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Rhinitis - Nonallergic (1 of 7)

Rhinitis - Nonallergic (1 of 7)

Rhinitis - Nonallergic (1 of 7)

1 Patient presents w/ signs & symptoms suggestive of rhinitis

2 • Consider allergic rhinitis DIAGNOSIS No - See Rhinitis-Allergic Is nonallergic rhinitis disease management chart confi rmed?

Yes

3 DETERMINE ETIOLOGY

A Avoidance of triggers B Pharmacological  erapy • Anticholinergics (nasal) • (nasal) • Corticosteroids (nasal) • Decongestants (nasal & oral)

• Review diagnosis Improvement of No • Review compliance symptoms? • Consider specialist referral

Yes ©CONTINUE THERAPYMIMS & FOLLOWUP

Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

A1 © MIMS Pediatrics 2019 RHINITIS - NONALLERGIC • • (NARES) Syndrome w/Eosinophilia Rhinitis Nonallergic • • Rhinitis Infectious • • Rhinitis Hormonal • • Rhinitis Gustatory • • Rhinitis Drug-induced Types Rhinitis ofNonallergic • • Exam Nasal • • • • • • rhinitis: ofnonallergic aresuggestive history theclinical in features efollowing • • • • • &symptoms signs Other • • &symptoms signs Major inflRhinitis: ammation liningmembranes ofthe nasal • fi physical Other may include: ndings • Symptoms are perennial & may consist of nasal obstruction, sneezing, rhinorrhea, nasal pruritus & hyposmia pruritus nasal rhinorrhea, Symptoms are perennial sneezing, &may consist obstruction, ofnasal smear onnasal eosinophilia by Characterized management - Acute issuspected Rhinosinusitis Bacterial infection ifbacterial chart See - discharge ofany quality, orpostnasal nasal cough &fever w/sinus involvement infection bacterial isacommonSecondary complication, ofwhich may symptoms include infection aviral by Usually caused congestionUsual are &rhinorrhea nasal symptoms in adolescents) pregnancy oreven ceptive use Symptoms imbalances when occur hormonal (eg appear hypothyroidism, puberty, menstruation, oralcontra- foods triggersCommon are hot&spicy hoursoforalingestion afew within that occurs vasodilatation nasal that rhinorrhea mediated due to vagally mayUsually be w/watery presents Symptoms congestion include &edema nasal - decongestants Rhinitis medicamentosa is a rebound nasal congestion that results from prolonged use (5-7 days) of nasal decongestants) nasal (eg ofmedications NSAID, Aspirin, avariety by caused May be w/clear, Rhinorrhea cloudy orcolored discharge - Swollen turbinates &color) nasal (notesize - hyperemic orpale Mucosa edematous, may be - the following: May reveal - (anterior endoscopy rhinoscopy) orby speculum outusinganasal carried be Can Facial pain ordrying crusting Nasal decongestants oftopical Overuse environmental &changes inweather tosmoke,perfume, irritants conditionsSensitivity testing allergy negative Previous are the drip more common congestion compared presenting symptoms &postnasal Nasal toallergic rhinitis ofrhinitis &symptoms mimic signs outother conditions torule nasal that obtained may shouldbe &physical exam history clinical A detailed allergenby skintesting Nonallergic ofrhinitis any rhinitis without is adiagnosis documented immunoglobulin as E(IgE)mediation, palate, ofthe ears nose, Pruritus pruritus eye Conjunctival symptoms, Headache Rhinorrhea itching Nasal Enlarged tonsils adenoidal hypertrophy, deviation, septal etc) polyps, nasal (eg tumors, if fi Patient to referred a specialist should be are morendings consistent than rhinitis etiology w/ a structural inchronic Mouth congestion breathing especially -

- Bacterial sinusitis isconsidered Bacterial ifcolored discharge isnoted - ulceration &polyps perforations, ofnasal forassessment treatment; despite persist when symptoms isindicated Endoscopy © MIMS 3 ETIOLOGY OF NONALLERGIC RHINITIS 1 SIGNS & SYMPTOMS OF RHINITIS OF &SYMPTOMS SIGNS Rhinitis-Nonallergic(2of7) 2 DIAGNOSIS A2 • • • • • Impaired smell Postnasal drainage Sneezing congestion, obstruction w/orwithout Nasal Lymphadenopathy © MIMS Pediatrics 2019 RHINITIS - NONALLERGIC Decongestants Nasal • Decongestants • • • • • (Nasal) Corticosteroids • • Antihistamines Oral • • • • • • Decongestants Oral • • Antihistamines Nasal • Antihistamines • • • Anticholinergics • • • • ofPrinciples erapy • • rhinitis ofnonallergic symptoms torelieve measures Other • • • • • Autonomic/Vasomotor Rhinitis Nonallergic orIdiopathic Rhinitis Types (Cont’d) Rhinitis ofNonallergic <2 years ofage<2 years &XylometazolinePreparations inpatients containing used Oxymetazoline Ephedrine, shouldnotbe height areRegular measurements advised eff duetothe possible isneeded Caution ongrowth ect Patient eff onthe maintained lowest should be dose ective for patients w/chronic symptoms effi w/maximum weeks) ofactionisrelativelyOnset (upto 4 slow thus more days, recommended afew after cacy Eff ect: treatment ofNARES Generally lesseff the in ective fornonallergicrhinitisbut maybeusedasanadjuvanttonasalcorticosteroids 1st generation incontrolling drip antihistamines useful may be anterior &/orpostnasal rhinorrhea Eff rhinitis forvasomotor ective May cause CNS stimulation, arrhythmias &cardiac hypertension May CNS cause incombination corticosteroids used w/nasal May be congestion rebound nasal notcause Do &forpatients symptoms use w/sporadic forlong-term Ideal Eff ects: drainage &postnasal obstruction nasal Relieve Eff ect: effLess congestion have butsome innasal anti-inflective properties ammatory congestion itching ornasal Have sneezing, against noactivity rhinitis ingustatory especially forpatientsIdeal whopresent onlyw/rhinorrhea, the serous &seromucous that system innervates glands nervous InhibittheAction: parasympathetic therapy along-term oras basis onan“as-required” administered mayMedications be atPredominantly symptomatictreatment aimed Treatment eff less may be response than inallergicective rhinitis at treatment the aimed underlying causative ofnonallergicIf possible, shouldbe rhinitis physiology Nasal salineirrigationmaybeusedtorelievepostnasaldrip,sneezing,nasalcongestion &rhinorrhea patient water intakeAdvise toincrease hairspray, cosmetics, etc perfumes, avoiding by wearing irritants odorous Minimize - molds against &usingfungicides the regularly cleaning by house Reduce molds&dustindoors - the bedroom outside pet/s keep done,at least the ifthis be from house; cannot pets Remove - patients ) Advise toavoid (eg ortriggers ofsymptoms precipitating factors environmental irritants, Avoidance isfundamental inthe ofincitingfactors management ofnonallergic rhinitis w/absence ofidentifiAssociated able infl smear ammation onnasal ofexclusionA diagnosis orenvironmentalirritants changes intemperature, humidity of nonspecifi to a variety hyperresponsiveness due to nasal Rhinitis chemical like strong odors, c irritants,

Decrease nasal obstruction nasal Decrease Have been shown tocontrol shown Have rhinorrhea been Relieve nasal obstruction & postnasal drainage &postnasal obstruction nasal Relieve

© MIMS 3 ETIOLOGY OF NONALLERGIC RHINITIS (CONT’D) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B A PHARMACOLOGICAL THERAPY Rhinitis-Nonallergic(3of7) AVOIDANCE OF TRIGGERS A3 © MIMS Pediatrics 2019 RHINITIS - NONALLERGIC 1 Antihistamines combined w/ other cold remedies are available. Please see theAntihistamines forspecifi combined w/other latest MIMS cold see are available. remedies Please c formulations. Generation Second Mebhydrolin 6-8hrly 1-2mgPO Chlorpheniramine First Generation All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not ANTIHISTAMINES (ORAL) &ANTIALLERGICS 5 mg PO 24hrly 5mgPO <30 kg: 24hrly 10mgPO >30 kg: 2-12 yr: 12hrly 1.25mgPO 2-6 yr: 24hrly 5mgPO >6 yr: 12hrly 30mgPO 6-11 yr: 24hrly 5-10mgPO 6-12 yr: 24hrly 2.5mgPO 6-11 yr: 24hrly 1.25mgPO 1-5 yr: 24hrly 12hrly or10mgPO 5mgPO 6-12 yr: 24hrly 12hrly or5mgPO 2.5mgPO yr: 2-6 12hrly 2.5mgPO dose: Max to increased May be 24hrly 2.5mgPO 1-2 yr: 24hrly 2.5mgPO 6 mth-1yr: 12hrly PO 0.5 mg/kg/dose 12hrly divided 0.25 mg/kg/day PO 8hrly 50-100mgPO >10 yr: doses individed 100-200mg/day PO 5-10 yr: doses individed 50-150mg/day PO 2-5 yr: doses individed 50-100mg/day PO <2 yr: 300mg/day dose: Max 6-8hrly 12.5mgPO 6-12 yr: 6-8hrly 6.25mgPO 2-6 yr: 6mg/day dose: Max 4-6hrly 1mgPO 6-12 yr: 3mg/day dose: Max 4-6hrly 0.5mgPO 2-6 yr: 12hrly 0.5-1mgPO 6-12 yr: 12hrly 0.5mgPO 3-6 yr: 12hrly 0.25-0.5mgPO 1-3 yr: 12mg/day dose: Max 6-8hrly 2-4mgPO 6-12 yr: 6mg/day dose: Max 8hrly 1-2mgPO 1-5 yr: 6-8hrly 2-4mgPO 6-12 yr: 6-8hrly 1-2mgPO 3-6 yr: 6hrly divided 0.4-1mg/kg/day PO <3 yr: 0.5-1 mg PO 12hrly 0.5-1mgPO 6-12 yr: 12hrly 0.25mgPO 1-6 yr: Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Rhinitis-Nonallergic(4of7) Dosage Guidelines Dosage A4 • Instructions Special • • Reactions Adverse • Instructions Special • • Reactions Adverse disease, seizure disorder seizure disease, chronic bronchitis), liver breathing problems (eg asthma, Use w/ caution inpatients w/ w/ caution inpatients <2yr used Carbinoxamine shouldbe - Cetirizine may higher cause Cetirizine - occur may reactions hypersensitivity arrhythmias, Palpitations, generation antihistamines. antimuscarinic eff than 1st ect & sedation less Cause disease, seizure disorder seizure disease, chronic bronchitis), liver breathing problems (eg asthma, Use w/caution inpatients w/ reactions) hypersensitivity effDermatologic (rashes, ects ventricular arrhythmias); rarely hazardous arrhythmias, effCV (palpitations, ects appetite) anorexia orincreased pain, epigastric diarrhea, GIeff vision); blurred (N/V,ects retention, urinary secretions, eff mouth, viscous (dry ects Antimuscarinic high doses); stimulation may at occur esp incoordination; paradoxical headache, dizziness, somnolence, lassitude, effCNS (drowsiness, ects

generation antihistamines compared w/other 2nd incidence as ofdrowsiness 1 Remarks © MIMS Pediatrics 2019 RHINITIS - NONALLERGIC propionate Fluticasone 32mcg/spray Budesonide 50mcg/spray Beclometasone racnln 55mcg/spray Triamcinolone furoate Mometasone furoate Fluticasone Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed nasal spray nasal 50 mcg/spray spray nasal 100 mcg/spray spray nasal 64 mcg/spray spray nasal 50 mcg/spray spray nasal spray nasal 100 mcg/spray spray nasal © spray nasal MIMS spray nasal 50 mcg/spray spray nasal 27.5 mcg/spray Available Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing CORTICOSTEROIDS (NASAL) Rhinitis-Nonallergic(5of7) 1 sprays each nostril 24hrly 1sprays nostril each ≥4 yr: 24hrly 2 sprays nostril each 12hrly 1spray or nostril each >6 yr: 12hrly or divided 24hrly 1-4sprays nostril each >6 yr: 24hrly sprays nostril each 12hrly1 spray or2 nostril each 5sprays/day dose: Max 12-24 hrly 1spray nostril each <12 yr: 8sprays/day dose: Max 12hrly 2 sprays nostril each 6-8hrly 1spray or nostril each >6 yr: 24 hrly nostril 1spray each dose: Maintenance 24 hrly 2sprays nostril each dose: Initial >12 yr: 24 hrly 2sprays nostril each dose: Max 24hrly 1spray nostril each 4-12 yr: 4sprays nostril/day each dose: Max 24 hrly nostril 1spray each dose: Maintenance reduce to Once are controlled, symptoms may 24hrly 2sprays nostril each ≥12 yr: 24hrly 1spray nostril each 2-11 yr: nostril/day 1spray each dose: Maintenance 24hrly 2sprays nostril each ≥12 yr: nostril/day 1spray each dose: Maintenance 24hrly nostril to2sprays each increased May be 24hrly 1spray nostril each 2-11 yr: 2sprays nostril/day each dose: Max 24 hrly to2sprays nostril each May increase Dosage Guidelines Dosage A5 • • • • • Instructions Special • • Reactions Adverse <4 yr ofage<4 yr contraindicated inpatients propionate is Fluticasone impairment hepatic patients w/severe w/caution in used be should furoate Fluticasone for maintenance effUse lowest dose ective growth linear corticosteroids may aff ect Use w/caution as effsystemic ects amounts toproduce insuffiabsorbed cient be May occasionally infection Candida Headache, pharyngitis; epistaxis burning, congestion,irritation, effLocal nasal ects: © Remarks MIMS Pediatrics 2019 RHINITIS - NONALLERGIC 1 Decongestants combined w/ antihistamines are available. Please see latest MIMS foravailable latest MIMS formulations. combined w/antihistamines see are available.Decongestants Please Ephedrine cromoglicate) Na Cromolyn sulfate, Na, Cromolyn cromoglycate, Cromoglycate (Na Agents Antiallergic Phenylephrine Pseudoephedrine All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 2-3 mg/kg/day PO or100mg/m 2-3mg/kg/day PO 2-6 yr: 2% spray Max dose: 150mg/day dose: Max 3-4hr every 12.5-50mgPO ≥12 yr: 75mg/day dose: Max 4hr every 6.25-12.5mgPO 7-11 yr: doses divided (as tannate salt) 7.5-15 mg PO 12hrly tannate salt)7.5-15mgPO (as or 4hrly; salt)10-20mgPO HCl (as >12 yr: 12hrly tannate salt)3.75-7.5 mgPO (as or 4hrly; salt)10mgPO HCl (as 6-12 yr: 12hrly tannate salt)1.87-3.75mgPO (as 2-6 yr: 8hrly 60mgPO >12 yr: 120mg/day dose: Max 6-8hrly 30mgPO 6-12 yr: 60mg/day dose: Max 6-8hrly 15mgPO 2-5 yr: Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Available Strength Rhinitis-Nonallergic(6of7) DECONGESTANTS (ORAL) Dosage Guidelines CROMONES (NASAL) nostril 4hrly nostril 1spray each dose: Maintenance 4hrly nostril 1spray each dose: Initial >6 yr: Dosage A6 Dosage 2 /day in4-6 1 • Reactions Adverse • • Instructions Special • Reactions Adverse somnolence drowsiness, fatigue, epistaxis, laryngitis, bitter taste, stinging, Transient burning, nasal patients <2yr in used Should not be phenylketonuria patients w/ Use w/caution in arrhythmias) hypertension, eff (tachycardia, ects tremor );CV restlessness, anxiety, insomnia, effCNS (headache, ects © Remarks Remarks MIMS Pediatrics 2019 RHINITIS - NONALLERGIC bromide Ipratropium Anticholinergics Antihistamines epnhnlIncombination Dexpanthenol Other spray 0.05%nasal Sodium chloride 0.65% nasal 0.65%nasal chloride Sodium Naphazoline 0.05% nasal 0.05%nasal Naphazoline Topical Preparations Combination Sympathomimetic Xylometazoline 0.05% nasal drops 0.05%nasal Xylometazoline (Tetrahydrozoline) Tetryzoline drops 0.01%nasal Oxymetazoline Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All NASAL DECONGESTANTS &OTHERNASALPREPARATIONS Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS (21 mcg/spray) 0.03% spray (140 mcg/spray) 0.1% spray w/ sea water w/ sea 2.3% nasal spray 2.3% nasal spray 0.9% nasal spray nasal drops, drops, nasal spray nasal drops, 0.1% nasal spray 0.1% nasal soln 0.05% nasal soln 0.1% nasal spray nasal drops, 0.05% nasal spray nasal drops, 0.025% nasal Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Available Strength Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please Rhinitis-Nonallergic(7of7) Dosage Guidelines 8-12 hrly 2sprays nostril each ≥6 yr: 1 spray each nostril 12hrly 1spray nostril each >6 yr: nostril 6-8hrly nostril to2sprays each May increase hrly 12 2sprays nostril each ≥9 yr: 1-2 sprays each nostril as needed as 1-2 sprays nostril each nostril 6-24hrly,nostril needed oras orsprays1-4 drops into each 1 spray each nostril 6 hrly 6 1spray nostril each 6-12 yr: 3drops/day dose: Max 12-24hrly nostril each drops 1-2 <6yr: &children Infant 12hrly nostril into 1-2drops each <1yr: Infants 8-12hrly nostril 1drop each <4wk: Neonates nostril upto6hrly nostril or1spray 2-3drops each yr: >6 3-4hr every 2-3drops 2-6 yr: 3-4 hr every or3-4sprays 2-4drops >6 yr: 12hrly nostril each or2-3sprays 2-3drops ≥6 yr: 12hrly nostril orsprays 2-3drops each 2-6 yr: 8-12 hrly nostril each 1-2drops >1 yr: A7 Dosage • Reactions Adverse • Reactions Adverse • Reactions Adverse • Instructions Special • Instructions Special • • Reactions Adverse nausea dryness, nasal Epistaxis, somnolence drowsiness, fatigue, epistaxis, laryngitis, bitter taste, stinging, Transient burning, nasal Dexpanthenol to reactions hypersensitivity Allergic & Spray upright w/head extended use ≥10days use extended for Not recommended headache Systemic eff N/V,ects: or ≥10days use occur w/extended rebound congestion may mucosa; ofnasal dryness sneezing, irritation, effLocal Transientects: © Remarks MIMS Pediatrics 2019

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