allergy</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Yilmaz and others 2014)Prospective57Children with asthma ex’ionEvaluate the risk factors for recovery of lung function tests after moderate/severe asthma exacerbationAR is a significant factor affecting the recovery time of pulmonary function tests and impacts asthma managementPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkliYW5lejwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Ibanez and others 2013)Prospective multicentre 1275ChildrenFrom 271 centresEvaluation of comorbidities for AR in a Spanish population49.5% co-morbidity with asthma: allergy is a systemic disease ADDIN REFMGR.CITE <Refman><Cite><Author>Navarro</Author><Year>2008</Year><RecNum>1732</RecNum><IDText>Coexistence of asthma and allergic rhinitis in adult patients attending allergy clinics: ONEAIR study</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1732</Ref_ID><Title_Primary>Coexistence of asthma and allergic rhinitis in adult patients attending allergy clinics: ONEAIR study</Title_Primary><Authors_Primary>Navarro,A.</Authors_Primary><Authors_Primary>Valero,A.</Authors_Primary><Authors_Primary>Julia,B.</Authors_Primary><Authors_Primary>Quirce,S.</Authors_Primary><Date_Primary>2008</Date_Primary><Keywords>Adult</Keywords><Keywords>Allergens</Keywords><Keywords>Asthma</Keywords><Keywords>Comorbidity</Keywords><Keywords>Disease</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Prevalence</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Spain</Keywords><Reprint>Not in File</Reprint><Start_Page>233</Start_Page><End_Page>238</End_Page><Periodical>J.Investig.Allergol.Clin.Immunol.</Periodical><Volume>18</Volume><Issue>4</Issue><Address>Allergy Unit, Hospital El Tomillar, AH de Valme, Seville, Spain. anam.navarro.sspa@juntadeandalucia.es</Address><Web_URL>PM:18714529</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Investig.Allergol.Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Navarro and others 2008)EpidemiologicprospectiveMulti centre942with asthmaMean age 35.563% femaleInvestigate the link between the upper and lower airways89.5% had ARCorrelation between severity of rhinitis and asthma (P<0001) ADDIN REFMGR.CITE <Refman><Cite><Author>de Andrade</Author><Year>2008</Year><RecNum>1733</RecNum><IDText>Asthma and allergic rhinitis co-morbidity: a cross-sectional questionnaire study on adolescents aged 13-14 years</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1733</Ref_ID><Title_Primary>Asthma and allergic rhinitis co-morbidity: a cross-sectional questionnaire study on adolescents aged 13-14 years</Title_Primary><Authors_Primary>de Andrade,C.R.</Authors_Primary><Authors_Primary>da,Cunha,I</Authors_Primary><Authors_Primary>Goncalves,Alvim C.</Authors_Primary><Authors_Primary>Fernandes Fontes,M.J.</Authors_Primary><Authors_Primary>de Lima Belizario Facury Lasmar LM</Authors_Primary><Authors_Primary>Moreira Camargos,P.A.</Authors_Primary><Date_Primary>2008/12</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Aged</Keywords><Keywords>Asthma</Keywords><Keywords>Brazil</Keywords><Keywords>Cohort Studies</Keywords><Keywords>Comorbidity</Keywords><Keywords>complications</Keywords><Keywords>Conjunctivitis,Allergic</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>epidemiology</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Health</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Prevalence</Keywords><Keywords>Primary Health Care</Keywords><Keywords>Questionnaires</Keywords><Keywords>Respiratory Sounds</Keywords><Keywords>Rhinitis</Keywords><Keywords>Schools</Keywords><Keywords>Students</Keywords><Keywords>Universities</Keywords><Reprint>Not in File</Reprint><Start_Page>222</Start_Page><End_Page>225</End_Page><Periodical>Prim.Care Respir.J.</Periodical><Volume>17</Volume><Issue>4</Issue><Misc_3>pcrj-2008-02-0024 [pii];10.3132/pcrj.2008.00056 [doi]</Misc_3><Address>Jose do Rosario Vellano University, Belo Horizonte, Brazil</Address><Web_URL>PM:18701968</Web_URL><ZZ_JournalStdAbbrev><f name="System">Prim.Care Respir.J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(de Andrade and others 2008)Cross sectional study using ISAAC questionnaire 3083 students(47.3% males)13-14 years old, 47.3% male.Evaluation of Asthma and AR co-morbidity Comorbidity of asthma and rhinitis symptoms was 8.4%Among asthmatic adolescents, AR symptoms were reported in 46.5%PFJlZm1hbj48Q2l0ZT48QXV0aG9yPktvPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVjTnVt
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ADDIN EN.CITE.DATA (Ko and others 2010)Cross sectional on questionnaire 600 (with asthma)267 male333 femaleEvaluation of prevalence of AR in asthma77% of asthmatic had rhinitis in the past 12 months (of whom 96% were previously diagnosed with AR)Patients with asthma and rhinitis: nasal steroid usage (49%) had < ED visits 13 vs 25%) and <hospitalization for asthma (5% vs 13%)PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVyaWtzc29uPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48
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ADDIN REFMGR.CITE PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVyaWtzc29uPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48
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ADDIN EN.CITE.DATA (Eriksson and others 2011)Postal Questionnaireon respiratory health 18087(62% responded)AdultsEvaluation between rhinitis phenotypes and symptoms presentation and risk factor patterns in asthmaPrevalence of asthma in AR was 19.8%Prevalence of AR in asthma was 63.9% Asthma with chronic rhinitis had more asthma symptoms and bronchitis (P<0.01)FH of allergy has a higher OR for asthma and AR than for asthma and CRSBertelasan RParental interviews254Children with rhinitis Evaluation of co morbidities of rhinitis 87.4% had at least one allergy related co-morbidityChildren with rhinitis and allergic sensitization (72.8%) had>BHR, severe BHR (7.5% vs 5.8%) and conjuntivitisPFJlZm1hbj48Q2l0ZT48QXV0aG9yPlZhbGVybzwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Valero and others 2009)Cross sectional international population study based on questionnaire 3225 (one +ve skin test ) 10-5053% MaleEvaluation on the link between AR, asthma and skin test sensitizationAsthma was present in 49% of AR Asthma severity was associated with longer time since the onset and allergic rhinitis severity.Patients with asthma have higher number of allergen sensitization and sensitization intensity than those without asthma (P<0.01) ADDIN REFMGR.CITE <Refman><Cite><Author>Kim</Author><Year>2013</Year><RecNum>1756</RecNum><IDText>Prevalence and comorbidity of allergic diseases in preschool children</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1756</Ref_ID><Title_Primary>Prevalence and comorbidity of allergic diseases in preschool children</Title_Primary><Authors_Primary>Kim,H.Y.</Authors_Primary><Authors_Primary>Kwon,E.B.</Authors_Primary><Authors_Primary>Baek,J.H.</Authors_Primary><Authors_Primary>Shin,Y.H.</Authors_Primary><Authors_Primary>Yum,H.Y.</Authors_Primary><Authors_Primary>Jee,H.M.</Authors_Primary><Authors_Primary>Yoon,J.W.</Authors_Primary><Authors_Primary>Han,M.Y.</Authors_Primary><Date_Primary>2013/8</Date_Primary><Keywords>Adult</Keywords><Keywords>Asthma</Keywords><Keywords>Child</Keywords><Keywords>Comorbidity</Keywords><Keywords>Conjunctivitis</Keywords><Keywords>Cross-Sectional Studies</Keywords><Keywords>Dermatitis</Keywords><Keywords>Disease</Keywords><Keywords>Food</Keywords><Keywords>Health</Keywords><Keywords>methods</Keywords><Keywords>Prevalence</Keywords><Keywords>Quality of Life</Keywords><Keywords>Rhinitis</Keywords><Reprint>Not in File</Reprint><Start_Page>338</Start_Page><End_Page>342</End_Page><Periodical>Korean J.Pediatr.</Periodical><Volume>56</Volume><Issue>8</Issue><User_Def_5>PMC3764258</User_Def_5><Misc_3>10.3345/kjp.2013.56.8.338 [doi]</Misc_3><Address>Department of Pediatrics, Bundang Jesaeng General Hospital, Seongnam, Korea</Address><Web_URL>PM:24019844</Web_URL><ZZ_JournalStdAbbrev><f name="System">Korean J.Pediatr.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Kim and others 2013b)Cross sectionalStudy using ISAAC questionnaire 615Children (306)Evaluation of allergic co-morbidities in pre-school childrenPrevalence of AR in children with asthma was 64.3%Prevalence of asthma in children with R was 21.6%Oral allergy syndrome/food pollen syndrome/food allergy ADDIN REFMGR.CITE <Refman><Cite><Author>Westman</Author><Year>2012</Year><RecNum>1738</RecNum><IDText>Natural course and comorbidities of allergic and nonallergic rhinitis in children</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1738</Ref_ID><Title_Primary>Natural course and comorbidities of allergic and nonallergic rhinitis in children</Title_Primary><Authors_Primary>Westman,M.</Authors_Primary><Authors_Primary>Stjarne,P.</Authors_Primary><Authors_Primary>Asarnoj,A.</Authors_Primary><Authors_Primary>Kull,I.</Authors_Primary><Authors_Primary>van,Hage M.</Authors_Primary><Authors_Primary>Wickman,M.</Authors_Primary><Authors_Primary>Toskala,E.</Authors_Primary><Date_Primary>2012/2</Date_Primary><Keywords>Allergens</Keywords><Keywords>Asthma</Keywords><Keywords>blood</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>Cohort Studies</Keywords><Keywords>Comorbidity</Keywords><Keywords>Disease</Keywords><Keywords>Eczema</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Food</Keywords><Keywords>Food Hypersensitivity</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity</Keywords><Keywords>Immunoglobulin E</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Phenotype</Keywords><Keywords>Research</Keywords><Keywords>Rhinitis</Keywords><Keywords>Rhinitis,Allergic,Perennial</Keywords><Keywords>Sweden</Keywords><Keywords>Syndrome</Keywords><Keywords>Time</Keywords><Reprint>Not in File</Reprint><Start_Page>403</Start_Page><End_Page>408</End_Page><Periodical>J.Allergy Clin.Immunol.</Periodical><Volume>129</Volume><Issue>2</Issue><Misc_3>S0091-6749(11)01559-4 [pii];10.1016/j.jaci.2011.09.036 [doi]</Misc_3><Address>CLINTEC, Karolinska Institutet, Stockholm, Sweden. marit.westman@ki.se</Address><Web_URL>PM:22056609</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Allergy Clin.Immunol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Westman and others 2012)Prospective2024Children IgE tested (inhalants) at 4 and 8yearsNatural course of AR and co-morbidities in children Increase AR from 5% to 14% from 4 to 8years; decrease of NAR from 8% to 6%.4yrs sensitized but not allergic had AR at 8years in 56% of cases25% of 8yrs with AR has also OASPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhbGlza2FuZXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Sahin-Yilmaz and others 2010)Retrospective283Peanut, shrimp and milk IgE and rhinitis23.4% peanut IgE +ve and 22.2% IgE+ shrimp in inhalant +patientsPeanut and shrimp were the >common sensitivities in rhinitis patientsLaryngeal symptomsVergut MM L 2011 et alObservational prospective 6control6 AR adult singers4 females2menEffects of nasal provocation with pollen extracts and during the HF on Laryngeal parametersRapid induction of laryngeal irritation/ globus (no objective laryngeal changes on provocation and during the season)Rhinitis/atopic disease and migraine ADDIN REFMGR.CITE <Refman><Cite><Author>Munoz-Jareno</Author><Year>2011</Year><RecNum>1737</RecNum><IDText>[Relationship between migraine and atopy in childhood: a retrospective case-control study]</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1737</Ref_ID><Title_Primary>[Relationship between migraine and atopy in childhood: a retrospective case-control study]</Title_Primary><Authors_Primary>Munoz-Jareno,N.</Authors_Primary><Authors_Primary>Fernandez-Mayoralas,D.M.</Authors_Primary><Authors_Primary>Martinez-Cervell,C.</Authors_Primary><Authors_Primary>Campos-Castello,J.</Authors_Primary><Date_Primary>2011/12/16</Date_Primary><Keywords>Adolescent</Keywords><Keywords>analysis</Keywords><Keywords>Asthma</Keywords><Keywords>Case-Control Studies</Keywords><Keywords>Child</Keywords><Keywords>Child,Preschool</Keywords><Keywords>Comorbidity</Keywords><Keywords>Conjunctivitis,Allergic</Keywords><Keywords>Dermatitis</Keywords><Keywords>Dermatitis,Atopic</Keywords><Keywords>diagnosis</Keywords><Keywords>Disease</Keywords><Keywords>English Abstract</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypersensitivity,Immediate</Keywords><Keywords>immunology</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Migraine Disorders</Keywords><Keywords>Odds Ratio</Keywords><Keywords>Prevalence</Keywords><Keywords>Questionnaires</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Rhinitis</Keywords><Keywords>Time</Keywords><Reprint>Not in File</Reprint><Start_Page>713</Start_Page><End_Page>720</End_Page><Periodical>Rev.Neurol.</Periodical><Volume>53</Volume><Issue>12</Issue><Misc_3>rn2011396 [pii]</Misc_3><Address>Unidad de Neuropediatria, Hospital Infanta Leonor, Madrid, Espana. nuriamunozjareno@yahoo.es</Address><Web_URL>PM:22127657</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rev.Neurol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(Munoz-Jareno and others 2011)Retrospective study FU for 6months2165-15 Prevalence of atopy in children with migrainePrevalence of rhinoconjunctivitis, asthma and atopic dermatitis are statistically significant in children with migraine (OR 7.3; P<0.01for rhinoconjunctivitis; OR 4.69: P<0.01 for asthma; OR 7.1; P< 0.01 for atopic dermatitisTable 3: Recommendations for allergen avoidance This measure may be useful if used as part of a range of measures to reduce HDM exposureHouse Dust Mite – recommendations from trialsGrade of recommendationEncase mattress, pillow and duvet in allergen- impermeable fabricA (against use as a single intervention)Use of acaricides on carpets and soft furnishingBPollen - Other practical avoidance measures not tested in trialsMinimizing outdoor activity when pollen is highest (early morning, early evening, during mowing) DAvoiding going out during/after thunderstorms DPlanning holidays to avoid the pollen season. DKeeping windows closed (house and car). DShower/ wash hair following high exposures DAvoid drying washing outdoors when count is high DTable 4: Pharmacotherapy- effects on individual rhinitis symptoms (adapted from PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlZhbiBDYXV3ZW5iZXJnZTwvQXV0aG9yPjxZZWFyPjIwMDA8
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ADDIN EN.CITE.DATA (Van Cauwenberge and others 2000)Sneezing RhinorrheaNasal obstructionNasal itchEye symptomsH1-antihistamines Oral++++++++++ Intranasal+++++++0 Eye drops0000+++Corticosteroids Intranasal++++++++++++Chromones Intranasal++++0Eye drops0000++Decongestants Intranasal00++++00 Oral00+00Anticholinergics0++000Antileukotrienes0+++0++Intranasal steroids and Intranasal anti-histamine 1+++++++++++++++Figure 1: Basic mechanisms of allergic rhinitisGreiner A et al. Allergic Rhinitis. Lancet, 201122631402925445002263140472567010534654944745 Check use, concordance, dose00 Check use, concordance, dose10534652639695Check use, concordance, dose00Check use, concordance, dose226314037160200022821902353945018440401577340Rx failure00Rx failure22631401376680133921512204700355854012204700133921513728700-26098565544702291715450024522917154500245229171545002452967990944245 INS00 INS786765944245 AH 00 AH 2739390401320 Moderate/Severe00 Moderate/Severe510540401320 Mild 00 Mild 22250401944370Figure 2: Pharmacotherapy algorithm for allergic rhinitis348424566675129159067310204787414922500198120012826900434340053340Key:IN=intranasalOC= oral corticosteroidsAH= H1 antihistamineLTRA=leukotriene receptor antagonist00Key:IN=intranasalOC= oral corticosteroidsAH= H1 antihistamineLTRA=leukotriene receptor antagonist129222537134Combination Rx with INS and INAH00Combination Rx with INS and INAH153987533195 Rx failure00 Rx failure22701252286052666905270534880554318018497554318033528043180329565387354498340151765Blockage, Add (briefly) IN decongestant00Blockage, Add (briefly) IN decongestant2740660161290CatarrhAdd LTRA if asthmatic00CatarrhAdd LTRA if asthmatic1214120151765Itch/sneeze/ extra nasal itch/ rash switch to non -sedating oral anti-H100Itch/sneeze/ extra nasal itch/ rash switch to non -sedating oral anti-H1-184785150495Watery rhinorrheaAdd ipratropium 00Watery rhinorrheaAdd ipratropium 53911504762535718755715019196054762540005047625263461538103962406350002183130120650Rx failure00Rx failure4176395144780Inflammatory rhinitis,Course of OC, continue local Rx00Inflammatory rhinitis,Course of OC, continue local Rx-952501905?infection/structural problem, Surgical referral00?infection/structural problem, Surgical referral140398573660003098800660402634615914401431925116840 Consider immunotherapyif Rx predominantly due to one allergen00 Consider immunotherapyif Rx predominantly due to one allergenFigure3 : Intranasal steroids bioavailability (Roberts, 2013)-130175-22860Figure 4a: Correct procedure for the application of nasal sprays (Rhinitis guideline 1st Edition)Shake bottle wellLook downUsing RIGHT hand for LEFT nostril put nozzle just inside nose aiming towards outside wallSquirt once or twice (2 different directions)Change hands and repeat for other sideBreathe in gently through the nose DO NOT SNIFFFigure 4b: Correct procedure for the installation of nasal drops2571751029335EosinophilicAnti-inflammatory:INS, IN antiH1,or both togetherNo inflammationIpratropium for rhinorrhoeaCapsaicinMixed RhinitisTry anti – inflammatoryPlus ipratropium Treatment failure0EosinophilicAnti-inflammatory:INS, IN antiH1,or both togetherNo inflammationIpratropium for rhinorrhoeaCapsaicinMixed RhinitisTry anti – inflammatoryPlus ipratropium Treatment failureFigure 5: Treatment of NAR2636202-11431500-600075-29210Figure 6: Classification of rhinitis causation in children - from Roberts, 201300Figure 6: Classification of rhinitis causation in children - from Roberts, 2013 29667205143500694690339725Pre-schoolSchoolAdolescent00Pre-schoolSchoolAdolescent62357025146000394271524257000-911225353060Allergic rhinitis00Allergic rhinitis244792548453Rhinitis symptoms that are associated with exposures to an allergen to which the patient is sensitised00Rhinitis symptoms that are associated with exposures to an allergen to which the patient is sensitised-915311278793Infectious rhinitis00Infectious rhinitis741045328930Secondary to infection00Secondary to infection619125172720Irritant exposure (e.g. exhaled tobacco smoke), gastroesophageal reflux and in older children, hormonal (hypothyroidism, pregnancy), drug-induced (e.g. beta-blockers, contraceptives, NSAID), neurogenic or vasomotor, idiopathic00Irritant exposure (e.g. exhaled tobacco smoke), gastroesophageal reflux and in older children, hormonal (hypothyroidism, pregnancy), drug-induced (e.g. beta-blockers, contraceptives, NSAID), neurogenic or vasomotor, idiopathic-83488810105Non-allergic, non-infectious rhinitis00Non-allergic, non-infectious rhinitisFigure 7: Recognizing rhinitis in childhood, (from Roberts et al, 2013)-88582536195 Different pathophysiologies may co-exist, particularly allergic rhinitis and infectious rhinitis.00 Different pathophysiologies may co-exist, particularly allergic rhinitis and infectious rhinitis.Figure 8: Approach to therapy for paediatric allergic rhinitis (Roberts et al 2013)Appendix A1: Levels of evidence ADDIN REFMGR.CITE <Refman><Cite><Author>British Thoracic Society</Author><Year>2003</Year><RecNum>535</RecNum><IDText>British guideline on the management of asthma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>535</Ref_ID><Title_Primary>British guideline on the management of asthma</Title_Primary><Authors_Primary>British Thoracic Society</Authors_Primary><Date_Primary>2003</Date_Primary><Keywords>Asthma</Keywords><Reprint>Not in File</Reprint><Periodical>Thorax</Periodical><Volume>58 (Supplement 1)</Volume><Web_URL><u> name="System">Thorax</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(British Thoracic Society 2003)Level of evidence Definition1++High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias1+Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias1-Meta-analyses, systematic reviews, or RCTs with a high risk of bias2++High quality systematic reviews of case control or cohort or studiesHigh quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2-Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3Non-analytic studies, e.g. case reports, case series4Expert opinionAppendix A2: Evidence table – Recent combination therapy for rhinitis Bibliogra-phic citationStudy typeEvidence levelNo. patientsPatient characteristicsInterven-tionCompa-risonLength of follow-upOutcome measuresEffect sizeSource of fundingHas the study provided answers to the original question?Weakness / limitationsCited Y/NCarr W 2012 JACI PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhcnI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Carr and others 2012b)Meta-Analysis1+ (Grade A)339812 or above. Mod-Sev SARDymistaAz/FP/Pl14 daysPrimary rTNSS change Time to responseminus 5.7 mean r TNSSMEDAYes-combination Az/FP better than individual drugs aloneNone YCarr W 2012 Allergy Asthma Proc PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhcnI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Carr and others 2012c)Doub- blind placebo-control2+ (Grade C) 61012 or above. Mod-Sev SARAz vs FP vs Pl14 daysprimary rTNSS change. Secondary r T O S S??Az as good as FP overall in treating nose and eye. FP better for rhinorrhoea. At 14 days more volunteers eyes improved in Az group than FPpost-hoc analy from previous study on Dymista vs AZ/FP/PLYMeltzer EO 2012 Allergy Asthma Proc PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhcnI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Carr and others 2012c)Doub- blind placebo-control2+ (Grade C) 77912 or above. Mod-Sev SARDymistaAz/FP/Pl14 daysprimary rTNSS change. Secondary r T O S S Time to onset of action and 12 hour r individual nasal symptom scores Eye QOL?MEDAYes Time to onset action 30 minutes vs placebo. Dymista particularly decreased nasal congestion compared to FP and Az used alone. Dymista overall better at treating eyes than FP alone and possibly just better than Az alone. None YBaroody F Am J Rhinol AllergyPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJhcm9vZHk8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Baroody and others 2013)Doub- blind placebo-control 4 way X-over2- (Grade C) 2118-50 yrs NAC out of season in SARFF+OP vs FF/PL vs PL/OP vs PL/PL4 way x over Pre-Rx groups 1 week and then NACX2Symptoms nose and eye and nasal histamine and tryptase?GSKFF/OL no better than FF/PL. Suggests treating the nose with an INS is best for treating the nasal ocular reflex. BUT if done in SAR will OL drops in eye act on effects of pollen in the conjunctiva Small numbers NAC out of season is artificialYBernstein D Ann Allergy Asthma Immunol 2012 PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJlcm5zdGVpbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA (Bernstein and others 2012) Pooled data from 4 DBPC studies 2+ (Grade C) 96212 or above. Mod-Sev SAR subgroup MF-only looked at. Placebo15 daysEar and palate itch? MSDYes. Decreases itch mouth and earspost-hoc analy from previous studies. Confined only to MF YBaroody F JACI 2011 PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJhcm9vZHk8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Meltzer and others 2013) Unblinded, single dummy for MF, placebo control for MF NOT Oxy2-(Grade C)705SARMF + OXY different doses vs MF vs Oxy vs Placebovs baseline TNSS?TNSS ?MSDMF/OXY (both doses) same efficacy and better than Oxy or placebo alone. Faster onset of action than just MF alone (MF still as good for relieving TNSS to same level as MF/OXY combinationsBlinding/Placebo/single dummyYPrice D, Shah S, Bhatia S, Bachert C, Berger W, Bousquet J, Carr W, HellingsP, Munzel U, Scadding G, Lieberman P. A new therapy (MP29-02) is effective forthe long-term treatment of chronic rhinitis. J Investig Allergol Clin Immunol.2013;23(7):495-503. PubMed PMID: 24654314.AbstractBACKGROUND AND OBJECTIVE:MP29-02 (Dymista), a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP), is significantly better than first-line therapy for the treatment of moderate-to-severe seasonal allergic rhinitis (SAR), and is well tolerated following 52 weeks of continuous use in chronic rhinitis. The aim of this study was to evaluate the long-term efficacy of MP29-02 versus FP in patients with chronic rhinitis.PATIENTS AND METHODS:In total, 612 chronic rhinitis patients (perennial allergic rhinitis [PAR], n = 424; nonallergic rhinitis, n=188) aged 12 years or older were enrolled into this open-label, parallel-group study and randomized to MP29-02 (1 spray/nostril bid) or FP nasal spray (2 sprays/nostril qd) for 52 weeks. Efficacy was assessed by change from baseline in PM reflective total nasal symptom score (rTNSS), time to first achieve 100% PM rTNSS reduction from baseline, and percentage of symptom-free days in the total and PAR populations posthoc.RESULTS:MP29-02 reduced patients' PM rTNSS from baseline significantly more than FP, from Day 1 up to and including week 28 (-2.88 vs -2.53; P = .0048), with treatment difference maintained for 52 weeks. Fluctuation in significance after week 28 might be explained, at least in part, by decreasing sample size, permitted according to ICH guidelines. By Day 1 almost twice as many MP29-02-patients were symptom free. After 1 month, 71.1% of MP29-02 patients experienced 100% rTNSS reduction (60.3% for FP), and did on a median of 9 days faster (P=.0024). Over 52 weeks MP29-02 patients experienced 8.4% more symptom-free days (P = .0005). These results were mirrored in the PAR subpopulation.CONCLUSION:These results confirm MP29-02's wide therapeutic spectrum and assert its consistent superiority over an intranasal corticosteroid.PMID:?24654314 ................
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