xRead - Nonallergic Rhinitis (September 2025)

1438

BAROODY ET AL

J ALLERGY CLIN IMMUNOL PRACT JUNE 2024

ClassificaƟon of Chronic RhiniƟs

Mixed RhiniƟs (AR and NAR)

NAR (Non–IgE-mediated)

AR (IgE-mediated)

Nonallergic rhinopathy (vasomotor rhiniƟs)

NARES Senile rhiniƟs

PAR

SAR

Atrophic rhiniƟs Gustatory rhiniƟs Hormonal rhiniƟs

Entopic rhiniƟs

Drug-induced rhiniƟs OccupaƟonal rhiniƟs (low molecular weight irritant-induced rhiniƟs)

Symptoms year-round

Symptoms seasonal

FIGURE 1. Classification of chronic rhinitis subtypes.

TABLE I. Classification of AR and NAR by physician diagnosis based on history and specific IgE testing to aeroallergens vs using a quantitative IIS with specific IgE testing to aeroallergens 3

Physician diagnosis (number of patients in each group at baseline)

IIS reclassification (number of patients in each group after reclassification)

Clinical characteristic pre- and post-reclassification*

Rhinitis subtype

AR total MR total

404 129

254 low IIS 279 high IIS

Increased number of patients with more rhinitis symptoms. Increased number of patients with a diagnosis of asthma

NAR total

123

79 low IIS 44 high IIS

Increased number of patients with more rhinitis symptoms. Increased number of patients with a diagnosis of asthma

*Signi fi cant differences in clinical characteristics after reclassi fi cation using the IIS that were not discernable at baseline ( P < .01).

an intranasal antihistamine (INAH) was initiated. She was seen back in the of fi ce a month later, at which time she reported improvement of nasal symptoms but had persistence of anterior clear nasal drainage. Ipratropium bromide 0.03% nasal spray was added to her regimen 2 to 3 times a day as needed for rhinorrhea, which resulted in signi fi cant improvement of her symptoms. CLASSIFICATION AND EPIDEMIOLOGY The classi fi cation of CR conditions includes allergic rhinitis (AR) conditions (seasonal, perennial and entopic) and nonal lergic rhinitis conditions including NAR, NARES, senile rhinitis, atrophic rhinitis, gustatory rhinitis, drug-induced rhinitis, hor monal rhinitis, and occupational rhinitis induced by low mo lecular weight chemical irritants (Figure 1). 9-11 Nonallergic rhinopathy can be acute or chronic and, as mentioned, up to 50% of cases involve both allergic and neurogenic pathways referred to as MR. 9 Many have considered MR to represent AR with allergic in fl ammation causing secondary nasal airway hy perreactivity, making patients more reactive to irritant and me chanical triggers. However, there is now suf fi cient evidence to support parallel neuropathic mechanisms that can elicit

symptoms concomitantly because MR patients are not completely responsive to treatments commonly used for AR such as INCS and second-generation H1-antihistamines. 9,10,12 Differentiation of the nonallergic rhinitis conditions, NAR and NARES, is limited to the presence or absence of eosinophils in the nasal passages. 13 In retrospect, NARES may represent localized (entopic) AR, which would need to be excluded by speci fi c allergen nasal provocation to con fi rm this diagnosis. 14 Therefore, NAR is a non e Type 2 neuroin fl ammatory condi tion whereas NARES is a Type 2 in fl ammatory condition. It should be emphasized that symptoms and physical fi ndings are not pathognomonic for AR because patients with NAR often manifest similar features. Bernstein and colleagues 7 used an irritant index score (IIS) to further characterize patients with a physician diagnosis of AR and found that many of these patients had a high IIS consistent with MR (also referred to as AR with a high IIS burden) (Table I). Similarly, patients with NAR were also reclassi fi ed based on their IIS as having a high versus a low IIS burden. Interestingly, AR and NAR patients with a high IIS burden were found to have more frequent rhinitis symptoms and were more likely to have a physician diagnosis of asthma than those patients with a low IIS burden (Table I). 7 These results