From alternate approaches to proper medication, there are ways for sleep clinicians to help treat rhinitis in patients with poor quality of sleep.
Rhinitis—the inflammation of the mucus membrane in the nose—plays a significant role in quality of sleep, as well as CPAP adherence, for those with obstructive sleep apnea (OSA). Patients should be treated for both allergic (AR) and nonallergic (NAR) rhinitis due to its effect on this patient population and their quality of sleep. Here are five reasons why it is so important for sleep clinicians to be looking for and treating rhinitis in their patients.
1. You can improve patients’ sleep up front with an easy-to-adhere-to therapy before introducing them to CPAP.
“When clinicians give patients a combination of either internal treatments like nasal sprays or neti pot rinses, and external ones like nasal strips, around 80% to 90% of those people report feeling better with less inflammation,” says Barry Krakow, MD, a sleep physician at Maimonides Sleep Arts & Sciences Ltd, Albuquerque, NM, and first author of a study about nonallergic rhinitis in a community-based sleep center. “And they find that when they address the rhinitis with those initial therapy options, their symptoms significantly improve.” This also starts their clinical sleep medicine treatment experience on a positive note, paving the way for further therapies (such as CPAP) as needed.
2. CPAP use can lead to nonallergic rhinitis in some patients, inducing them to quit therapy.
A 2017 study showed that CPAP leads to inflammation in the nasal passages in both AR and NAR patients, as well as exacerbates dryness and worsens the movement of mucus out of the airways. “The CPAP is essentially wind in your nose,” says Krakow. “So, we ask people this question: ‘Does wind, weather, or temperature make you congested?’ If they say yes, we know the therapy could be causing rhinitis, which in turn will affect the patients’ compliancy with the therapy.”
3. Allergic rhinitis can lead to disuse of CPAP for months out of the year.
“I see patients whose congestion from allergic rhinitis makes it seemingly impossible to use the CPAP,” says Timothy Craig, MD, an allergy and immunology specialist and professor of medicine and pediatrics at Penn State University. “The best therapy for this is a nasal steroid because it decreases congestion, and it also decreases inflammation in the nose. I looked at a series of studies years ago that analyzed all sorts of medications and nasal steroids were by far the best option, and they all had similar efficacy for sleep.”
4. Patients will likely “normalize the behavior.”
“What’s remarkable is how many people don’t ask their patients questions about their nasal breathing,” says Krakow. “Eventually, patients no longer pay attention to whether or not they have a stuffy nose. That’s called ‘normalizing the behavior.’ If the patient is normalizing the behavior, the clinician has to probe and be able to get information out of their patient, or else [the patient] won’t be treated properly and their symptoms will persist.”
5. Multiple effective treatments are available.
“I’m not aware of anything that’ll be as good as nasal steroids coming out in the future,” says Craig. However, he also says that for allergic rhinitis in particular, immunotherapy could definitely be of help in getting patients to breathe and sleep easier. A 2016 study showed that long-term use of subcutaneous allergen immunotherapy was effective in treating seasonal and perennial allergic rhinitis.
Krakow agrees that nasal sprays are the most effective treatment right now. “There are prescription nasal sprays that are very powerful and useful for both allergic and nonallergic. There’s an older drug called Atrovent that many ENTs (ear-nose-throat physicians) use for nonallergic rhinitis and it has a lot of success. So, we have started using that at our practice, and we’ve seen some really positive results. And there is also Azelastine, which is more recent and very popular.”
Dillon Stickle is associate editor for Sleep Review.
1. Kalpaklioglu AF, Kavut AB, Ekici M. Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea. Ann Allergy Asthma Immunol. 2009 Jul;103(1):20-5.
2. Mygind N. Chem Immunol Allergy. 2014;100:62-8.
3. Mayo Clinic Staff. Nonallergic rhinitis. 18 Aug 2017. www.mayoclinic.org/diseases-conditions/nonallergic-rhinitis/diagnosis-treatment/drc-20351235.
4. Krakow B, Foley-Shea M, Ulibarri VA, et al. Prevalence of potential nonallergic rhinitis at a community-based sleep medical center Sleep Breath. 2016; 20:987-93.
5. Cisternas A, Aguilar F, Montserrat JM, et al. Effects of CPAP in patients with obstructive apnoea: is the presence of allergic rhinitis relevant? Sleep Breath. 2017 May 10. [Epub ahead of print]
6. Oktemer T, Alt?ntoprak N, Muluk NB, Senturk M, et al. Clinical efficacy of immunotherapy in allergic rhinitis. Am J Rhinol Allergy. 2016 Sep 1;30(5):4-7.
7. Pakes GE, Brogden RN, Heel RC, et al. Ipratropium Bromide: A Review of its Pharmacological Properties and Therapeutic Efficacy in Asthma and Chronic Bronchitis. Drugs. 1980;20:237-66.
8. Ellis AK, Zhu Y, Steacy LM, et al. A four-way, double-blind, randomized, placebo controlled study to determine the efficacy and speed of azelastine nasal spray, versus loratadine, and cetirizine in adult subjects with allergen-induced seasonal allergic rhinitis. All Asth Clin Immun. 2013;9:16.