Rhinitis and Lavage Response – with Professor Pete Smith
Since 2003, ENT Technologies Pty Ltd has led the way by providing the most innovative nasal and sinus irrigations in the Australian marketplace. ENT Technologies is committed to the latest advancements and technologies in developing effective formulations and easy delivery systems for managing a wide range of common nasal and sinus problems.
Professor Pete Smith is one of Australia’s most accomplished and respected allergists and immunologists. He has a PhD in molecular immunology and is the Medical Director of Allergy Medical. Pete is also a Professor of Clinical Medicine at Griffith University, where he is conducting research into molecular aspects of pain in allergic conditions. He is also involved in medical education and frequently speaks at national and international meetings and conferences.
Editor: Professor Smith, we all have patients with both seasonal and perennial rhinitis and most of them use nasal steroid sprays, not infrequently, with suboptimal results. Could you suggest additional treatment options for these customers?
Prof. Smith: First off, the World Health Organisation sponsored Allergic Rhinitis and its Impact on Asthma (ARIA) report of 2001 suggested we call rhinitis as intermittent and persistent (rather than seasonal or perennial) and we also think about severity when classifying. In some regions a seasonal allergen may be a mould or a grass, which in other areas this allergen is present all year round (e.g. grass in a tropical or subtropical area). A good percentage (34–50%) of patients with allergic rhinitis have non-allergic triggers as well (e.g. smoke, cold air, solvents) so working out irritants is helpful. Up to one third of patients attending US rhinitis clinics were found to be purely non-allergic.
If you use a nasal spray, use it correctly. Aim to the outer canthus or the ear side of the nostril you are treating. Aim to the lateral wall of the nose. You do not need to sniff hard.
There is little evidence that an oral antihistamine ADDs to a nasal steroid in symptom control but intranasal nasal corticosteroids (INCS) are better than oral antihistamines in treating rhinitis. Topical antihistamines and combination intranasal antihistamine/INCS are more effective. 20% of patients do not fill their steroid script — they are worried about the word steroid. That results in non-compliance use of oral antihistamines (which are not as effective as nasal steroids and are not as cost effective). I find explaining that allergies are an “over-response” to a perceived threat — their body is over-working to that threat and they have symptoms of allergy — which are all fairly protective. If the body is stressed, it makes steroids to control inflammation. Treating a 50 cent area in each nostril is smarter and easier to do than the whole body being “stressed” and making endogenous steroids.
The ARIA report of 2008 said that there is no role for sedating antihistamine in the treatment of rhinitis. Note that 70% of patients take more than the recommended dose of antihistamines and about 60% of patients with rhinitis do not feel they have good control with their medication. Make sure that they are not taking an alpha-agonist agent as this can cause rhinitis medicamentosa and refractory rhinitis. Nasal steroids are safe for long-term use as well. Immunotherapy is another add that is very effective in well selected patients.
Editor: There have been publications suggesting that washing the nose prior to instillation of the medicated spray improves results. Could you comment on this please?
Prof. Smith: Yes, there is pioneering work on this that aligns the concepts I have outlined above. If there is an allergen or irritant, there are receptors that detect the threat and respond to it with neural activation (sneezing, itch and discomfort/sinus pain); mucous and destructive enzyme production; increased cilia beating and also turbinate swelling. Turbinate swelling increases the surface area that will come in contact with the real or perceived threat (allergen/irritant). Whilst this can be useful acutely, it is dysfunctional chronically and causes a heavy and often under-recognised burden on airway function, productivity and quality of life. The nose has very important roles in warming, humidifying and filtering the greater than 10,000 litres we breathe every day. If the nose is blocked, the work of breathing increases. This impacts the lower airway from a physiological point of view (there is also immune activation) and also there is increased risk of ENT infections and upper airway obstruction which contributes to poor learning and workplace productivity.
Nasal lavages both remove the threat and also help to remove components (enzymes and mucous) of the dysfunctional response — as stated by an independent Cochrane summary.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010728/full
“Nasal saline has been used as a homeopathic remedy for centuries and has recently gained attention as an adjunctive treatment for a number of sinonasal diseases. Nasal saline is able to clear allergens, mucus and other irritants from the nasal passages and to increase nasal patency with few associated side effects. Additionally, several studies have shown that the use of nasal saline may decrease medication requirements (Garavello 2003; Garavello 2005; Harvey 2007; Li 2009).”
Nasal saline works for both allergic and non-allergic rhinitis.
Editor: Is there a role for the use of nasal saline solutions being used intermittently throughout the day as well?
Prof. Smith: It is very safe to use these nasal salines as required, as long as they are at the correct osmolality and do not contain irritants. Symptom relief is very quick and patients can self dose. Use these before medications as there is evidence of augmented response in terms of reduced nasal symptom scores.
Editor: There are many options of nasal saline irrigation solutions, some with preservatives, namely Benzalkonium Chloride (BKC), and others without. Some publications suggest that prolonged use of saline with this preservative shows adverse effects on normal physiology after use for only 3 weeks. For patients with allergic rhinitis, from whichever cause, is there any downside to using nasal saline solutions containing this preservative?
Prof. Smith: There are several levels to this answer. BKC is an antimicrobial and is a compound that can cause mucosal irritation. Many medications used in the nose have this preservative as well. BKC also appears to impair nasal mucocillary clearance. Countering this, there may be benefits of not having topical steroid medications cleared. The mucosa in the inflamed nose is also more vulnerable to irritation. Many pharma companies have taken BKC out of their INCS sprays in the last 10 years, but then many have not. Studies in healthy individuals show nasal stuffiness with BKC compared to controls — but this is in health controls. The nasal microbiome is also important in rhinitis and destruction of this with a preservative may result in a dysbiosis and aberrant inflammation.
Editor: Many of the steroid nasal sprays also contain the preservative Benzalkonium Chloride, is there any reason to suggest that we should recommend formulations which have an alternate preservative system?
Prof. Smith: For many patients BKC does not cause symptoms. It is a big step to:
- Use an INCS
- Use if correctly
- Use it regularly
Currently, there is not enough research looking at the microbiome and airway inflammation with BKC in patients with allergic rhinitis. Potassium sorbate is being used as a preservative in products and appears to cause less irritation than BKC.
Editor: Many patients with Allergic Rhinitis have significant nasal obstruction when they first see a healthcare practitioner. Could you let us know how you feel about the use of medicated decongestant sprays in these patients?
Prof. Smith: There is a recent study of 4 weeks of concomitant use of nasal steroids when used with oxymetazoline. Whist we talk about rebound after 3–5 days, the study did not find that was the case with patients treated with oxymetazoline alone for 4 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/21377716
Do not use oxymetazoline alone. It is best to be cautious.
I personally suggest using this combination up to 4 times a day with acute rhinosinusitis and frequent nasal lavage. In my clinical experience, this makes a difference on the first day, but I have not run a randomised controlled trial of this.