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Chronic rhinitis in South Africa: update 2013.

1. Introduction

The South African Allergic Rhinitis Working Group (SAARWG) met on 6 April 2013 to discuss and review important concepts in allergic rhinitis diagnosis and management. The theme of that meeting, and this update, is to remind clinicians that all patients with rhinitis may not have allergic rhinitis (AR) specifically. The reason is twofold: (i) patients with chronic rhinitis (CR) may have one of a number of conditions that are more significant and may herald more sinister diagnoses, and (ii) many forms of chronic rhinitis may not respond as well to standard allergic rhinitis therapy. This review will focus specifically on the differential diagnosis of AR and the management of these alternative conditions.

2. Definitions

The term 'rhinitis' implies inflammation of the lining of the nose. The characteristic symptoms are a blocked nose, anterior and posterior rhinorrhea, sneezing and itching. [1] Most patients with AR have an IgE or type I allergic basis, [2] and the Allergic Rhinitis and its Impact on Asthma (ARIA) Working Group has classified allergic rhinitis into 4 groups based on symptom duration and symptom severity (Fig. 1). [3] This classification has become important for South Africa, because where grass pollen is a major allergen (such as across the Highveld) the disease is usually persistent over several months and usually moderate to severe in nature. [4] In contrast, chronic non-allergic rhinitis, by definition, is a condition where ongoing rhinitic symptoms are present for many months (as for persistent AR) [3] but where there is no IgE basis. A long list of conditions may present as CR (Table 1).

3. Prevalence of CR

South Africa was fortunate enough to be represented in the International Study of Asthma and Allergies in Childhood (ISAAC). Two centres (Cape Town and Polokwane) participated in this study of the epidemiology of allergic rhinitis. In Phase I of the ISAAC Study, conducted in 1995, questioning of 13 - 14-year-old subjects reported that the prevalence of AR was 30.4% in Cape Town. [5] By Phase II of the study in 2003, the prevalence had gone up to 38.5%.'61 In addition, that study revealed that AR's impact on quality of life was becoming more significant. [6] However, the major problem with these data is that although the subjects' condition was labelled as AR, no testing for allergy was performed. This raises a concern about the above epidemiological definition of AR and its prevalence.

It is clear that when subjects are questioned on the presence of nasal symptoms, a significantly higher rate of symptoms is reported than for true AR. For example, in one study, although 48% of subjects reported chronic nasal symptoms, only 14.9% had true AR with a positive skin -prick test (SPT). [7] This study emphasises that the term AR should not be used unless there is either a positive allergy test (either SPT or ImmunoCAP) or a clear history of symptoms triggered by specific allergens, possibly with a seasonal variation. If such evidence of allergy is not present, then the condition should be labelled as CR and the conditions listed in Table 1 should always be considered.

Another important consideration in defining AR is that a positive allergy test does not always confirm AR in isolation. Specific IgE may be a pointer to AR but specific symptoms need to be present before the diagnosis is made. [8] Laboratory tests to confirm the diagnosis of AR should be selected based on careful history-taking, rather than applying a large panel of allergy tests.

In children the allergic component of CR may be more frequent than in adults.

4. Climate change, urban air pollution and CR

We live in a dynamic environment, with rising average temperature and increasing anthropogenic greenhouse gases, which may increase the generation of pollen-producing plant species. [9,10] Increased levels of pollutants such as carbon dioxide, ozone and nitrogen dioxide enhance the allergic response, [11] and pollutants may induce their own form of irritant rhinitis. Changes in vegetation biomes, as a result of climate change, are likely to cause changes in outdoor pollen and fungal allergens. Changes in the climate are expected to alter the presentation, seasonality and epidemiology of allergic rhinitis and other allergic respiratory diseases in future.

5. Impact of rhinitis on South Africans

In light of the statement above that most epidemiological studies of AR are in fact studies of CR, there are valuable lessons to be learned from studies of the impact of rhinitis on quality of life. [12] Many South African studies have suggested that CR impacts significantly on patient quality of life and the major effect is impaired sleep. [13-15] Trivialising CR as a minor, non-life-threatening illness promotes the idea that CR does not affect patients significantly. However, CR may result in significant co-morbidity, presenteeism and absenteeism from work and school.

6. Local allergic rhinitis

Recently, local allergic rhinitis (LAR) has been recognised as a condition. [16] In LAR, patients report typical allergy-induced rhinitic symptoms but all IgE-based allergy testing is negative. IgE is produced locally in response to allergens in the nose, but not systemically. [16] Only provocation testing diagnoses the problem; however, these tests are not widely available and only a limited number of allergens can be tested. However, patients with this condition do respond to the usual treatments for AR (including antihistamines and intranasal steroids).

7. Treating CR

Antibiotics must not be used for a 'cold'. [17] Upper respiratory tract infections are usually viral, and antibiotic use in this condition only leads to the evolution of resistant flora.

Previous SAARWG guidelines have discussed the therapeutic modalities for AR in depth. [18,19] Topical use of corticosteroids remains the drug of choice, although antihistamines appear to be more acceptable for the treatment of young children and are effective. Allergen immunotherapy is an important therapeutic option.

Aspirin-induced respiratory disease is a condition where sensitivity to non-steroidal anti-inflammatory drugs leads to asthma, nasal symptoms and polyposis. Therapy involves specific aspirin desensitisation and avoidance of Cox-I inhibitors. Montelukast is a useful therapeutic option for some patients. [20]

Therapy of non-allergic, so-called 'vasomotor' rhinitis is difficult. There is no standard therapy which always works. Some patients respond to intranasal corticosteroids, [21] and other therapies that may work in selected patients are topical anticholinergics [22] and occasional use of topical decongestants. However, the benefit of topical decongestants often leads to the overuse of this form of therapy, which may lead to rebound or rhinitis medicamentosa.

8. Surgical intervention for CR

A number of anatomical abnormalities of the nose and sinuses may cause rhinitis symptoms and many may co-exist with AR. Thus at some stage in the medical management and investigation of CR, where therapy is ineffective, the patient should be evaluated for anatomical abnormalities, including septal deviation, nasal polyposis and tumours of the nose and sinuses. Referral to a specialist and radiological imaging may be necessary.

Every patient who experiences chronic snoring must be investigated for CR and have the condition managed adequately. If the snoring continues, they should be evaluated and managed for adenoidal hypertrophy. This is particularly important in children, who are at risk of developing right-sided heart failure and cor pulmonale.

9. New international guidelines on CR/AR

Doctors in South Africa have regularly updated AR guidelines for local application. [1,18,19] The previous revision of the ARIA guideline has suggested 10 areas that require global applicability of ARIA and have unmet needs. [23] Recent South African guidelines have addressed some of these issues. There are, however, some areas, especially for CR, that still require attention (Table 2).

10. Sport and CR

Competitive sportsmen may experience significant rhinitic symptoms and require that their symptoms be managed. [24] A number of reasons for this phenomenon have been proposed. [24] Care must be taken with medication because of potential adverse effects and/or 'anti-doping' codes. Permitted and banned medications are listed in Table 3. [25]

11. Doctor and patient education for CR

Patients with CR must be educated about their condition and therapy. Clinical studies indicate that only 31% of patients are regularly shown how to use nasal sprays. [26] There is good evidence from international and local studies that patients are frustrated by CR - education helps to allay fears and concerns, and improves medication compliance. [26,27]

Conflict of interest. Aspen HealthCare provided an unrestricted grant for the meeting of the South African Allergic Rhinitis Working Group (SAARWG).


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[2.] Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of allergic and nonallergic rhinitis. Clin Exp Allergy 2008;38:19-42. 'http://dx.doLorg/10.1111/j.1365-2222.2007.02888.x;

[3.] Bousquet J, Khaltaev N, Cruz AA, et al. ARIA (Allergic Rhinitis and its impact on Asthma (ARIA) 2008 Update. Allergy 2008;63(Suppl 86):8-160. '

[4.] Mercer MJ, van der Linde GP, Joubert G. Rhinitis (allergic and nonallergic) in an atopic pediatric referral population in the grasslands of inland South Africa. Ann Allergy Asthma Immunol 2002;89(5):503-12. '

[5.] Strachan D, Sibbald B, Weiland S, et al. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8(4):161-176.

[6.] Zar HJ, Ehrlich RI, Workman L, Weinberg EG. The changing prevalence of asthma, allergic rhinitis and atopic eczema in African adolescents from 1995 to 2002. Pediatr Allergy Immunol 2007;18(7):560-565. '

[7.] Zhang YM, Zhang J, Liu SL, et al. Prevalence and associated risk factors of allergic rhinitis in preschool children in Beijing. Laryngoscope 2013;123(1):28-35. '

[8.] Blomme K, Tomassen P, Lapeere H, et al. Prevalence of allergic sensitization versus allergic rhinitis symptoms in an unselected population. Int Arch Allergy Immunol 2012;160(2):200-207. 'http://

[9.] Blando J, Bielory L, Nguyen V, Diaz RI, Jeng HA. Anthropogenic climate change and allergic disease. Atmosphere 2012;3(1):200-212. '

[10.] Berman D. Climate change and aeroallergens in South Africa. Curr Allergy Clin Immunol 2011;24(2):65-71.

[11.] Lin G, Zacharek M. Climate change and its impact on allergic rhinitis and other allergic respiratory diseases. Curr Opin Otolaryngol Head Neck Surg 2012;20(3):188-193. ' MOO.0b013e3283524b141

[12.] Green RJ, Davis G, Price D. Concerns of patients with allergic rhinitis: The Allergic Rhinitis Care Programme in South Africa. Prim Care Respir J 2007;16(5):299-303. ' pcrj.2007.000621

[13.] Potter PC, Van Niekerk CH, Schoeman HS. Effects of triamcinolone on quality of life in patients with persistent allergic rhinitis. Ann Allergy Asthma Immunol 2003;91(4):368-374. 'http://dx.doi. org/10.1016/S1081-1206(10)61684-51

[14.] Potter PC, Paediatric Levocetirizine Study Group. Efficacy and safety of levocetirizine on symptoms and health-related quality of life of children with perennial allergic rhinitis: A double-blind, placebocontrolled randomized clinical trial. Ann Allergy Asthma Immunol 2005;95(2):175-180. 'http://

[15.] Green RJ, Luyt DK. Clinical presentation of chronic non-infectious rhinitis in children. S Afr Med J 1997;87(8):987-991.

[16.] Rondon C, Campo P, Togias A, et al. Local allergic rhinitis: Concept, pathophysiology, and management. J Allergy Clin Immunol 2012;129(6):1460-1467. '

[17.] Brink A, Cotton M, Feldman C, et al. Updated guidelines for the management of upper respiratory tract infections in South Africa: 2008. S Afr J Fam Prac 2009;51:105-114.

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[19.] Green RJ, Hockman M, Friedman R, et al. Allergic rhinitis in South Africa: 2012 guidelines. S Afr Med J 2012;102(8):693-696. '

[20.] Scow DT, Luttermoser GK, Dickerson KS. Leukotriene inhibitors in the treatment of allergy and asthma. Am Fam Physician 2007;75(1):65-70.

[21.] Baccioglu Kavut A, Kalpaklioglu F. Efficacy and safety of once daily triamcinolone acetonide aqueous nasal spray in adults with non-allergic and allergic rhinitis. Allergol Immunopathol 2012 (Epub ahead of print). '

[22.] Druce HM, Spector SL, Fireman P, et al. Double-blind study of intranasal ipratropium bromide in nonallergic perennial rhinitis. Ann Allergy 1992;69(1):53-60.

[23.] Bousquet J, Schunemann HJ, Samolinski B, et al. Allergic Rhinitis and Its impact on Asthma (ARIA): Achievements in 10 years and future needs. J Allergy Clin Immunol 2012;130(5):1049-1062. 'http://

[24.] Bonini S, Bonini M, Bousqet J, et al. Rhinitis and asthma in athletes: An ARIA document in collaboration with GA2LEN. Allergy 2006;61(6):681-992. '

[25.] The World Anti-doping Agency (WADA). The 2013 prohibited list effective January 1, 2013. Adapted form ARIA guidelines 2006: Athletes. Lausanne, Switzerland: WADA; 2012. http://www.wada-ama. org (accessed 5 May 2013)

[26.] Blaiss MS, Meltzer EO, Derebery MJ, Boyle JM. Patient and healthcare-provider perspectives on the burden of allergic rhinitis. Allergy Asthma Proc 2007;28 Suppl 1:S4-10. ' aap.2007.28.29911

[27.] Gani F, Pozzi E, Crivellaro MA, et al. The role of patient training in the management of seasonal rhinitis and asthma: Clinical implications. Allergy 2001;56(1):65-68.

R J Green, (1) PhD, Dip Allergol (SA); M Hockman, (2) FCS (SA) (ORL); R Friedman, 2,3) FCS (SA) (ORL); M Davis, (4)FC Paed (SA);

M McDonald, (3) MB ChB, Dip Allergol (SA); R Seedat, (5) FCS (SA) (ORL); C Els, 6) FC Paed (SA), Dip Allergol (SA), Cert Pulm (Paed) (SA);

M Levin, (7) PhD, Dip Allergol (SA); P Potter, (8) MD; C Feldman , (9) PhD, DSc

(1) Department of Paediatrics and Child Health, University of Pretoria, South Africa

(2) Department of ENT Surgery, Netcare Linksfield Clinic, Johannesburg, South Africa

(3) Mediclinic Sandton, Johannesburg, South Africa

(4) Department of Paediatrics, Netcare Linksfield Clinic, Johannesburg, South Africa

(5) Department of Otorhinolaryngology, University of the Free State, South Africa

(6) Department of Paediatric Pulmonology and Allergy, Linksfield Clinic, Johannesburg, South Africa

(7) Department of Paediatrics and Adolescent Health, University of Cape Town, South Africa

(8) Department of Medicine, University of Cape Town, South Africa

(9) Division of Pulmonology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa

On behalf of the South African Allergic Rhinitis Working Group. S Bouwer, G P Tunguy-Desmarais, A McCulloch, H Lewis, I Hunt, E Vardas, L Wolff, F Mokgoadi, M Gill, P Jeena, F Jooma, G J Joyce, T Moodley.

Endorsed by the Allergy Society of South Africa.

Corresponding author: R J Green (

Table 1. Causes of chronic rhinitis (CR)

* Allergic rhinitis (intermittent or persistent)

* Local allergic rhinitis

* Non-allergic rhinitis:

* Acute exacerbation of a low-grade chronic rhinitic condition
(e.g. By a common cold)

* Drug-induced: rhinitis medicamentosa caused by topical
decongestants or other drugs (beta-blockers, ACE inhibitors,
reserpine, calcium channel blockers, methyldopa, alphareceptor
antagonists, phosphodiesterase-5 inhibitors, aspirin,
NSAIDS, oral contraceptives)

* Vasomotor rhinitis (non-allergic rhinopathy)

* Occupational rhinitis

* Chronic infective rhinosinusitis

* Gustatory rhinitis

* Pregnancy-associated rhinitis

* Primary ciliary dyskinesia

* Primary or secondary immune deficiency

* Cystic fibrosis

* Senile rhinitis

Table 2. Recommendations for action in treating chronic
rhinitis (CR)

* Consider CR as a multifactorial condition of which AR is only
one cause

* Long-term studies of change in prevalence of CR in relation to
climate change are needed

* The AR Essential Drug List (EDL) for South Africa should
be updated to reflect safe and effective therapy - sedating
antihistamine therapy must not be recommended

* Medical aid organisations must be encouraged to allow therapy
for CR to be paid for through chronic benefits

* Medication should be tailored to individual patients

* Patient education for CR is very important

Table 3. World Anti-Doping Agency (WADA): Chronic rhinitis (CR)
drugs that are permitted and not permitted in sport

Treatment              WADA rules

Antihistamines         Permitted (WADA 2006)

Antileukotrienes       Permitted (WADA 2006)

Oral steroids          Prohibited

Topical steroids       Require an abbreviated therapeutic
                       use exemption (WADA 2006)

Oral beta-2 agonists   Prohibited

Inhaled salbutamol,    Require an abbreviated therapeutic
formoterol or          use exemption

Ephedrine              Prohibited

Pseudoephedrine        Prohibited

Immunotherapy          Permitted

Treatment              Notes

Antihistamines         Second-generation antihistamines should be
                       preferred, to avoid cardiotoxic effects and
                       somnolence. (Nothing mentioned: WADA 2013)

Antileukotrienes       Nothing mentioned: WADA 2013

Oral steroids          All glucocorticoids prohibited

Topical steroids       Nothing mentioned: WADA 2013

Oral beta-2 agonists

Inhaled salbutamol,    The presence in urine of salbutamol in excess
formoterol or          of 1 000 ng/ml or formoterol in excess of 40
salmeterol             ng/ml is presumed not to be an intended
                       therapeutic use of the substance. It will be
                       considered an adverse analytical finding unless
                       the athlete proves, through a controlled
                       pharmacokinetic study, that the abnormal result
                       was the consequence of the use of the
                       therapeutic inhaled dose up to the maximum
                       indicated above

Ephedrine              Each of ephedrine and methylephedrine is
methylephedrine        prohibited when its concentration in urine is
                       greater than 10 [micro]g/ml

Pseudoephedrine        Pseudoephedrine is prohibited when its
                       concentration in urine is greater than 150

Immunotherapy          Subcutaneous immunotherapy injections should
                       not be performed before or after physical
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Article Details
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Title Annotation:GUIDELINES
Author:Green, R.J.; Hockman, M.; Friedman, R.; Davis, M.; McDonald, M.; Seedat, R.; Els, C.; Levin, M.; Pot
Publication:South African Medical Journal
Article Type:Disease/Disorder overview
Geographic Code:6SOUT
Date:Jun 1, 2013
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