Rhinitis - Nonallergic (1 of 7)
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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) • Antihistamines (nasal) • Corticosteroids (nasal) • Decongestants (nasal & oral) • Review diagnosis Improvement of No • Review compliance symptoms? • Consider specialist referral Yes ©CONTINUE THERAPYMIMS & FOLLOWUP 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 (2 of 7) 1 SIGNS & SYMPTOMS OF RHINITIS Rhinitis: infl ammation of the nasal lining membranes Major signs & symptoms • Nasal itching • Nasal congestion, w/ or without obstruction • Rhinorrhea • Sneezing Other signs & symptoms • Headache • Postnasal drainage • Conjunctival symptoms, eye pruritus • Impaired smell RHINITIS - NONALLERGIC • Pruritus of the nose, palate, ears 2 DIAGNOSIS • Nonallergic rhinitis is a diagnosis of rhinitis without any immunoglobulin E (IgE) mediation, as documented by allergen skin testing • A detailed clinical history & physical exam should be obtained to rule out other nasal conditions that may mimic signs & symptoms of rhinitis e following features in the clinical history are suggestive of nonallergic rhinitis: • Nasal congestion & postnasal drip are the more common presenting symptoms compared to allergic rhinitis • Previous negative allergy testing • Sensitivity to smoke, perfume, environmental irritants & changes in weather conditions • Overuse of topical decongestants • Nasal crusting or drying • Facial pain Nasal Exam • Can be carried out using a nasal speculum (anterior rhinoscopy) or by endoscopy - Endoscopy is indicated when symptoms persist despite treatment; for assessment of nasal perforations, ulceration & polyps • May reveal the following: - Mucosa may be edematous, hyperemic or pale - Swollen nasal turbinates (note size & color) - Rhinorrhea w/ clear, cloudy or colored discharge - Bacterial sinusitis is considered if colored discharge is noted - Mouth breathing especially in chronic congestion • Patient should be referred to a specialist if fi ndings are more consistent w/ a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation, adenoidal hypertrophy, etc) Other physical fi ndings may include: • Enlarged tonsils • Lymphadenopathy 3 ETIOLOGY OF NONALLERGIC RHINITIS Types of Nonallergic Rhinitis Drug-induced Rhinitis • May be caused by a variety of medications (eg NSAID, Aspirin, nasal decongestants) • Rhinitis medicamentosa is a rebound nasal congestion that results from prolonged use (5-7 days) of nasal decongestants - Symptoms include nasal congestion & edema Gustatory Rhinitis • Usually presents w/ watery rhinorrhea that may be due to vagally mediated nasal vasodilatation that occurs within a few hours of oral ingestion • Common triggers are hot & spicy foods Hormonal Rhinitis • Symptoms appear when hormonal imbalances occur (eg hypothyroidism, puberty, menstruation, oral contra- ceptive use or even pregnancy in adolescents) • Usual symptoms are nasal congestion & rhinorrhea Infectious Rhinitis • Usually caused by a viral infection • Secondary bacterial infection w/ sinus involvement is a common complication, symptoms of which may include nasal or© postnasal discharge of any quality,MIMS cough & fever - See Rhinosinusitis - Acute Bacterial management chart if bacterial infection is suspected Nonallergic Rhinitis w/ Eosinophilia Syndrome (NARES) • Characterized by eosinophilia on nasal smear • Symptoms are perennial & may consist of nasal obstruction, sneezing, rhinorrhea, nasal pruritus & hyposmia A2 © MIMS Pediatrics 2019 Rhinitis - Nonallergic (3 of 7) 3 ETIOLOGY OF NONALLERGIC RHINITIS (CONT’D) Types of Nonallergic Rhinitis (Cont’d) Autonomic/Vasomotor Rhinitis or Idiopathic Nonallergic Rhinitis • Rhinitis due to nasal hyperresponsiveness to a variety of nonspecifi c irritants, like strong odors, chemical irritants or environmental changes in temperature, humidity • A diagnosis of exclusion • Associated w/ absence of identifi able infl ammation on nasal smear RHINITIS - NONALLERGIC A AVOIDANCE OF TRIGGERS • Avoidance of inciting factors is fundamental in the management of nonallergic rhinitis • Advise patients to avoid precipitating factors or triggers of symptoms (eg environmental irritants, medications) - Remove pets from the house; if this cannot be done, at least keep pet/s outside the bedroom - Reduce molds & dust indoors by cleaning the house regularly & using fungicides against molds - Minimize odorous irritants by avoiding wearing perfumes, cosmetics, hair spray, etc Other measures to relieve symptoms of nonallergic rhinitis • Advise patient to increase water intake • Nasal saline irrigation may be used to relieve postnasal drip, sneezing, nasal congestion & rhinorrhea B PHARMACOLOGICAL THERAPY Principles of erapy • If possible, treatment should be aimed at the underlying causative physiology of nonallergic rhinitis • Treatment response may be less eff ective than in allergic rhinitis • Predominantly aimed at symptomatic treatment • Medications may be administered on an “as-required” basis or as a long-term therapy Anticholinergics • Action: Inhibit the parasympathetic nervous system that innervates the serous & seromucous glands • Ideal for patients who present only w/ rhinorrhea, especially in gustatory rhinitis • Have no activity against sneezing, itching or nasal congestion Antihistamines • Less eff ective in nasal congestion but some have anti-infl ammatory properties Nasal Antihistamines • Eff ect: Have been shown to control rhinorrhea • Eff ective for vasomotor rhinitis Oral Antihistamines • 1st generation antihistamines may be useful in controlling anterior rhinorrhea &/or postnasal drip • Generally less eff ective for nonallergic rhinitis but may be used as an adjuvant to nasal corticosteroids in the treatment of NARES Corticosteroids (Nasal) • Eff ect: Decrease nasal obstruction • Onset of action is relatively slow (up to 4 weeks) w/ maximum effi cacy after a few days, thus more recommended for patients w/ chronic symptoms • Patient should be maintained on the lowest eff ective dose • Caution is needed due to the possible eff ect on growth • Regular height measurements are advised Decongestants • Preparations containing Ephedrine, Oxymetazoline & Xylometazoline should not be used in patients <2 years of age Nasal Decongestants • Relieve nasal obstruction & postnasal drainage Oral Decongestants • Eff ects: Relieve nasal obstruction & postnasal drainage • Ideal for long-term use & for patients w/ sporadic symptoms • Do not cause rebound nasal congestion • May be used in combination w/ nasal corticosteroids • © MIMS May cause CNS stimulation, hypertension & cardiac arrhythmias Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. A3 © MIMS Pediatrics 2019 Rhinitis - Nonallergic (4 of 7) Dosage Guidelines ANTIHISTAMINES & ANTIALLERGICS (ORAL)1 Drug Dosage Remarks First Generation RHINITIS - NONALLERGIC Azatadine 1-6 yr: 0.25 mg PO 12 hrly Adverse Reactions 6-12 yr: 0.5-1 mg PO 12 hrly • CNS eff ects (drowsiness, Brompheniramine <3 yr: 0.4-1 mg/kg/day PO divided 6 hrly somnolence, lassitude, dizziness, headache, 3-6 yr: 1-2 mg PO 6-8 hrly incoordination; paradoxical 6-12 yr: 2-4 mg PO 6-8 hrly stimulation may occur esp at Carbinoxamine 1-2 mg PO 6-8 hrly high doses); Antimuscarinic eff ects (dry mouth, viscous Chlorpheniramine 1-2 mg PO 8 hrly 1-5 yr: secretions, urinary retention, Max dose: 6 mg/day blurred vision); GI eff ects (N/V, 6-12 yr: 2-4 mg PO 6-8 hrly diarrhea, epigastric pain, Max dose: 12 mg/day anorexia or increased appetite) Clemastine 1-3 yr: 0.25-0.5 mg PO 12 hrly • CV eff ects (palpitations, 3-6 yr: 0.5 mg PO 12 hrly arrhythmias, rarely hazardous 6-12 yr: 0.5-1 mg PO 12 hrly ventricular arrhythmias); Dermatologic eff ects (rashes, Dexchlorpheniramine 2-6 yr: 0.5 mg PO 4-6 hrly hypersensitivity reactions) Max dose: 3 mg/day Special Instructions 6-12 yr: 1 mg PO 4-6 hrly • Use w/ caution in patients w/ Max dose: 6 mg/day breathing problems (eg asthma, chronic bronchitis), liver Diphenhydramine 2-6 yr: 6.25 mg PO 6-8 hrly disease, seizure disorder 6-12 yr: 12.5 mg PO 6-8 hrly • Carbinoxamine should be used Max dose: 300 mg/day w/ caution in patients <2 yr Mebhydrolin <2 yr: 50-100 mg/day PO in divided doses 2-5 yr: 50-150 mg/day PO in divided doses 5-10 yr: 100-200 mg/day PO in divided doses >10 yr: 50-100 mg PO 8 hrly Mequitazine 0.25 mg/kg/day PO divided 12 hrly Oxatomide 0.5 mg/kg/dose PO 12 hrly Second Generation Cetirizine 6 mth-1 yr: 2.5 mg PO 24 hrly Adverse Reactions 1-2 yr: 2.5 mg PO 24 hrly • Cause less sedation & May be increased to antimuscarinic eff ect than 1st Max dose: 2.5 mg PO 12 hrly generation antihistamines. 2-6 yr: 2.5 mg PO 12 hrly or 5 mg PO 24 hrly Palpitations, arrhythmias, 6-12 yr: 5 mg PO 12 hrly or 10 mg PO 24 hrly hypersensitivity reactions may occur Desloratadine 1-5 yr: 1.25 mg PO 24 hrly - Cetirizine may cause higher 6-11 yr: 2.5 mg PO 24 hrly incidence of drowsiness as Ebastine 6-12 yr: 5-10 mg PO 24 hrly compared w/ other 2nd generation antihistamines Fexofenadine 6-11 yr: 30 mg PO 12 hrly Special Instructions Levocetirizine >6 yr: 5 mg PO 24 hrly • Use w/ caution in patients w/ 2-6 yr: 1.25 mg PO 12 hrly breathing