Just Call It 'Chronic Rhinitis' and Reach for These Treatments

Allergic rhinitis? Nonallergic rhinitis? It's all chronic rhinitis, and the drugs you recommend could differ (but not always) depending on the cause. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- Matthew F. Watto, MD: I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul, are you ready to talk about rhinitis? Paul N. Williams, MD: I'm excited. It's always the season to talk about rhinitis. Watto: We had a great guest for this podcast, Rhinitis and Environmental Allergies with Dr Olajumoke Fadugba from Penn Medicine. She's an allergist and immunologist. One of her pet peeves is when people just call everything "allergic rhinitis" because we should be calling it "chronic rhinitis," if it's chronic. That's an umbrella term, and there are many buckets underneath it that people could fall into. When you're taking a history, you have to figure out whether it's perennial (meaning it happens year round) because certain things can cause that. Cat dander is around all the time, so people with cats might have sinus symptoms all year. Dust mites are another one, and it's pretty hard to avoid those. Those are some perennial allergens. Then there is allergic vs nonallergic rhinitis, which is something I hadn't really put too much thought into. Williams: I didn't realize exactly how nuanced it got. Nonallergic rhinitis can still be seasonal because changes in temperature and humidity can trigger the rhinitis. And it matters what medications you use for what. Watto: Here are some ways you can try to figure out if rhinitis is allergic or nonallergic. Ask the patient if they have itchy eyes and are sneezing a lot. That can be more of an allergic rhinitis, but both allergic and nonallergic rhinitis have the congestion, the rhinorrhea, so you can't figure it out based on that alone. Dr Fadugba said that one clue that it might be nonallergic rhinitis is the age of onset. If the symptoms are later in onset (older age), then 30%-40% of rhinitis is nonallergic. If the patient has never had allergies and now all of a sudden they have new chronic sinus symptoms, it's probably nonallergic rhinitis. It's a diagnosis of exclusion. I guess they need allergy testing? Williams: If you want to make a definitive diagnosis, you need to rule it out. I suspect that you might be able to get away with some empirical treatment. If they get better, you can feel like a winner because getting booked in for allergy testing can be a little bit of a challenge. Watto: The main treatment difference is that the oral antihistamines do not really seem to work for nonallergic rhinitis, but they can help with allergic rhinitis. Weirdly, the nasal antihistamines and nasal steroids do seem to work for both allergic and nonallergic rhinitis. I don't understand the mechanism there, but if you think someone might have nonallergic rhinitis, I wouldn't go with the oral antihistamines as your first-line treatment. I would go with a nasal spray; you pretty much can't go wrong with either an antihistamine or a steroid nasal spray. Williams: We typically start with the nasal sprays. That's kind of first-line for almost everybody, allergic or nonallergic. You're probably going to start with an intranasal steroid, and then it's kind of dealer's choice what the patient can tolerate and afford. Sometimes you can get them covered by insurance, at least in my experience. Transcript in its entirety can be found by clicking here: https://www.medscape.com/viewarticle/...