Allergic Rhinitis in the General Practitioner’s Office: How to Proceed in Primary Care?
Up to 60% of the population has a genetic predisposition to allergic disease. Diagnosis and therapy of allergic conditions are therefore very common topics in primary care. How should we proceed correctly in the diagnostic process when suspecting allergic rhinitis? When to refer to a specialist and what are the treatment options?
Medical History as the Basis of Diagnosis
It is always advisable to specifically inquire about allergic manifestations in the family. The propensity for atopy is genetically fixed, but the clinical manifestation of allergies depends on external environmental factors. The manifestation of inhalant allergies usually occurs in connection with immediate contact with the causative allergen. Pollen allergies are most noticeable during dry, sunny, and windy weather. Animal dander allergies are triggered upon contact with animals but can also manifest in different environments through allergen retention on clothing or in the hair of pet owners, etc. Dust mite allergies most often appear at the beginning of the heating season (autumn/winter), when heated spaces cause more indoor dust particles to circulate. Symptoms intensify after lying down in bed, upon waking up, and during cleaning activities.
Physical Examination
Observations may include conjunctival redness, tearing, watery nasal discharge, hyponasal speech, frequent nose rubbing, sneezing, redness of the nasopharynx, and dry coughing. Lung auscultation should always be performed to rule out expiratory wheezing. About 40% of patients with allergic rhinitis also exhibit signs of bronchial asthma.
Laboratory Tests
If allergic etiology is suspected, the following parameters should be determined:
- proportion of eosinophilic granulocytes
- total IgE levels
Indicators of an allergic condition include eosinophil counts > 5%, or > 0.35 × 109/l, and total IgE antibodies > 100–150 IU/ml.
When to Refer to a Specialist?
If the manifestations of allergic rhinitis are mild and respond well to basic treatment, the aforementioned medical history, physical, and laboratory examinations are sufficient. Patients with moderate to severe allergy symptoms and cases where basic therapy appears insufficiently effective should be referred for specialist examination. Patients should also be referred for ENT examination if there is suspicion of chronic inflammation of the nasal cavity or paranasal sinuses, or the presence of a mechanical or organic obstacle in this area. Specialist examination is also indicated when bronchial asthma coexists.
Treatment
The foundation consists of lifestyle measures, and patients should always be directed towards finding ways to limit contact with the allergen. The goal of pharmacotherapy is disease control. The choice of medication should consider the patient's age and preferences, main symptoms, their severity, comorbidities, and the safety profile and efficacy of the treatment (including the speed of onset and the impact on sleep and work productivity).
According to current recommendations from the ARIA initiative (Allergic Rhinitis and Its Impact on Asthma) applicable in the Czech Republic, for patients with seasonal allergic rhinitis, it is recommended to administer an intranasal steroid (INS) in monotherapy, combined with an oral antihistamine, or combined with an intranasal antihistamine according to the patient's preference. Some patients, especially at the beginning of therapy (in the first approximately 2 weeks), prefer a combination of intranasal antihistamine and steroid for faster onset of action.
In patients with perennial allergic rhinitis, monotherapy with INS is preferred, possibly combined with an intranasal antihistamine, over a combination of INS with oral antihistamine.
Monotherapy or Combination?
The currently recommended therapeutic algorithm has been refined using real-world data from patients and results from studies conducted in allergen exposure chambers. New data indicate that the combination of INS with an oral antihistamine is no more effective than INS alone, although this combination is often used in practice. Conversely, the combination of INS with a nasal antihistamine is more effective than INS monotherapy.
The effect of INS usually appears within a few hours to a few days. Intranasal antihistamines have an effect within a few minutes. If nasal symptoms are inadequately controlled by other treatments, the use of a fixed combination of INS + intranasal antihistamine is recommended, despite the higher cost of this therapy.
Contraindications
First-generation oral antihistamines (e.g., bisulepin, dimethindene, or promethazine) have a sedative effect and should not be given. Intramuscular and depot corticosteroids are contraindicated for the treatment of allergic rhinitis. Prolonged continuous use of nasal vasoconstrictors (e.g., naphazoline, oxymetazoline, xylometazoline) should also be warned against.
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Sources:
1. Bystroň J. Allergic Rhinitis in the General Practitioner's Office. Medicine for Practice 2012; 9 (3): 95–100.
2. Seberová E., Bachert C., Fokkens W. J. et al. ARIA 2019: Recommendations for the care of patients with allergic rhinitis in the Czech Republic. Allergy 2020; Suppl. 1. Available at: www.csaki.cz/dokumenty/ARIA2019.pdf
3. Bousquet J., Schünemann H. J., Togias A. et al.; Allergic Rhinitis and Its Impact on Asthma Working Group. Next-generation Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. J Allergy Clin Immunol 2020; 145 (1): 70–80.e3, doi: 10.1016/j.jaci.2019.06.049.
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