Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

Allergic Rhinitis
Author: Javed Sheikh, MD; Chief Editor: Michael A Kaliner, MD more... Updated: Sep 2, 2011

Background
Rhinitis is defined as inflammation of the nasal membranes [1] and is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea.[2] The eyes, ears, sinuses, and throat can also be involved. Allergic rhinitis is the most common cause of rhinitis. It is an extremely common condition, affecting approximately 20% of the population. Although allergic rhinitis is not a life-threatening condition, complications can occur and the condition can significantly impair quality of life,[3, 4] which leads to a number of indirect costs. The total direct and indirect cost of allergic rhinitis was recently estimated to be $5.3 billion per year.[5] A 2011 analysis determined that patients with allergic rhinitis averaged 3 additional office visits, 9 more prescriptions filled, and $1500 in incremental healthcare costs in 1 year than similar patients without allergic rhinitis.[6]

Pathophysiology
Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is involved, and the other organs are affected in certain individuals. Inflammation of the mucous membranes is characterized by a complex interaction of inflammatory mediators but ultimately is triggered by an immunoglobulin E (IgE)mediated response to an extrinsic protein.[7] The tendency to develop allergic, or IgE-mediated, reactions to extrinsic allergens (proteins capable of causing an allergic reaction) has a genetic component. In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins. This specific IgE coats the surface of mast cells, which are present in the nasal mucosa. When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators.[7, 8, 9] The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin.[8, 9] The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2.[10, 11, 12] These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (ie, nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip). Mucous glands are stimulated, leading to increased secretions. Vascular permeability is increased, leading to plasma exudation. Vasodilation occurs, leading to congestion and pressure. Sensory nerves are stimulated, leading to sneezing and itching. All of these events can occur in minutes; hence, this reaction is called the early, or immediate, phase of the reaction. Over 4-8 hours, these mediators, through a complex interplay of events, lead to the recruitment of other inflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, and macrophages.[13] This results in continued inflammation, termed the late-phase response. The symptoms of the late-phase response are similar to those of the early phase, but less sneezing and itching and more congestion and mucus production tend to occur.[13] The late phase may persist for hours or days. Systemic effects, including fatigue, sleepiness, and malaise, can occur from the inflammatory response. These symptoms often contribute to impaired quality of life.

Epidemiology
Frequency
United States Allergic rhinitis affects approximately 40 million people in the United States.[14] Recent US figures suggest a 20%

1 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

cumulative prevalence rate.[15, 16] International Scandinavian studies have demonstrated a cumulative prevalence rate of 15% in men and 14% in women.[17] The prevalence of allergic rhinitis may vary within and among countries.[18, 19, 20, 21] This may be due to geographic differences in the types and potency of different allergens and the overall aeroallergen burden.

Mortality/Morbidity
While allergic rhinitis itself is not life-threatening (unless accompanied by severe asthma or anaphylaxis), morbidity from the condition can be significant. Allergic rhinitis often coexists with other disorders, such as asthma, and may be associated with asthma exacerbations.[22, 23, 24] Allergic rhinitis is also associated with otitis media, eustachian tube dysfunction, sinusitis, nasal polyps, allergic conjunctivitis, and atopic dermatitis.[1, 2, 25] It may also contribute to learning difficulties, sleep disorders, and fatigue.[26,
27, 28]

Numerous complications that can lead to increased morbidity or even mortality can occur secondary to allergic rhinitis. Possible complications include otitis media, eustachian tube dysfunction, acute sinusitis, and chronic sinusitis. Allergic rhinitis can be associated with a number of comorbid conditions, including asthma, atopic dermatitis, and nasal polyps. Evidence now suggests that uncontrolled allergic rhinitis can actually worsen the inflammation associated with asthma[22, 23, 24] or atopic dermatitis.[25] This could lead to further morbidity and even mortality. Allergic rhinitis can frequently lead to significant impairment of quality of life. Symptoms such as fatigue, drowsiness (due to the disease or to medications), and malaise can lead to impaired work and school performance, missed school or work days, and traffic accidents. The overall cost (direct and indirect) of allergic rhinitis was recently estimated to be $5.3 billion per year.[5]

Race
Allergic rhinitis occurs in persons of all races. Prevalence of allergic rhinitis seems to vary among different populations and cultures, which may be due to genetic differences, geographic factors or environmental differences, or other population-based factors.

Sex
In childhood, allergic rhinitis is more common in boys than in girls, but in adulthood, the prevalence is approximately equal between men and women.

Age
Onset of allergic rhinitis is common in childhood, adolescence, and early adult years, with a mean age of onset 8-11 years, but allergic rhinitis may occur in persons of any age. In 80% of cases, allergic rhinitis develops by age 20 years.[29] The prevalence of allergic rhinitis has been reported to be as high as 40% in children, subsequently decreasing with age.[15, 16] In the geriatric population, rhinitis is less commonly allergic in nature.

Contributor Information and Disclosures

Author Javed Sheikh, MD Assistant Professor of Medicine, Harvard Medical School; Clinical Director, Division of Allergy and Inflammation, Clinical Director, Center for Eosinophilic Disorders, Beth Israel Deaconess Medical Center Javed Sheikh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American College of Allergy, Asthma and Immunology Disclosure: Nothing to disclose. Coauthor(s) Umer Najib, MD Clinical Research Fellow, Department of Medicine, Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center Disclosure: Nothing to disclose. Specialty Editor Board William F Schoenwetter, MD Consultant in Allergic Diseases, Brainerd Medical Center, Brainerd, Minnesota William F Schoenwetter, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians,

2 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

American Medical Association, Joint Council of Allergy, Asthma and Immunology, and Minnesota Medical Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Stephen C Dreskin, MD, PhD Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology Disclosure: Genentech, Inc. Consulting fee Consulting; Clinical Immunization and Safety Assessment (CISA) Network (CDC) administered by America's Health Insurance Plans (AHIP) Consulting fee Consulting; Genentech, Inc. Grant/research funds Other; Medical Expert Panel, Department of Health and Human Services, Division of Vaccine Injury Compensation None Independent contractor; American Board of Allergy and Immunology Honoraria Board membership; Novartis, Inc Consulting fee Review panel membership Timothy D Rice, MD Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians Disclosure: Nothing to disclose. Chief Editor Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians Disclosure: Alcon Consulting fee Consulting; Teva Consulting fee Consulting; Meda Honoraria Speaking and teaching; Ista Consulting fee Consulting; sunovian Consulting fee Consulting; dey Honoraria Review panel membership

References
1. Togias AG. Systemic immunologic and inflammatory aspects of allergic rhinitis. J Allergy Clin Immunol. Nov 2000;106(5 Suppl):S247-50. [Medline]. 2. Druce HM. Allergic and nonallergic rhinitis. In: Middleton EM Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 5th ed. St. Louis, Mo: Mosby Year-Book; 1998:1005-16. 3. Blaiss MS. Quality of life in allergic rhinitis. Ann Allergy Asthma Immunol. Nov 1999;83(5):449-54. [Medline]. 4. Thompson AK, Juniper E, Meltzer EO. Quality of life in patients with allergic rhinitis. Ann Allergy Asthma Immunol. Nov 2000;85(5):338-47; quiz 347-8. [Medline]. 5. Ray NF, Baraniuk JN, Thamer M, Rinehart CS, Gergen PJ, Kaliner M. Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses. J Allergy Clin Immunol. Mar 1999;103(3 Pt 1):401-7. [Medline]. 6. Bhattacharyya N. Incremental healthcare utilization and expenditures for allergic rhinitis in the United States. Laryngoscope. Sep 2011;121(9):1830-3. 7. Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol. Jul 2001;108(1 Suppl):S2-8. [Medline]. 8. Walls AF, He S, Buckley MG, McEuen AR. Roles of the mast cell and basophil in asthma. Clin Exp Allergy. 2001;1:68. 9. Haberal I, Corey JP. The role of leukotrienes in nasal allergy. Otolaryngol Head Neck Surg. Sep 2003;129(3):274-9. [Medline]. 10. Iwasaki M, Saito K, Takemura M, Sekikawa K, Fujii H, Yamada Y. TNF-alpha contributes to the development of allergic rhinitis in mice. J Allergy Clin Immunol. Jul 2003;112(1):134-40. [Medline].

3 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

11. Cates EC, Gajewska BU, Goncharova S, Alvarez D, Fattouh R, Coyle AJ. Effect of GM-CSF on immune, inflammatory, and clinical responses to ragweed in a novel mouse model of mucosal sensitization. J Allergy Clin Immunol. May 2003;111(5):1076-86. [Medline]. 12. Salib RJ, Kumar S, Wilson SJ, Howarth PH. Nasal mucosal immunoexpression of the mast cell chemoattractants TGF-beta, eotaxin, and stem cell factor and their receptors in allergic rhinitis. J Allergy Clin Immunol. Oct 2004;114(4):799-806. [Medline]. 13. Hansen I, Klimek L, Mosges R, Hormann K. Mediators of inflammation in the early and the late phase of allergic rhinitis. Curr Opin Allergy Clin Immunol. Jun 2004;4(3):159-63. [Medline]. 14. Meltzer EO. The prevalence and medical and economic impact of allergic rhinitis in the United States. J Allergy Clin Immunol. Jun 1997;99(6 Pt 2):S805-28. [Medline]. 15. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Management of Alllergic and Nonallergic rhinitis. May 2002. AHQR publication 02:E023, Boston, MA. Summary, Evidence Report/Technology Assessment: No 54. http://www.ahrq.gov/clinic/epcsums/rhinsum.htm. Last accessed August 3, 2007. 16. Settipane RA. Demographics and epidemiology of allergic and nonallergic rhinitis. Allergy Asthma Proc. Jul-Aug 2001;22(4):185-9. [Medline]. 17. Nihlen U, Greiff L, Montnemery P, Lofdahl CG, Johannisson A, Persson C. Incidence and remission of self-reported allergic rhinitis symptoms in adults. Allergy. Nov 2006;61(11):1299-304. [Medline]. 18. Sly RM. Changing prevalence of allergic rhinitis and asthma. Ann Allergy Asthma Immunol. Mar 1999;82(3):233-48; quiz 248-52. [Medline]. 19. Von Mutius E, Weiland SK, Fritzsch C, et al. Increasing prevalence of hay fever and atopy among children in Leipzig, East Germany. Lancet. 1998;351:862. 20. Romano-Zelekha O, Graif Y, Garty BZ, Livne I, Green MS, Shohat T. Trends in the prevalence of asthma symptoms and allergic diseases in Israeli adolescents: results from a national survey 2003 and comparison with 1997. J Asthma. Jun 2007;44(5):365-9. [Medline]. 21. Lima RG, Pastorino AC, Casagrande RR, et al. Prevalence of asthma, rhinitis and eczema in 6 - 7 years old students from the western districts of Sao Paulo City, using the standardized questionnaire of the "International Study of Asthma and Allergies in Childhood" (ISAAC)-phase IIIB. Clinics. 2007;62:225. 22. Watson WT, Becker AB, Simons FE. Treatment of allergic rhinitis with intranasal corticosteroids in patients with mild asthma: effect on lower airway responsiveness. J Allergy Clin Immunol. Jan 1993;91(1 Pt 1):97-101. [Medline]. 23. Meltzer EO, Grant JA. Impact of cetirizine on the burden of allergic rhinitis. Ann Allergy Asthma Immunol. Nov 1999;83(5):455-63. [Medline]. 24. Nayak AS. The asthma and allergic rhinitis link. Allergy Asthma Proc. Nov-Dec 2003;24(6):395-402. [Medline]. 25. Kiyohara C, Tanaka K, Miyake Y. Genetic susceptibility to atopic dermatitis. Allergol Int. Mar 2008;57(1):39-56. [Medline]. 26. Fireman P. Otitis media and eustachian tube dysfunction: connection to allergic rhinitis. J Allergy Clin Immunol. Feb 1997;99(2):S787-97. [Medline]. 27. McColley SA, Carroll JL, Curtis S, Loughlin GM, Sampson HA. High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea. Chest. Jan 1997;111(1):170-3. [Medline]. 28. Craig TJ, Teets S, Lehman EB, Chinchilli VM, Zwillich C. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J Allergy Clin Immunol. May 1998;101(5):633-7. [Medline]. 29. Dykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R, Blessing-Moore J. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol. Nov 1998;81(5 Pt 2):478-518. [Medline]. 30. Banov CH, Lieberman P,. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol. Jan 2001;86(1):28-35. [Medline].

4 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

31. Torres-Borrego J, Molina-Teran AB, Montes-Mendoza C. Prevalence and associated factors of allergic rhinitis and atopic dermatitis in children. Allergol Immunopathol (Madr). Mar-Apr 2008;36(2):90-100. [Medline]. 32. Frew AJ. Advances in environmental and occupational diseases 2003. J Allergy Clin Immunol. Jun 2004;113(6):1161-6. [Medline]. 33. Boulet LP, Turcotte H, Laprise C, Lavertu C, Bedard PM, Lavoie A. Comparative degree and type of sensitization to common indoor and outdoor allergens in subjects with allergic rhinitis and/or asthma. Clin Exp Allergy. Jan 1997;27(1):52-9. [Medline]. 34. Fornadley JA, Corey JP, Osguthorpe JD, Powell JP, Emanuel IA, Boyles JH. Allergic rhinitis: clinical practice guideline. Committee on Practice Standards, American Academy of Otolaryngic Allergy. Otolaryngol Head Neck Surg. Jul 1996;115(1):115-22. [Medline]. 35. Hadley JA. Evaluation and management of allergic rhinitis. Med Clin North Am. Jan 1999;83(1):13-25. [Medline]. 36. Vazquez-Nava F, Quezada-Castillo JA, Oviedo-Trevino S, Saldivar-Gonzalez AH, Sanchez-Nuncio HR, Beltran-Guzman FJ. Association between allergic rhinitis, bottle feeding, non-nutritive sucking habits, and malocclusion in the primary dentition. Arch Dis Child. Oct 2006;91(10):836-40. [Medline]. 37. Siracusa A, Desrosiers M, Marabini A. Epidemiology of occupational rhinitis: prevalence, aetiology and determinants. Clin Exp Allergy. Nov 2000;30(11):1519-34. [Medline]. 38. Gelber LE, Seltzer LH, Bouzoukis JK, Pollart SM, Chapman MD, Platts-Mills TA. Sensitization and exposure to indoor allergens as risk factors for asthma among patients presenting to hospital. Am Rev Respir Dis. Mar 1993;147(3):573-8. [Medline]. 39. Kang B, Vellody D, Homburger H, Yunginger JW. Cockroach cause of allergic asthma. Its specificity and immunologic profile. J Allergy Clin Immunol. Feb 1979;63(2):80-6. [Medline]. 40. Eggleston PA, Ansari AA, Ziemann B, Adkinson NF Jr, Corn M. Occupational challenge studies with laboratory workers allergic to rats. J Allergy Clin Immunol. Jul 1990;86(1):63-72. [Medline]. 41. Phipatanakul W, Eggleston PA, Wright EC, Wood RA,. Mouse allergen. II. The relationship of mouse allergen exposure to mouse sensitization and asthma morbidity in inner-city children with asthma. J Allergy Clin Immunol. Dec 2000;106(6):1075-80. [Medline]. 42. Matsui EC, Simons E, Rand C, Butz A, Buckley TJ, Breysse P. Airborne mouse allergen in the homes of inner-city children with asthma. J Allergy Clin Immunol. Feb 2005;115(2):358-63. [Medline]. 43. Gendo K, Larson EB. Evidence-based diagnostic strategies for evaluating suspected allergic rhinitis. Ann Intern Med. Feb 17 2004;140(4):278-89. [Medline]. 44. Platts-Mills TA. Allergen avoidance. J Allergy Clin Immunol. Mar 2004;113(3):388-91. [Medline]. 45. Morgan WJ, Crain EF, Gruchalla RS, O'Connor GT, Kattan M, Evans R 3rd. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. Sep 9 2004;351(11):1068-80. [Medline]. 46. McDonald LG, Tovey E. The role of water temperature and laundry procedures in reducing house dust mite populations and allergen content of bedding. J Allergy Clin Immunol. Oct 1992;90(4 Pt 1):599-608. [Medline]. 47. Miller JD, Miller A. Ten minutes in a clothes dryer kills all mites in blankets. J Allergy Clin Immunol. 1996;97:423. 48. Korsgaard J. House-dust mites and absolute indoor humidity. Allergy. Feb 1983;38(2):85-92. [Medline]. 49. de Blay F, Chapman MD, Platts-Mills TA. Airborne cat allergen (Fel d I). Environmental control with the cat in situ [see comments]. Am Rev Respir Dis. 1991;143:1334. 50. Weber RW. Immunotherapy with allergens. JAMA. Dec 10 1997;278(22):1881-7. [Medline]. 51. Li JT. Immunotherapy for allergic rhinitis. Immunol Allergy Clin North Am. 2000;20:383. 52. Leynadier F, Banoun L, Dollois B, Terrier P, Epstein M, Guinnepain MT. Immunotherapy with a calcium phosphate-adsorbed five-grass-pollen extract in seasonal rhinoconjunctivitis: a double-blind, placebocontrolled study. Clin Exp Allergy. Jul 2001;31(7):988-96. [Medline].

5 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

53. Walker SM, Pajno GB, Lima MT, Wilson DR, Durham SR. Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomized, controlled trial. J Allergy Clin Immunol. Jan 2001;107(1):87-93. [Medline]. 54. Ewbank PA, Murray J, Sanders K, Curran-Everett D, Dreskin S, Nelson HS. A double-blind, placebocontrolled immunotherapy dose-response study with standardized cat extract. J Allergy Clin Immunol. Jan 2003;111(1):155-61. [Medline]. 55. Nanda A, O'connor M, Anand M, Dreskin SC, Zhang L, Hines B. Dose dependence and time course of the immunologic response to administration of standardized cat allergen extract. J Allergy Clin Immunol. Dec 2004;114(6):1339-44. [Medline]. 56. Meltzer EO. Performance effects of antihistamines. J Allergy Clin Immunol. Oct 1990;86(4 Pt 2):613-9. [Medline]. 57. Vacchiano C, Moore J, Rice GM, Crawley G. Fexofenadine effects on cognitive performance in aviators at ground level and simulated altitude. Aviat Space Environ Med. Aug 2008;79(8):754-60. [Medline]. 58. Newer antihistamines. Med Lett Drugs Ther. Apr 30 2001;43(1103):35. [Medline]. 59. De Weck AL, Derer T, Bahre M. Investigation of the anti-allergic activity of azelastine on the immediate and late-phase reactions to allergens and histamine using telethermography. Clin Exp Allergy. Feb 2000;30(2):283-7. [Medline]. 60. [Best Evidence] Lee TA, Pickard AS. Meta-analysis of azelastine nasal spray for the treatment of allergic rhinitis. Pharmacotherapy. Jun 2007;27(6):852-9. [Medline]. 61. [Best Evidence] Berger W, Hampel F Jr, Bernstein J, Shah S, Sacks H, Meltzer EO. Impact of azelastine nasal spray on symptoms and quality of life compared with cetirizine oral tablets in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. Sep 2006;97(3):375-81. [Medline]. 62. Chervinsky P, Philip G, Malice MP, Bardelas J, Nayak A, Marchal JL. Montelukast for treating fall allergic rhinitis: effect of pollen exposure in 3 studies. Ann Allergy Asthma Immunol. Mar 2004;92(3):367-73. [Medline]. 63. Perry TT, Corren J, Philip G, Kim EH, Conover-Walker MK, Malice MP. Protective effect of montelukast on lower and upper respiratory tract responses to short-term cat allergen exposure. Ann Allergy Asthma Immunol. Nov 2004;93(5):431-8. [Medline]. 64. Patel P, Philip G, Yang W, et al. Randomized, double-blind, placebo-controlled study of montelukast for treating perennial allergic rhinitis. Ann Allergy Asthma Immunol. Dec 2005;95(6):551-7. [Medline]. 65. Nayak A, Langdon RB. Montelukast in the treatment of allergic rhinitis: an evidence-based review. Drugs. 2007;67(6):887-901. [Medline]. 66. Gengo FM, Manning C. A review of the effects of antihistamines on mental processes related to automobile driving. J Allergy Clin Immunol. Dec 1990;86(6 Pt 2):1034-9. [Medline]. 67. Verster JC, Volkerts ER. Antihistamines and driving ability: evidence from on-the-road driving studies during normal traffic. Ann Allergy Asthma Immunol. Mar 2004;92(3):294-303; quiz 303-5, 355. [Medline]. 68. O'Hanlon JF, Ramaekers JG. Antihistamine effects on actual driving performance in a standard test: a summary of Dutch experience, 1989-94. Allergy. Mar 1995;50(3):234-42. [Medline]. 69. Ray WA, Thapa PB, Shorr RI. Medications and the older driver. Clin Geriatr Med. May 1993;9(2):413-38. [Medline]. 70. Cimbura G, Lucas DM, Bennett RC, Warren RA, Simpson HM. Incidence and toxicological aspects of drugs detected in 484 fatally injured drivers and pedestrians in Ontario. J Forensic Sci. Oct 1982;27(4):855-67. [Medline]. 71. van Bavel J, Findlay SR, Hampel FC Jr, Martin BG, Ratner P, Field E. Intranasal fluticasone propionate is more effective than terfenadine tablets for seasonal allergic rhinitis. Arch Intern Med. Dec 12-26 1994;154(23):2699-704. [Medline]. 72. Welsh PW, Stricker WE, Chu CP, Naessens JM, Reese ME, Reed CE. Efficacy of beclomethasone nasal solution, flunisolide, and cromolyn in relieving symptoms of ragweed allergy. Mayo Clin Proc. Feb 1987;62(2):125-34. [Medline]. 73. Kaszuba SM, Baroody FM, deTineo M, Haney L, Blair C, Naclerio RM. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis.

6 of 7

30-12-2011 21:11

Allergic Rhinitis

http://emedicine.medscape.com/article/134825-overview

Arch Intern Med. Nov 26 2001;161(21):2581-7. [Medline]. 74. Rak S, Heinrich C, Jacobsen L, Scheynius A, Venge P. A double-blinded, comparative study of the effects of short preseason specific immunotherapy and topical steroids in patients with allergic rhinoconjunctivitis and asthma. J Allergy Clin Immunol. Dec 2001;108(6):921-8. [Medline]. 75. Pullerits T, Praks L, Ristioja V, Lotvall J. Comparison of a nasal glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in the treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. Jun 2002;109(6):949-55. [Medline]. 76. Onrust SV, Lamb HM. Mometasone furoate. A review of its intranasal use in allergic rhinitis. Drugs. Oct 1998;56(4):725-45. [Medline]. 77. Norris AA, Alton EW. Chloride transport and the action of sodium cromoglycate and nedocromil sodium in asthma. Clin Exp Allergy. Mar 1996;26(3):250-3. [Medline]. Medscape Reference 2011 WebMD, LLC

7 of 7

30-12-2011 21:11