Asthma Management Handbook

Managing allergic rhinitis in people with asthma

Recommendations

Prescribe or recommend intranasal corticosteroids for adults and children with persistent allergic rhinitis or moderate-to-severe intermittent allergic rhinitis, even if the person is already taking regular inhaled corticosteroids for asthma.

Table. Classification of allergic rhinitis

Pattern of symptoms

Intermittent

Persistent

Either of:

  • symptoms present <4 days per week
  • symptoms present <4 consecutive weeks

Both of:

  • symptoms present ≥4 days per week
  • symptoms present ≥4 consecutive weeks

Severity

Mild

Moderate-to-severe

No features of moderate-to-severe allergic rhinitis

Any of:

  • sleep disturbance
  • impairment of daily activities, leisure, physical activity
  • impairment of school or work
  • troublesome symptoms

Source: Bousquet J, Khaltaev N, Cruz AA et al. Allergic rhinitis and its impact on asthma (ARIA) 2008. Allergy 2008; 63(Suppl 86): 7-160. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2007.01620.x/full

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How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Brożek et al. 20101

If symptoms are troublesome to the patient, consider initially adding an agent with a more rapid onset of action (e.g. oral or intranasal H1-antihistamine or short-term intranasal decongestant).

Note: Warn patients not to take intranasal decongestants for more than 5 days, and only occasionally.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Bachert and Maspero, 20112
  • Bousquet et al. 20083
  • Brożek et al. 20101
  • Howarth, 19994
  • Kaliner et al. 20115
  • Wallace et al. 20086

For patients with mild intermittent allergic rhinitis, consider targeting predominant symptoms.

Table. Targeting specific symptoms for intermittent treatment of allergic rhinitis

Predominant symptom or sign

Effective options

Itching and sneezing

Intranasal corticosteroids

Oral H1-antihistamines

Intranasal cromolyn sodium

Rhinorrhoea

Intranasal corticosteroids

Ipratropium bromide

Nasal congestion

Intranasal corticosteroids

Intranasal H1- antihistamines

Sources

Brożek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010; 126: 466-76. Availble from: http://www.jacionline.org/article/S0091-6749(10)01057-2/fulltext

Howarth P. Assessment of antihistamine efficacy and potency. Clin Exp Allergy 1999; 29 (Suppl 3): 87-97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10444220

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For young children with mild allergic rhinitis or intermittent allergic rhinitis, or those who will not tolerate intranasal medicines, consider an oral H1-antihistamine. Avoid older, sedating antihistamines.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If allergic rhinitis symptoms do not resolve within 3–4 weeks, consider allergy testing and review the diagnosis.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For patients with asthma who need long-term regular medication for allergic rhinitis, explain to patients that effective management of allergic rhinitis is part of their asthma care. Emphasise the need to take intranasal corticosteroids consistently, and reassure patients that these medicines have a good safety profile when taken long term.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Demonstrate correct technique for using intranasal sprays and check patients’ technique regularly.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider specialist referral for patients with allergic rhinitis who have:

  • poorly controlled asthma, despite appropriate treatment, good adherence and good inhaler technique
  • other significant allergic disease (e.g. food allergies or severe eczema)
  • symptoms that suggest an alternative diagnosis (e.g. unilateral nasal symptoms, persistent nasal obstruction that does not respond to intranasal corticosteroids, or suspected chronic sinusitis).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

In pharmacies, advise people with co-occurring asthma and allergic rhinitis to consult their GP for thorough investigation if:

  • rhinitis symptoms are not well controlled by self-management with over-the-counter medicines (e.g. S2 intranasal corticosteroids, oral antihistamines)
  • they need to take rhinitis treatment for more than 4 weeks at a time
  • there are any complications (e.g. pain, loss of hearing or sense of smell, persistent cough).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

At each review, check adherence to medications and topical therapy technique, as for asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Inspect nasal mucosa one month after starting treatment then every 6 months for resolution of turbinate hypertrophy and any evidence of local crusting or bleeding. 

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Allergic rhinitis and asthma: links

Prevalence, aetiology and symptoms

Asthma and allergic rhinitis frequently coexist. At least 75% of patients with asthma also have rhinitis, although estimates vary widely.1

Allergic rhinitis that starts early in life is usually due to a classical IgE hypersensitivity. Adult-onset asthma or inflammatory airway conditions typically have more complex causes. Chronic rhinosinusitis with nasal polyps is not a simple allergic condition and generally needs specialist care.7

Symptoms and signs of allergic rhinitis can be local (e.g. nasal discharge, congestion or itch), regional (e.g. effects on ears, eyes, throat or voice), and systemic (e.g. sleep disturbance and lethargy). Most people with allergic rhinitis experience nasal congestion or obstruction as the predominant symptom. Ocular symptoms (e.g. tearing and itch) in people with allergic rhinitis are usually due to coexisting allergic conjunctivitis.8

Patients may mistake symptoms of allergic rhinitis for asthma. Allergic rhinitis is sometimes more easily recognised only after asthma has been stabilised.

Effects on asthma

The presence of allergic rhinitis is associated with worse asthma control in children and adults.9101112

Both rhinitis and asthma can be triggered by the same factors, whether allergic (e.g. house dust mite, pet allergens, pollen, cockroach) or non-specific (e.g. cold air, strong odours, environmental tobacco smoke). Food allergies do not cause allergic rhinitis. Most people with allergic rhinitis are sensitised to multiple allergens (e.g. both pollens and house dust mite), so symptoms may be present throughout the year. Pollens (e.g. grasses, weeds, trees) and moulds are typically seasonal allergens in southern regions, but can be perennial in tropical northern regions.7 Pollen calendars provide information on when airborne pollen levels are likely to be highest for particular plants.

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Allergic rhinitis and asthma: treatment

Intranasal corticosteroids

Intranasal corticosteroids are effective in reducing congestion, rhinorrhoea, sneezing and itching in adults and children with allergic rhinitis,1 and are also effective against ocular symptoms associated with allergic rhinitis.1, 6, 13 Intranasal corticosteroids are more effective in reducing nasal symptoms than other treatments,1, 6 including oral H1-antihistamines6, 5 and montelukast,1, 6 and are at least as effective as intranasal H1-antihistamines.1, 5 The use of intranasal corticosteroids in patients with concomitant allergic rhinitis and asthma may improve asthma control.614

Intranasal corticosteroids are generally well tolerated in long-term use. In patients with asthma already taking inhaled corticosteroids, the intranasal corticosteroid dose should be taken into account when determining the total daily corticosteroid dose.

Patients need careful training to use intranasal sprays correctly. Detailed information and instructional videos for health professionals and patients are available on the National Asthma Council Australia website.

Antihistamines

Intranasal antihistamines reduce all symptoms of allergic rhinitis.5 Some have a more rapid onset of action than intranasal corticosteroids.5 Intranasal antihistamines are as effective as newer, less sedating oral H1-antihistamines,1 but are generally less effective than intranasal corticosteroids for the treatment of allergic rhinitis.6

Second-generation, less sedating oral H1-antihistamines (e.g. cetirizine, desloratadine, fexofenadine, levocetirizine or loratadine) are effective in managing allergic rhinitis symptoms of rhinorrhoea, sneezing, nasal itching and ocular symptoms,2 but are less effective for congestion.3 They are also effective for managing co-occurring ocular symptoms of allergy.6, 4

Specific allergen immunotherapy

Specific allergen immunotherapy (desensitisation) is effective in reducing allergic rhinitis symptoms (See separate topic).1, 15

Decongestants

Intranasal decongestants have a limited role in the management of allergic rhinitis because they should only be used for very short courses (up to 5 days maximum). Repeated or long-term use can cause rebound swelling of nasal mucosa necessitating dose escalation (rhinitis medicamentosa), with a risk of atrophic rhinitis.

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Specific allergen immunotherapy (desensitisation)

Options available in Australia

Two forms of specific allergen immunotherapy are available:

  • sublingual immunotherapy
  • subcutaneous immunotherapy.

Both forms of specific allergen immunotherapy require at least 3 years of treatment and should be prescribed by an allergy specialist (allergist or clinical immunologist) where possible.

Once immunotherapy has been successfully initiated by the specialist, co-management with the patient’s GP can be considered.

Commercial allergen preparations for immunotherapy are available in Australia for aeroallergens including house dust mite, pollens (e.g. grass, tree and weed pollens), animal dander and moulds.

Sublingual immunotherapy

Sublingual immunotherapy is effective in:15

  • reducing asthma symptoms in adults and children
  • reducing allergic rhinitis symptoms in adults and children
  • improving disease-specific quality of life in patients with asthma or allergic rhinitis
  • reducing medication requirements, particularly in patients allergic to grasses or house dust mite.

However, most studies have been in mild asthma, and few studies have compared immunotherapy with inhaled corticosteroid therapy, or have assessed standardised outcomes such as flare-ups.

Local adverse effects include an unpleasant taste, localised swelling in the mouth, and abdominal pain and nausea.16 Local adverse effects are common in children receiving sublingual immunotherapy.1

Anaphylaxis is extremely rare. The rate of serious systemic adverse reactions has been estimated at 1.4 serious adverse events per 100,000 doses.11615 The majority of adverse events occur soon after beginning treatment.16

The extract must be held under the tongue without swallowing for 2 minutes (liquid extracts) or 1 minute (tablets).

Asthma

Acarizax (house dust mite) is indicated for adults 18–65 years with house dust mite allergic asthma that is not well controlled by inhaled corticosteroids and is associated with mild-to-severe house dust mite allergic rhinitis.17 It is contraindicated in patients with FEV1 <70% predicted after adequate treatment, and for patients who have experienced a severe flare-up within the previous 3 months.17

Allergic rhinitis

Several commercial preparations of aeroallergens for sublingual immunotherapy in patients with allergic rhinitis are used in Australia, including:

  • Acarizax (house dust mite) – indicated for adults 18–65 years with persistent moderate to severe house dust mite allergic rhinitis despite symptomatic treatment.17
  • Actair (house dust mite) – indicated for the treatment of house dust mite allergic rhinitis with or without conjunctivitis in adults and adolescents over 12 years diagnosed with house dust mite allergy.18
  • Oralair tablets (mix of grass pollens) – indicated for adults and children over 5 years with grass pollen allergic rhinitis.19

Various single allergens and/or multiple allergen mixes are available for use as advised by the treating allergist, available as liquid extracts. Age restrictions vary between products.

Note: PBS status as at October 2016: Treatment with sublingual immunotherapy specific allergen preparations is not subsidised by the PBS.

Subcutaneous immunotherapy

Subcutaneous immunotherapy involves injections in which the dose is gradually increased at regular intervals (usually weekly), or until a therapeutic/maintenance dose is reached. This can take approximately 3–6 months.20

Subcutaneous immunotherapy is administered under medical supervision, either in a hospital or at a doctor’s office where appropriate facilities to manage potential systemic reactions are available.

Subcutaneous immunotherapy is associated with local adverse effects which may occur in up to 10% of patients (e.g. injection-site swelling) and, less frequently, serious systemic adverse effects (e.g. anaphylaxis).1, 16

Subcutaneous immunotherapy is generally not suitable for younger children (e.g. less than 7 years) because they may not be able to tolerate frequent injections.

Several commercial preparations of aeroallergens for subcutaneous immunotherapy are available in Australia, including various single allergens and/or multiple allergen mixes for use as advised by the treating allergist. Age restrictions vary between products.

Note: PBS status as at October 2016: Treatment with subcutaneous specific allergen immunotherapy preparations is not subsidised by the PBS.

 

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References

  1. Brożek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol. 2010; 126: 466-476. Available from: http://www.jacionline.org/article/S0091-6749(10)01057-2/fulltext
  2. Bachert C, Maspero J. Efficacy of second-generation antihistamines in patients with allergic rhinitis and comorbid asthma. J Asthma. 2011; 48: 965-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21970671
  3. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008. Allergy. 2008; 63: 8-160. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2007.01620.x/full
  4. Howarth PH. Assessment of antihistamine efficacy and potency. Clin Exp Allergy. 1999; 29 Suppl 3: 87-97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10444220
  5. Kaliner MA, Berger WE, Ratner PH, Siegel CJ. The efficacy of intranasal antihistamines in the treatment of allergic rhinitis. Ann Allergy Asthma Immunol. 2011; 106: S6-s11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277531
  6. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008; 122: S1-S84. Available from: http://www.jacionline.org/article/S0091-6749(08)01123-8/fulltext
  7. National Asthma Council Australia. Managing allergic rhinitis in people with asthma. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/allergic-rhinitis-asthma-hp
  8. Spangler DL, Abelson MB, Ober A, Gotnes PJ. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther. 2003; 25: 2245-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14512132
  9. Pawankar R, Bunnag C, Chen Y, et al. Allergic rhinitis and its impact on asthma update (ARIA 2008)–western and Asian-Pacific perspective. Asian Pac J Allergy Immunol. 2009; 27: 237-243. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20232579
  10. de Groot EP, Nijkamp A, Duiverman EJ, Brand PL. Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax. 2012; 67: 582-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22213738
  11. Thomas M, Kocevar VS, Zhang Q, et al. Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis. Pediatrics. 2005; 115: 129-34. Available from: http://pediatrics.aappublications.org/content/115/1/129.long
  12. Price D, Zhang Q, Kocevar VS, et al. Effect of a concomitant diagnosis of allergic rhinitis on asthma-related health care use by adults. Clin Exp Allergy. 2005; 35: 282-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15784104
  13. Hong J, Bielory B, Rosenberg JL, Bielory L. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: A systematic review. Allergy Asthma Proc. 2011; 32: 22-35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21262095
  14. Kersten ET, van Leeuwen JC, Brand PL, et al. Effect of an intranasal corticosteroid on exercise induced bronchoconstriction in asthmatic children. Pediatr Pulmonol. 2012; 47: 27-35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22170807
  15. Lin S, Erekosima N, Kim J, et al. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: A systematic review. JAMA. 2013; 309: 1278-1288. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23532243
  16. Canonica GW, Bousquet J, Casale T, et al. Sub-lingual immunotherapy. World Allergy Organization information position paper 2009. WAO Journal. 2009; November: 233-281. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488881/
  17. Seqirus. Product Information: Acarizax (standardised allergen extract from the house dust mites. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  18. Stallergenes. Product Information: Actair Initiation Sublingual Tablets 100 IR & 300 IR and Actair Continuation Treatment Sublingual Tablets 300 IR (mixture of. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  19. Stallergenes. Product Information: Oralair (allergen pollen extract of five grasses). Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/
  20. Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergen Immunotherapy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/patients/allergy-treatment/immunotherapy