Allergic or Non-Allergic Rhinitis: Asthma and Allergy
- Friday, September 4, 2009, 22:43
- Asthma
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- Andrew:
- In the next few minutes, you’ll hear a top expert explain how people with asthma and allergies no longer have to suffer.
- Dr. Lieberman:
- “If you have to end up in an emergency room or you have to use your rescue inhaler more than once a week, then we’re failing you or you’re failing us.”
- Andrew:
- And you’ll learn there’s also a price to pay if you don’t get proper treatment for even a more benign problem like rhinitis or a chronic runny or stuffy nose.
- Dr. Lieberman:
- “We know that they exert a profound effect on the quality of life of individuals. They affect your sleep. They affect your capacity to work. They affect kids’ capacity to learn. They affect personality development.”
- Andrew:
- This is Andrew Schorr from HealthTalk Interactive’s Asthma and Allergy Education Network. Dr. Phil Lieberman is one of America’s top allergists. For more than 30 years he’s helped people control asthma and allergies. In fact, he suffers from allergies himself. Dr. Lieberman is clinical professor of medicine and pediatrics at the University of Tennessee College of Medicine in Memphis. Dr. Lieberman, despite all the commercials about seasonal allergies, I understand there are some people who feel like they have allergies but actually they don’t.
- Dr. Lieberman:
- Well, there are people like that, and it’s a very, very important clinical difference. In our practice at least 30 percent and perhaps as high as 60 percent of certain ages of patients who come to see me for an allergy evaluation either on their own, or at the referral of another physician, actually don’t have allergies. That is, they have the symptoms of allergy. They have sneezing, they have runny nose, they have nasal congestion, they have nasal drainage, they feel pain over the sinus areas, and for all practical purposes, they think they are allergic because unfortunately those symptoms are oftentimes considered synonymous with allergies. But indeed, they’re not. And especially in adults, a very large percent of patients can have the symptoms, but they don’t have allergy. And the important concept for people to understand is when you present with those symptoms, what you’re expressing is a process in the nose called inflammation. And inflammation produces swelling, weeping, and sneezing, and that weeping can either run out the front or go down the back. Now, what people don’t understand is that allergy is only one cause of that.
There is a group of people who are totally non-allergic and have those symptoms and, quite often, have those symptoms more severe than the allergic patients. And when they come to see us for an allergy evaluation, they’re then quite surprised to find that they have no allergy at all. That is, when we evaluate them, with very sensitive tests that are 100 percent accurate, we find that they’re allergic to nothing.
They have a condition known as rhinitis, “rhin” meaning nose, “itis” meaning inflamed, but they don’t have the allergic variety. They have what we call chronic non-allergic rhinitis. What makes these people worse are things which aren’t allergens but rather irritants, and the distinction between those two substances is probably the most important concept that you need to understand to be able to understand the differences in these conditions.
An allergen is by definition a substance that is non-irritating. That is, if you were exposed to large amounts of that substance and you didn’t happen to be an allergic individual, you wouldn’t even notice its presence. These are things like pollen, feathers, dust mite, mold spores and animal danders. If you take a non-allergic person, for example, and you put him in a room with a dozen cats, they will have no adverse effect. Allergens are all organic – that means alive or have been alive – and they’re all non-irritating. We can’t detect them with our senses of smell, sense of taste. They have no irritating property. An irritant is a substance that would bother anyone if present in large enough amounts.
- Andrew:
- It’s like paint fumes. If you went by and they were painting a room, everybody would say, “Oh, I can’t stay in here. I can’t breathe.”
- Dr. Lieberman:
- That’s exactly right. There are some of us who are much more sensitive to these irritants than what we would call the “normal” population so that infinitesimally small amounts of, for example, a strong perfume, cigarette smoke, paint fumes, particulate dust in the air, give these patients symptoms of rhinitis. And since the symptoms are identical to those produced by allergies, patients think they are “allergic” to perfume.
- Andrew:
- Right. So, it’s not seasonal allergies. That’s the main thing.
- Dr. Lieberman:
- It is entirely different.
- Andrew:
- Dr. Lieberman, for our listeners, is there sort of a quiz someone could give themselves to get a handle on are they the person who gets ragweed in the air and they have seasonal allergies or that they could have this non-allergic rhinitis that you’re talking about? Is there sort of a toolkit you could give them?
- Dr. Lieberman:
- Well, there are some simple questions that you can ask yourself to help decide whether or not you have allergic rhinitis or non-allergic rhinitis, or more importantly, a mixture of the two because at least a third of the patients that we see have both non-allergic and allergic disease. The questions can be asked of yourself, and they take about perhaps three to five minutes to ask, and the conclusions, although not 100 percent accurate, are reasonably accurate and certainly will give you a guideline. They’re things like whether or not your symptoms are made worse by exposure to animals such as cats, or whether or not they’re made worse by weather changes, or whether or not they’re made worse by cigarettes and paint fumes or fresh-cut grass, for example. And the list of questions is designed to tell whether or not you have allergic rhinitis, non-allergic rhinitis, or a combination of both. And you can actually access these questions on the Internet. The Internet address is www.aboutrhinitis.com so that if you’re interested in taking the self-test, you can simply go on the Internet and ask yourself those questions.
- Andrew:
- And could you take the results of your quiz and then share that with your own doctor?
- Dr. Lieberman:
- You could certainly take these results to your physician and get their opinion as to whether or not you have allergic or non-allergic or mixed conditions, and then now that we have a treatment for non-allergic rhinitis, you can perhaps ask for that treatment specifically.
- Andrew:
- There’s this concept of antihistamines that people know about, and been around for many years. Are there benefits to those that can help with this condition?
- Dr. Lieberman:
- Non-allergic rhinitis is usually a more difficult disease to treat than the allergic form. And until recently there were very few drugs approved for use in non-allergic rhinitis. Recently, one drug called azelastine or Astelin, which is an antihistamine but a unique antihistamine that one sprays in their nose rather than takes by mouth, has been shown to be effective in the treatment of this disorder. And so now we have for the first time a non-corticosteroid drug that is useful in the treatment of this disease, and patients suffering from this type of non-allergic rhinitis should be able to get care and should seek care for this disorder.
- Andrew:
- Is there a connection between asthma and this type of rhinitis you’re talking about? And also, I heard that there could be a connection with even gastric reflux, which affects many adults, and that that could affect their upper respiratory system too. So maybe you could help us understand that.
- Dr. Lieberman:
- Well, there is a connection, and there’s a connection between all three of the things you mentioned: that is, asthma, rhinitis, and reflux. Let me start first with the connection between rhinitis, inflammation of the nose, and asthma, a peculiar form of inflammation of the bronchial tissue in the lungs. The nose can be considered the guardian of the lungs. The function of the nose is to filter, moisten, and warm the air we breathe in preparation for that air’s entrance into the lungs. So that whenever you have a condition affecting the nose’s ability to do those three things, then asthma worsens. So that we know that patients with active rhinitis, for example, have worse asthma when their rhinitis is active than they do when their rhinitis is inactive. It’s now been clearly shown that if you treat rhinitis alone, even if you don’t treat the patient’s asthma, their asthma can get better, and vice-a-versa. Anything that activates the rhinitis in the nose can activate the asthma, so that keeping the nose disease-free, or symptom-free, is a very important principle in taking care of the lungs. There is a very strong connection between the two. And the mechanism of production of that connection has been studied extensively, and we really don’t know for sure, but we do know that more than likely it’s a reflex. That is, if you titillate the nose or irritate it, it sends a message to the brain. That message is then translated, and it returns back not only to the nose, but to the lungs. Because when the brain gets the message, it knows it’s coming from the respiratory tract, but it isn’t quite sure where, and then it causes the lungs, not only the nose, to weep and the bronchial muscles to constrict.
Now, how does gastroesophageal reflux enter into that picture? The same mechanism – that is, gastroesophageal reflux – a reflex produced by the reflux is probably accountable for worsening not only the nose but also the lungs. For example, people who have heartburn, regardless of whether the acid from the stomach appears only in the lower esophagus, producing heartburn, or the upper esophagus, regardless of the location of that acid, will have worsened symptoms of rhinitis. And, therefore, acid in the esophagus makes the nose worse, probably through the reflex, and it also can make the lungs worse as well.
- Andrew:
- So, are you saying that we need to take care of nasal secretions and keep our very top of our respiratory system, treat that perhaps with medication, and that could help someone with asthma? And also, if they had heartburn, an adult, or reflux condition, that taking care of that might also help their asthma and their sinuses and nose?
- Dr. Lieberman:
- That’s exactly what I meant, and the flip side of that coin is also important. Namely, if you don’t take care of those things, the asthma and the rhinitis is worsened, and so that someone who has asthma needs to investigate whether or not they’re having rhinitis, whether or not they’re having heartburn, and it’s one of the things they should discuss with their physician.
- Andrew:
- And so let’s talk about a proactive kind of mental toolkit for someone who has rhinitis nasal issues. Do they open a discussion with their doctor and say, “Could it be something more? I’ve never been diagnosed with asthma. Is that something we should look into? Yeah, I’ve had heartburn, but I’ve been taking just an over-the-counter thing for that. Is there more we should do to kind of control the whole picture?” What would you say to people listening as to how proactive they should be?
- Dr. Lieberman:
- They should be very proactive. And people, for example, who have to take Rolaids or Tums on a regular basis, should bring this up with their physician for several reasons, and one of those reasons is that the symptoms that they wouldn’t ordinarily think were related to that, symptoms such as postnasal drainage or recurrent hoarseness, can be due to that reflux. And in addition, that reflux can, as we said, aggravate asthma. And especially if you do have asthma or you do have symptoms of rhinitis, then it becomes even more important.
- Andrew:
- So, [for] one of our listeners, maybe a parent seeking information. What are the signs whether you need to seek treatment, not just try something over the counter, [but] bring it up with your primary care doctor or even seek a specialist? When should you be spurred to action when you’re not sure – you’re not a doctor yourself – how to evaluate it?
- Dr. Lieberman:
- Well, I think that the level of discomfort is an excellent guide to some extent. For most people, the discomfort itself will lead them to a physician. That is, are they having sneezing, nasal itching, postnasal drainage, or congestion that aggravates them? Now, in other people who are stoic, it becomes a little bit more difficult because these are the people that I am more worried about. They neglect the symptoms of rhinitis, for example, nasal congestion being one of these, and they don’t sleep well at night, and their companions complain of their snoring. And they don’t feel quite alert when they wake up in the morning, and their driving skills are impaired. These people may say, “Well, it’s only a little runny nose,” or “So, my nose is stopped up, and so isn’t everyone else’s?” And the answer to that is no, it isn’t true in everyone else, and that having nasal symptoms can exert effects beyond their perception of their own comfort. If I were giving advice to people, it would be not to have to deal with any form of upper respiratory tract symptom without seeking help, because what you don’t understand is that the symptoms themselves can have effects on other aspects of your health that you’re not quite aware of or you may not quite notice.
- Andrew:
- Let’s talk about treatment. There are many people who see millions of dollars worth of commercials on TV or on radio and particularly head to over-the-counter medications. How far can those over-the-counter medications go if you have a chronic condition, and how should they proceed as far as seeing do they need something more, and maybe not just one medication but a, if you will, combination therapy?
- Dr. Lieberman:
- Well, over-the-counter medications have their good side and their bad side. They have their good side because they’re convenient, they’re not terribly costly, and for some patients who rarely take medications, they serve a purpose. I can’t give you exact figures; however, it’s estimated that perhaps 35 percent of people who do suffer from rhinitis never seek care from a physician and treat themselves only with over-the-counter medication. Now, as long as that over-the-counter medication doesn’t produce a side effect, and one doesn’t have to take it, for example, more than two to three times a month, there’s probably nothing wrong with that. However, one has to be careful because some of the side effects produced by over-the-counter medications are, in essence, hidden from the patient. For example, we know quite well that over-the-counter antihistamines produce drowsiness, but what we don’t quite well understand is that you can be impaired without being overtly drowsy. That is, your performance on tests, your driving performance, can be impaired without the patient understanding this, so that it’s a two-edged sword. Over-the-counter medicines can serve a useful purpose, but they can also be somewhat dangerous, and oftentimes the patient doesn’t really understand that.
Now, that should, therefore, stimulate patients to seek medical care because we do have drugs that are superior to over-the-counter medications in that they cause fewer side effects. And in addition, we have drugs that are far more effective. And it is true that a combination of drugs is more effective than a single agent in many people.
- Andrew:
- So, should there be a fear of taking more than one medication if you have one of these chronic conditions? People often are hesitant. They say, “I don’t want to take all these medications. I want a natural approach,” or “I just want to breathe steam,” or whatever it may be, and “I wish I didn’t have to do this.” You’ve been in research and seen the development of your armamentarium for rhinitis and for asthma. How confident are you that these can provide long-term, effective approaches and that there’s a benefit for people using them?
- Dr. Lieberman:
- I’m so confident that I’m a user myself, and I prescribe these drugs to my family. I have three allergic children who all inherited their allergies from their father, and the drugs that I give my patients I give them, and I’ve been giving them these drugs throughout their childhood. They’re now grown. We have very effective drugs that are almost totally innocuous for the most part, and it’s unreasonable not to avail yourself of these agents because even though the conditions that we treat in terms of rhinitis aren’t life threatening, we know that they exert a profound effect on the quality of life of individuals. They affect your sleep. They affect your capacity to work. They affect kids’ capacity to learn. They affect personality development. And therefore, not to treat them maximally with drugs – which we know are effective and safe – is really unreasonable because of a fear of side effects. The side effects that we see are almost nonexistent, and these drugs have been approved for use in children down to age three. So, we have effective therapy. The therapy should be used, and I would consider fear of these medications for the most part phobic rather than rational.
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