xRead - Nonallergic Rhinitis (September 2025)

1442

BAROODY ET AL

J ALLERGY CLIN IMMUNOL PRACT JUNE 2024

TABLE VI. Cincinnati IIS 7,30 Instructions: Please rate on a scale of 0 to 10 the degree to which the following irritants cause or aggravate any upper respiratory symptoms or headaches. “ 0 ” means that the irritant has no effect on creating or aggravating upper respiratory symptoms or headache, and “ 10 ” means that the irritant has a maximal effect. If it does not provoke the disease at all, write “ 0. ” If you avoid the irritant because it aggravates your symptoms, please rate what your reaction was when you were exposed to the irritant in the past. Upper respiratory symptoms may include the following: stuffy nose; runny nose; itching of the nose; sneezing; itchy, red, watery eyes; postnasal drainage. 1. Perfume 2. Hair spray 3. Cosmetics (including aftershave lotion) 4. Antiperspirants/deodorants 5. Fresh newsprint 6. Cooking/frying odors 7. Bleach (Clorox)

been made, every effort should be undertaken to avoid envi ronmental triggers that can aggravate symptoms. This includes avoidance of fragrances, potpourris, cigarette smoke, bleach, formaldehyde, automobile emission fumes, light stimuli, tem perature changes, hot and spicy foods, and sometimes alcoholic beverages, which can cause nasal congestion in susceptible NAR patients.7 Many triggers for NAR can be subtle and it is important to discuss potential exposures in detail with patients. Studies on TRP channels show that agonists can be cumulative, and clinically, this has been observed, but not published specif ically for NAR. 29,44 For example, a patient with NAR may have more symptoms with an evening drop of temperature below 17 C ( w 63 F) when there has been more smoke in the air. 7,28,32 Air puri fi ers have been shown to reduce symptoms in patients with AR; however, they have not been studied specif ically in NAR. 45 Anecdotally, air cleaners with carbon and/or zeolite minerals that adsorb out chemical odorants or irritants are effective. Pharmacotherapy There are many therapeutic options for the treatment of NAR including saline irrigation, ipratropium bromide, mast cell e sta bilizing INAHs, INCS, combination INCS/INAHs, oral anti cholinergicss and capsaicin. Although studied primarily for SAR and PAR, real-world experience using combination intranasal decongestants and INCS for up to 4 to 6 weeks is well tolerated and reduces nasal congestion, sinus pressure, and eustachian tube dysfunction without causing rebound nasal congestion (rhinitis medicamentosa). 10 A meta-analysis that pooled data from 7 AR studies (n ¼ 112 adults; n ¼ 332 children) reported that saline irrigation was associated with improved patient-reported disease severity up to 4 weeks and pooled data from 6 of these studies (n ¼ 407) demonstrated saline irrigation was associated with signi fi cant bene fi t, compared with placebo, at follow-up periods between 4 weeks and 3 months. 46 However, the evidence supporting this treatment intervention was low or very low based on small sample sizes, variable scoring of symptoms, and high rates of bias. 46 There are inadequate studies investigating saline irrigation ef fi cacy speci fi cally for NAR patients. However, empirically, sa line acts as a mild decongestant and is effective at removing crusting and excessive mucus often present in these patients and may be a used adjunctive therapy. A meta-analysis of 5 studies evaluating intranasal ipratropium bromide in NAR has demonstrated ef fi cacy within the fi rst week of use and this was sustained throughout the studies, particularly with improvement of rhinorrhea. Studies also demonstrated bene fi t in physical and mental health outcomes. 47 Intranasal antihistamines have ef fi cacy in NAR as summa rized by a recent systematic review and meta-analysis, with improvements in symptom scores and quality of life. 48 Both azelastine and olopatadine are multimodal antihistamines that have mast cell e stabilizing effects. No difference in symptom improvement was distinguished between these 2 INAHs in this analysis. 48 Intranasal corticosteroids have shown to be bene fi cial in the treatment of NAR, with budesonide apparently having the greatest bene fi t. 49 There are multiple mechanisms by which INCS work; however, of most interest when considering the pathophysiology of NAR is the capacity for these agents to in crease the production of neutral endopeptidase, which results in

8. Soap powders (ie, laundry soap) 9. Ammonia (ie, Lysol, Windex) 10. Household cleaners (ie, Tilex, Comet) 11. Christmas tree odors or Pine-Sol 12. Varnish 13. Solvents (eg, turpentine, alcohol, nail polish remover) 14. Paints 15. Sawdust 16. Crude oil (eg, gasoline, diesel, kerosene) 17. Periods of high air pollution 18. Cold air 19. Weather (eg, rain, dampness, temperature changes) 20. Tobacco smoke/wood smoke (burning logs) 21. Mold/mildew odors

with and without nasal polyps, tension and migraine headaches, asthma, chronic cough, conjunctivitis, eustachian tube dysfunc tion, otitis media with or without effusion (with possible hearing impairment), nasal dyspnea (shortness of breath from nasal congestion causing mouth breathing), obstructive sleep apnea, and other sleep disturbances or related complications resulting in fatigue. 10 Short- and long-term complications from NAR are substan tial, in fl icting considerable physical and economic burdens on those af fl icted. These impediments include poor cognitive functioning, sleep loss, daytime fatigue, reduced school and workplace productivity, and absenteeism, all leading to overall decreased quality of life. 1 There is evidence that long-term exposure to particulate matter such as black carbon can cause NAR symptoms and contribute to CRS symptomatology and severity. 42,43 One of the most frequent clinically relevant conditions resulting from poorly controlled NAR is postnasal drainage leading to chronic cough. 9,32 These secretions likely stimulate cough receptors causing a persistent, refractory cough that needs to be differentiated from asthma and gastroesophageal re fl ux, which can also manifest as a chronic cough or occur concomi tantly with postnasal drainage e induced cough. 9,32 Often, NHR and bronchial hyperreactivity are associated. 7

TREATMENT Environmental interventions

A treatment algorithm for NAR is outlined in Figure 3 based on guideline recommendations. 10 Once a diagnosis of NAR has