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Two Conditions, One Airway: Co-managing Allergic Rhinitis and Asthma

Allergic rhinitis (AR), a common disorder that is strongly linked to asthma, often goes unnoticed in primary care; however, it can have a significant negative impact on a patient’s quality of life. Joint management of AR and asthma may lead to better control of both diseases.

Understanding Allergic Rhinitis

AR is an inflammatory disease that currently affects an estimated 40 percent of the population, and its prevalence is increasing. Epidemiological and pathophysiological studies indicate that rhinitis and asthma frequently coexist. Between 20 percent and 60 percent of patients with rhinitis have asthma, and up to 95 percent of patients with asthma have rhinitis. Current evidence indicates that AR may be one part of a systemic airway disease that involves the entire respiratory tract. Allergen provocation of the upper airways may lead to both a local inflammatory response in the nose and to inflammatory processes in the lower airways.

AR and Asthma

Rhinitis is one of the strongest independent risk factors for the onset and incidence of asthma. Additionally, it predicts poor asthma control. Compared with people who have no rhinitis, the odds of poor asthma control in people who have mild rhinitis is double. In people with severe rhinitis, poor asthma control more than quadruples.

Learn more on the connections between AR and asthma, the impact of AR on asthma medication use, the burden of AR on the patient population, and the differential diagnosis of AR in this MDBriefCase program, Two Conditions, One Airway: Co-managing Allergic Rhinitis and Asthma.

Treating Comorbid AR and Asthma

The treatment of AR involves allergen avoidance, pharmacotherapy, and immunotherapy, but many patients with AR remain symptomatic despite treatment. When assessing these patients, it is crucial to noteadherence to treatment, asthma inhaler techniques, and intranasal corticosteroid (INCS) technique.

Among the factors that should be considered when addressing adherence to treatment is the rationale behind the non-adherence. Some patients are not satisfied with their treatment regimen, and this can lead to poor adherence. Management of patients who did not respond to therapy will differ from treatment of patients who were non-adherent from the start.

According to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, treatment for AR should be based on how much the symptoms impact the patient’s day-to-day living, and clinicians should tailor treatment to the severity of the symptoms. First-line options include:

  • oral antihistamine
  • intranasal corticosteroid (INCS)
  • intranasal corticosteroid/intranasal antihistamine (INCS/INAH)

In patients with both AR and asthma, treatment of the AR symptoms may improve both AR and asthma symptoms.


First-generation antihistamines such as diphenhydramine are no longer recommended for AR due to the high risk of significant adverse effects. Second-generation oral antihistamines are the first-line option for AR and may be sufficient to control mild AR symptoms. Second-generation antihistamines are generally well-tolerated, but common adverse effects include occasional sedation, dry mouth, and headache.

Intranasal Corticosteroids

Intranasal corticosteroids (INCS) are superior to oral antihistamines for nasal symptoms and can improve ocular AR symptoms. They have also been shown to reduce bronchial hyperreactivity and improve asthma control, but they have a slower onset of action than other treatments.

Both INCSs and inhaled corticosteroids (ICs) are designed to be locally active, so there is a low risk of systemic adverse effects unless combined with high-dose oral corticosteroids. However, when patients are taking both INCSs and ICs, the cumulative dose may result in systemic side effects.

If a patient doesn’t respond to INCS alone, stepping up to a combination of an INCS and an intranasal antihistamine (INAH) may improve symptoms. It can be more effective than INCS alone and starts to work in minutes. This combination should be considered in patients who need an immediate effect as well as in patients who don’t respond to INCSs.

Stepped-up Treatment

Patients who continue to experience bothersome symptoms may require stepped-up treatment, which is outlined in our course, Two Conditions, One Airway: Co-managing Allergic Rhinitis and Asthma. Patients who continue to have AR symptoms following stepped-up treatment may be candidates for immunotherapy.

Immunotherapy has shown positive effects on rhinitis; however, it takes at least three years to produce persistent beneficial effects, and it is contraindicated in patients with severe asthma and in patients taking beta-blockers.

Clinicians play a key role in individualizing therapy in patients suffering from comorbid allergic rhinitis and asthma – ensure you’re current on the latest clinical data and guideline recommendations to guide your treatment. Complete this accredited course today.
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