rhinitis%20-%20nonallergic
RHINITIS - NONALLERGIC
Nonallergic rhinitis is the inflammation of the nasal lining membranes without any immunoglobulin E mediation, as documented by allergen skin testing.
Major signs and symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Symptoms can reverse spontaneously with or without treatment.

Principles of Therapy

  • If possible, treatment should be aimed at the underlying causative physiology of nonallergic rhinitis
  • No single medication or individual medication class can treat the entire spectrum of symptoms
  • Treatment response may be less satisfactory than in allergic rhinitis

Pharmacotherapy

Anticholinergics (Nasal)
  • Block the muscarinic receptors of the seromucinous glands
  • Ipratropium is ideal for patients who present w/ watery rhinorrhea
  • Have no activity against sneezing, itching or nasal congestion
Antihistamines (Nasal)
  • H1-receptor antagonists reduce nasal itching, sneezing & rhinorrhea, but are less effective for nasal obstruction
  • May have limited benefit in nonallergic rhinitis unless symptoms result from histamine release
  • Oral antihistamines may be used as adjunctive therapy in some patients; topical antihistamines have shown better efficacy for nonallergic rhinitis
  • Azelastine, Olopatadine, & a combination of Azelastine & Fluticasone can reduce symptoms for over a year
Corticosteroids (Nasal)
  • Reduce airway hyperresponsiveness, amount & activity of inflammatory mediators, & allow relaxation of smooth muscle
  • Decrease sneezing, pruritus, rhinorrhea & nasal obstruction
  • Recommended as 1st-line treatment for symptoms of nonallergic rhinitis
  • Onset of action is relatively slow (6-12 hours), w/ maximum efficacy developing after 2-3 weeks
  • Better response is achieved w/ continuous use rather than w/ as-required use
  • Patient should be maintained on the lowest dose which achieves symptom control
  • Aqueous preparations are preferred because they are less irritating to the nasal mucosa
  • Intranasal corticosteroids w/ low bioavailability is suggested since it has been shown to have no effect on growth
Decongestants
  • Provoke vasoconstriction by acting on adrenergic receptors, thus relieving swelling of the nasal mucosa
Nasal Decongestants
  • Very effective in relieving nasal obstruction
  • Because of the risk of rebound vasodilation (rhinitis medicamentosa) & atrophic rhinitis w/ prolonged use, use should be limited to <10 days
Oral Decongestants
  • Have weaker effect on nasal obstruction than topical preparations, but do not cause rebound vasodilatation
  • May be given to patients w/ nasal congestion unresponsive to intranasal corticosteroids, Azelastine, or a combination of both

Aspirin (Nasal)
  • For patients w/ inflammatory nonallergic rhinitis that have not responded to anti-inflammatory therapy & combination therapy, an Aspirin challenge can be done followed by desensitization if positive

Non-Pharmacological Therapy

Nasal Saline Irrigation
  • Nasal lavage or saline spray is useful for postnasal drainage symptoms
  • Cleanses nasal mucosa when used before intranasal corticosteroids or Azelastine
Other Investigational Agents
  • Some studies show benefit of Capsaicin, Ribomunyl & Silver nitrate for rhinitis symptoms
    • Capsaicin & Silver nitrate may be used for vasomotor rhinitis & Ribomunyl for infectious rhinitis
    • Topical Capsaicin desensitization reduces symptoms for several months
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