Episode transcript
Time stamps
0:30 - Introduction of today’s episode.
1:16 - Common observations of rhinitis.
3:02 - Allergic rhinitis.
4:26 - Non-allergic rhinitis.
6:41 - The triggers of non-allergic rhinitis.
8:49 – Different types of non-allergic rhinitis.
11:14 – Allergy medications and patients self-managing.
14:14 - What primary care clinicians can do to help during allergy season.
16:32 - Referrals to allergists.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed PA with over 11 years' experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons, with over five years of experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically backed allergy insights. Welcome back to ImmunoCAST. We have a fireside chat episode for you today specifically for Spring, because Spring is in the air and so are allergies.
Gary Falcetano:
Yeah, and I think many providers may already be seeing patients with rhinitis symptoms in their offices and clinics. But Luke, it's not just allergy that may be causing these Spring symptoms. Today we're going to be talking about many of the etiologies of rhinitis and that may be actually affecting patients that are presenting and give some tips to work through the differential diagnosis so that we can help patients find the most effective relief in the most efficient manner possible.
Luke Lemons:
Exactly, Gary. So why don't we start with what are some common observations regarding rhinitis from your clinical point of view?
Gary Falcetano:
So as clinicians, we tend to minimize the significance of rhinitis as a disease, even though we see so much of it. I think compared to a lot of the other things that patients present with, we tend to not give it quite the attention that it may and really does deserve. It's actually the fifth most prevalent chronic disease in America and is associated with increased rates of absenteeism, presenteeism, as well as sleep and mental health issues. People with chronic rhinitis also have really significant quality of life issues. As a matter of fact, multiple surveys have demonstrated that patients with chronic rhinitis have worse quality of life scores than patients with persistent asthma.
Luke Lemons:
When I first heard that, actually, I was shocked because we talk about asthma a lot and I think maybe it's just because we're so familiar with seasonal allergy symptoms, allergic rhinitis symptoms, that we don't think that it could contribute to such a worse quality of life score, but it does. And so that's why it's important to optimize management for these patients as they're coming in this time of year. But it starts first with confirming is it really pollen that's causing these patients to react.
Gary Falcetano:
Even a step further than that, or before we even confirm if it's pollen, let's confirm that it's truly allergy, because we do know that there are overlap symptoms involved between allergic and non-allergic rhinitis. So really the first step is is this allergy, and then if it is, what specifically is driving the symptoms. And that really speaks to all of the things that can potentially contribute to allergic symptoms.
So before we talk about non-allergic rhinitis, let's talk about allergic rhinitis. And in previous episodes we've talked a lot about specific IgE testing and identifying triggers, the symptom threshold, all of that warrants a little bit of coverage in this episode because it's important that we actually figure out if it is allergy and it's pollen season, is it indeed pollen? And then if it is, are there any other allergic triggers that are contributing to the patient's symptoms? So indoor triggers, things like dust mites, molds, pets. It's really easy to blame pollen when it's Spring and tree pollen is in the air, but it may not just be tree pollen.
Luke Lemons:
And more than 80% of patients who do have allergies are allergic to multiple allergens. So to your point, exactly, Gary. Just because it's the trees blooming right now this time of year doesn't mean that it's only the trees if a patient is sensitized and does have an allergy.
Gary Falcetano:
That's correct. And it may be something that's non-allergic as well. So identifying allergy or not first, what it is if it is allergy, and then if it's not allergy that's contributing to those symptoms, going down a diagnostic pathway to figure out what is causing these rhinitis symptoms and then what's the most effective treatment for the patient.
Luke Lemons:
And I think that's a good jumping off point, Gary, and why don't we explain a little bit what non-allergic rhinitis is because we're talking about how if it's not allergy, it may be this disease state.
Gary Falcetano:
That's correct. We know there's quite a few overlapping symptoms between the two. So common symptoms of sneezing, rhinorrhea, runny nose, coughing, postnasal drip, these are common in both allergic and non-allergic etiologies. Now when we're looking at specifically non-allergic rhinitis, it's fairly prevalent disorder. So over 7% of US citizens, around 20 million or so people are affected. And interestingly too, in this case, females are actually affected quite a bit more. Some studies show two to one, some three to one prevalence over males. So a little bit different than allergic rhinitis and allergy in general where we tend to see a prevalence of males, especially in younger age groups, over females.
But going back to non-allergic rhinitis, I think when we look at the pathophysiology involved, it is not an IgE-mediated disease, but it's more of a nervous system-mediated disease. So we know that both the sympathetic and the parasympathetic components of the autonomic nervous system can both equally contribute to the nasal, the pharyn organs. And it really maintains a delicate homeostasis between vasoconstriction and vasodilatation of the nasal vascular as well as affecting the secretion of the nasal glands. And when we see an imbalance between these components, between the sympathetic and the parasympathetic systems, that is likely to contribute to vascular permeability, glandular hypersecretion, and increased nasal congestion as well. And these are all things that we see in non-allergic rhinitis.
Luke Lemons:
There was a lot of tongue twisters in there, Gary. Parasympathetic.
Gary Falcetano:
Yeah, there was, right.
Luke Lemons:
But going a little deeper into what can contribute to these symptoms of non-allergic rhinitis, what are the triggers of this type of rhinitis and how may they be confused with allergies in the Spring? Or maybe a patient comes in with symptoms of rhinitis, what are some non-allergic triggers for it?
Gary Falcetano:
Yeah, so as we said, the symptoms definitely overlap, for sure. Probably the main non-allergic rhinitis diagnosis that we see is actually a vasomotor rhinitis, which really is more of an idiopathic rhinitis. So once we've ruled out all of the common causes of non-allergic rhinitis, it kind of gets that diagnosis of a vasomotor rhinitis. But some of those common causes, I think the one that we're most familiar with and see most frequently would be infectious rhinitis, whether that be bacterial or viral. And of course we see them in our offices all the time.
Some of the other little bit lesser known causes of rhinitis. We have a gustatory rhinitis. This is a rhinitis that occurs after we've eaten something and particularly after we've eaten things that may be irritants, such as hot sauce. It's also known as hot sauce rhinitis. There is hormonal rhinitis, so rhinitis of pregnancy or rhinitis related to hypothyroidism. And then even medication rhinitis. So certain medications cause nasal congestion, such as erectile dysfunction medications. All of this can be causes for a non-allergic type of phenotype. And it's important once we've ruled out the potential allergy being involved that we go down a differential diagnosis. And maybe you can speak to a resource that we have for people to work through that diagnosis.
Luke Lemons:
We actually have a rhinitis pathway document that'll be on this episode's page that will outline all the different types of rhinitis as well as ways you can optimize treatment of patients who come in who may suffer from these different types of disease states. But going back though, Gary, you had mentioned vasomotor rhinitis and that often this is usually the diagnosis of non-allergic rhinitis when it comes to common... Can you explain a little more about vasomotor rhinitis?
Gary Falcetano:
Yeah. So vasomotor, going back to that whole parasympathetic sympathetic innervations, it occurs when we have a dilation of the vasculature and then that causes permeability. We get increased mucus production, we get increased nasal congestion along with that. And that can be triggered by many things. It could be pollution, it could be cigarette smoke, ozone levels, perfumes and colognes. Those are all kind of under the category of chemical triggers. But there are also other triggers, as I mentioned, both infectious and different metabolic triggers like hormonal and medications.
Luke Lemons:
And I think that this is why it's important for primary care and other providers to remember that even though it is allergy season right now and patients are coming in with rhinitis symptoms, that all these triggers for non-allergic rhinitis don't just disappear in the Spring. And patients may also be suffering from non-allergic rhinitis, especially if their antihistamines aren't working and they're coming in to your office to speak about these symptoms, it may be one of these non-allergic triggers.
Gary Falcetano:
For sure. So there was a great study that was done a few years back that looked at patients who had had multiple prescriptions for non-sedating antihistamine. So this was done a while back, as I said, because almost everything was prescription at that time, unlike now where everything's over-the-counter. But these patients had had three or more prescriptions for non-sedating antihistamines over the course of a year. And they brought them back. They tested these patients and what they found was up to 65% of those patients were actually non-allergic. So I think it's important that we don't empirically kind of just based upon history and a physical exam, make the diagnosis of allergy without actually confirming that it is truly indeed an allergy that's driving the symptoms.
Luke Lemons:
That's always such a shocking statistic for me to hear that 65% of patients who were prescribed antihistamines were actually non-allergic. I mean, that's a lot of money when it comes to getting medication for something that may not be working for those patients.
Gary Falcetano:
For sure. And I think that really brings us to the point of now without these non-sedatings being prescription, patients are really managing their suspected allergic disease themselves. We have inhaled nasal corticosteroids, we have almost all the non-sedating antihistamines being available over the counter. So that being the case, why are they presenting to the clinic when they have all this availability? And I think it's really because they're not seeing relief or they're not getting the level of relief that they're expecting from what they've been doing thus far. And I think that's why it's so important for clinicians to then kind of take it to the next level and really discover what exactly is driving the symptoms and then guide patients to the appropriate interventions and therapeutics.
Luke Lemons:
And it's tricky because some of these antihistamines that have, let's say, decongestants in them may provide some relief for non-allergic rhinitis. The patient may think, "Oh, my allergies are just so bad that antihistamines are only helping a little," when really they don't have allergic rhinitis. They have non-allergic rhinitis and the antihistamine they're taking has a decongestant in it, which would help a bit with those symptoms.
Gary Falcetano:
We see a lot of these medications being advertised, these combination antihistamine, decongestant medications. The other area, and I think patients are still taking first-generation antihistamines, like diphenhydramine. And even though that's totally not recommended to be a first-line therapeutic for allergic rhinitis, we do see a lot of patients that take diphenhydramine and say it's the only thing that worked. And if they're non-allergic, it may be partially working just because diphenhydramine has anticholinergic properties, being a first generation antihistamine. Definitely not the path that we want to have patients going down. So guiding them to appropriate medications if they're allergic, certainly staying away from the first generations if they're non-allergic, then going to other therapeutics like inhaled nasal steroids or anticholinergic nasal sprays is really more indicated.
Luke Lemons:
And I would say with all these different types of therapeutics and over-the-counter medicine and things working, things not working, and I don't know if you would agree with me, Gary, but a lot of this could be cleared up if patients knew exactly what is causing symptoms. And that starts with diagnostic testing. So I want you to maybe speak a little more on this, Gary, but especially for primary care, what should primary care providers do if patients are coming in and they have those bad symptoms, or they're saying, "Oh, my antihistamines aren't working as well as they did or aren't working at all." What can primary care do to help shed some light on this confusing symptoms?
Gary Falcetano:
So I think we take a page from our allergist colleagues. When they see a patient with suspected allergic-mediated disease or symptoms, we do a thorough history and physical, but then you do an accurate diagnostic test and you correlate the two. And for seasonal or for any upper or lower respiratory symptoms that are suspected to be allergic, probably the best way to do that is through what is known as a Regional Respiratory Panel.
So for primary care providers, they can order a specific IgE blood test that includes the most common indoor allergens, things like dust mites, mold, pets, and then the most common outdoor allergens in their specific region, so grasses, trees, weeds. By ordering a comprehensive respiratory profile like that, it's very efficient because we don't order things we don't need. We don't need to order every grass, tree or weed that grows in your area. These profiles have been designed to really be very efficient in that they select cross-reactive grasses, trees, and weeds to be representative of the whole type of allergen. And when they get those results back, then we can make informed decisions. Is allergy driving these symptoms or not? And if it is, really giving them targeted advice on how to address all the things that they're sensitized to, not just the suspected things like the pollen that we know is in the air.
Luke Lemons:
And we have a resource that can help primary care offices find those codes for the labs that they use. We'll have a link to it on this episode's webpage. We call it the Lab Ordering Guide, but you enter your zip code and it will pull most of the local and national labs in your area that you might already use, and it'll make it very clear and apparent which panels have these concise testing for these patients who are coming in. And on that point too, primary care, oftentimes when a patient does come in with allergies, you may think that it's a referral to the allergist. Is that fair to say, Gary?
Gary Falcetano:
I think it probably varies depending on the clinician. But one of the other things, and I'm glad you brought this up, Luke, that I was going to mention is that testing early on in the patient's course in primary care can do a few things, right? It can help primary care manage these patients within their practice, eliminating unnecessary referrals, but also facilitating more optimized referrals. So knowing if someone is having symptoms, you've done everything that we've been talking about today with exposure reduction or pharmacology, and they're still not having effective relief, then that referral that you're planning can be guided by testing. So if the patient has been determined to be really not have any allergy playing into their symptoms, then this may be a referral to an otolaryngologist, an ENT. If it's somebody who needs in-depth assessment by an allergist based upon your testing, then that referral would go to the allergist. So the testing can be very helpful in managing patients on your own and then also guiding and informing referrals.
Luke Lemons:
Because primary care are often the frontline during-
Gary Falcetano:
Almost always the frontline, I would say.
Luke Lemons:
Yeah, during allergy season. How many allergists are in America? It's like...
Gary Falcetano:
It's four to 5,000 depend depending on the source. So we have got 50 million people with allergic disease. Primary care is the frontline and really needs to provide the most effective assessment and diagnostics and treatment that we can.
Luke Lemons:
Because I bet those allergists are slammed right now as Spring is happening and on the horizon for some areas of America.
Gary Falcetano:
Exactly. Because once we determine that a patient does need some more interventions, the allergist can be a perfect resource to do things like immunotherapy. And immunotherapy for respiratory allergy is very effective if those other techniques are not working.
Luke Lemons:
You don't want to send a patient who has non-allergic rhinitis to an allergist and who knows how long it is to get into that office as well. So diagnostic testing, Specific IgE blood testing in primary care for patients this time of year when they're suffering from symptoms of rhinitis and it's assumed to be allergies. It's always important. We say all the time, and you've probably heard it on TV shows, but knowledge is power and knowing exactly what is causing symptoms could make all the difference for this Spring and for Spring to come, because who knows, a patient may just have been dealing with what they think are allergies their whole life, and this is the year where they really can't, and who knows, maybe there's something else contributing to their suffering.
Gary Falcetano:
For sure. I think we'll wrap things up. We'd like to thank you again for tuning into this episode of ImmunoCAST. We invite you to follow and share ImmunoCAST with your fellow providers, bring them the information that they need to understand the importance of narrowing down the differential diagnosis this time of year or anytime of year. Thanks again for listening, and we'll see you next time.
Luke Lemons:
Thanks for listening. And don't forget to go to thermofisher.com/immunocast and view this episode's specific page to find that rhinitis pathway document, as well as a link to the Lab Ordering Guide to make ordering diagnostic testing this time of year all the easier for you. Thanks.
Gary Falcetano:
Thank you.
Anouncer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP Specific IgE diagnostics and Phadia Laboratory Systems. For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocast. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside Specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis, or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
