EN4.24 | Allergic Rhinitis — Summary & Reflection

KEY TAKEAWAYS

Allergic rhinitis is an IgE-mediated Th2 inflammatory disease of the nasal mucosa driven by early-phase (histamine — sneezing, rhinorrhoea, itch) and late-phase (leukotrienes/cytokines — congestion, mucosal oedema) responses. The four cardinal symptoms are watery rhinorrhoea, paroxysmal sneezing, nasal itch, and bilateral obstruction; associated eye symptoms (allergic conjunctivitis) are common. ARIA classifies it as intermittent vs persistent and mild vs moderate-severe. Pale boggy inferior turbinates on anterior rhinoscopy; skin prick test confirms specific allergen sensitisation. Management: allergen avoidance + INCS (first-line for moderate-severe persistent, best for congestion) + non-sedating antihistamines (for sneezing/rhinorrhoea/mild disease) + leukotriene antagonists (add-on, co-existing asthma) + allergen immunotherapy (for refractory disease, long-term modification). Never prescribe sedating antihistamines (chlorpheniramine) as first-line. Co-existing nasal polyps in allergic rhinitis are ethmoidal (bilateral, multiple) — not to be confused with the unilateral single antrochoanal polyp.

REFLECT

A patient with allergic rhinitis asks you: 'I've been told I need to take this nasal spray every single day for the rest of my life — is there no cure?' How would you counsel this patient about allergen immunotherapy as a disease-modifying option? What conditions must be met before you refer for immunotherapy? And how would you explain the difference between a drug that treats symptoms versus one that changes the underlying immune response? Practise this explanation in your head — it is a conversation you will have repeatedly in outpatient practice.