View source for Talk:Allergic rhinitis

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{{Vital article|topic=Biology|subpage=Health|level=5|class=C}}
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== Peer Review for bdbwiki1990 ==

Overall I believe the article is solid. It delivers a concise message and chunk of information without being overbearing. I felt that the information provided is all relevant and nothing was distracting. As someone with Allergic rhinitis, I believe it hit the major points that I can think of. I believe it would be understandable to a non-medical person because it is not bogged down by details. It includes hyperlinks for various other pages that can help if someone does not understand the topic.

The article seems neutral and balanced. The only spot where there could be bias is in the alternative medicine section. I like that you included the one study where acupuncture may help a bit, but still reinforce the idea there is not a lot of overall data supporting it. I would carefully look at the last sentence, stating “evidence is poor” and see if that could be reworded to sound less biased. As a medical student myself, I want to reinforce evidence based as well, but this would be an area to look at and make sure the language doesn’t turn people away.

Citations are appropriate throughout the article except for in one section, Steroids for treatment. I believe this section could be improved upon and more sources added for it. Considering that the article states steroids are the preferred treatment, this section should have more information or at least equivalent to the antihistamine section. One other section that could be edited is the Epidemiology section since it is lacking currently. With some more information there, the article is on its way to being much improved thanks to your efforts.

== Medical Student Work Plan ==
So far, most of my research and edits have been focused on the Treatment section (specifically Allergen Immunotherapy and Alternative Medicine), including one new image uploaded. I will continue to expand in this area over the week. In addition, I will also be editing the Diagnosis and Prevention sections. My final edits will be ready for submission by this Friday, 12/6. I do not believe I will edit the Causes section as originally planned-- this section seems to be well covered from the research I have gathered thus far.
[[User:Bdbwiki1990|Bdbwiki1990]] ([[User talk:Bdbwiki1990|talk]]) 16:06, 2 December 2019 (UTC)

I plan to prioritize the following sections: Diagnosis, Prevention, Causes, and Treatment (specifically Allergen Immunotherapy and Alternative Medicine). The immunotherapy section could use greater discussion on efficacy, in particular. The alternative medicine section could be expanded to include many other types of CAM and the most up to date studies regarding these treatments. Further information and comparison between skin testing and blood testing would also be helpful. Finally, I believe there is further discussion to be added on the "atopic triad" and peak pollen seasons with specific populations/regions here. I plan to use the following sources: Access Medicine, Clinical Key, PubMed and Uptodate. 
[[User:Bdbwiki1990|Bdbwiki1990]] ([[User talk:Bdbwiki1990|talk]]) 20:01, 18 November 2019 (UTC)


Sounds like a good plan. Looking forward to seeing your changes. 
--[[User:Emilybrennan|Emilybrennan]] ([[User talk:Emilybrennan|talk]]) 13:58, 25 November 2019 (UTC)

== Disjointed ==

The sentence starting with "Rinsing..." under "Management", is rather disjointed.


The sentance "In cases of allergic rhinitis, the most effective way to decrease allergic symptoms is to completely avoid the allergen." is a really stupid thing to say.
The most effective way to comabat fear of flying, is to never get on an aeroplane..  <small><span class="autosigned">— Preceding [[Wikipedia:Signatures|unsigned]] comment added by [[User:Treva26|Treva26]] ([[User talk:Treva26|talk]] • [[Special:Contributions/Treva26|contribs]]) 09:47, 15 August 2011 (UTC)</span></small><!-- Template:Unsigned --> <!--Autosigned by SineBot-->

==Dietary==
Refs do not support this content.
<blockquote>It is postulated that allergic rhinitis (and other allergies) are the result of [[immune disorders]] and in some cases [[autoimmune disorders]].<ref>[http://findarticles.com/p/articles/mi_m0BUM/is_9_87/ai_n30887052/ Prevalence of autoimmune thyroid disease in chronic rhinitis]</ref>  While the cause of these disorders is not discovered in most patients, clinical experience suggests a dietary root cause, led by chronic tissue inflammation.<ref>[http://linkinghub.elsevier.com/retrieve/pii/0306987794900973 Mild adrenocortical deficiency, chronic allergies, autoimmune disorders and the chronic fatigue syndrome: a continuation of the cortisone story]</ref>  Significant clinical evidence to suggest that diets high in [[carbohydrate]] (especially in individuals with concomitant high [[blood glucose]] levels),<ref>[http://www.jci.org/cgi/content/abstract/116/7/1793 Inflammation and insulin resistance]</ref> high in omega-6 fatty acids (due to metabolism via [[eicosanoid]] pathways) <ref>[http://www.jacn.org/cgi/content/abstract/21/6/495 Omega-3 fatty acids in inflammation and autoimmune diseases]</ref> and high in [[gluten]] contribute directly to autoimmune disorders.<ref>[http://journals.lww.com/jpgn/Abstract/2005/04001/Celiac_Disease_as_a_Model_of_Gastrointestinal.25.aspx Celiac disease as a model of gastrointestinal inflammation]</ref></blockquote> [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) 03:34, 13 March 2011 (UTC)

{{reflist talk}}

== Western  ==

The word "Western" seems to be a euphemism for "european".

== 16 th ==

The Oxford English Dictionary says that the name hay-fever has been used since the 16th century.  <span style="font-size: smaller;" class="autosigned">— Preceding [[Wikipedia:Signatures|unsigned]] comment added by [[Special:Contributions/86.178.220.16|86.178.220.16]] ([[User talk:86.178.220.16|talk]]) 14:10, 29 May 2011 (UTC)</span><!-- Template:UnsignedIP --> <!--Autosigned by SineBot-->

== Allergic rhinitis without specific symptoms ==

Some people have atypical symptoms from allergic rhinitis, such as no or almost no symptoms other than fatigue and malaise.  
I've been looking for a reference that mentions this.  It seems to be common knowledge among the allergists I've seen.  I found a webpage http://thebigl.web.officelive.com/Interpreter/V2/Content/allergic_rhinitis.html which does talk about this.  I'm trying to find the source for their info.

Can anyone come up with a good reference for allergic rhinitis with no or almost no specific symptoms?  

If someone goes to a doctor with fatigue and malaise without other symptoms, allergic rhinitis is a possibility.  And I'd like to see a good reference for that, too.  [[User:Puffysphere|Puffysphere]] ([[User talk:Puffysphere|talk]]) 17:39, 15 January 2012 (UTC)Puffysphere

== Local allergic rhinitis section ==

I made a new section on local allergic rhinitis.

I thought about making a separate page for LAR.  

But the symptoms and treatment of LAR are the same so far as for allergic rhinitis (including allergy shots working!)

So clinically, LAR is a matter of a problem with the current diagnosis of allergic rhinitis - the standard allergy tests can be negative, but you can still have allergic rhinitis from a local allergy.  

Physiologically, LAR is quite interesting.  Classically allergies were supposed to involve the lymph nodes, so finding that an allergy can be generated locally is novel.  This has been dubbed "entopy" (vs atopy).  I don't know what evidence there is for entopy in other places in the body besides the nose (like possibly responsible for delayed food allergies), but an Entopy page would be a good idea.  [[User:Puffysphere|Puffysphere]] ([[User talk:Puffysphere|talk]]) 23:02, 21 January 2012 (UTC)Puffysphere

== Hay in hay-fever ==

"Ironically, in hay fever, there is neither any fever nor any hay, but since grasses shed their pollens into the air, at about the same time that hay is being cut, the common term hay fever is used."

This seems to suggest that hay itself can't cause hay fever? Surely pollen exists within hay?

- I am allergic to hay. It gives me a rash and also makes me sneeze. I have over 100 different allergies, and hay is one of them. My allergy to hay is different to my allergy to pollens though, which simply make me sneeze. My allergy to grass is different again, as that gives me a rash and makes me a sneeze. And my allergy to dust is different again, as it gives me a small but annoying rash isolated around the eyes, causing me to rub them for relief, leading to having red eyes. 

- Put simply, I would say that all of these are distinct and very different types of symptoms. I agree that hay can be a part of it and that it is incorrect to ignore hay as part of allergic rhinitis. 

- It also should be noted that some of my allergies do give me a fever, but those are food allergies. I am sure that in some people allergies to the kinds of things mentioned in this article could lead to fever though. [[Special:Contributions/203.4.164.1|203.4.164.1]] ([[User talk:203.4.164.1|talk]]) 23:35, 22 November 2012 (UTC)

:There were so many problems with that sentence, I changed it. Since hay is not a plant, but an animal feed product made by cutting and drying grasses, a lot of it didn't make sense.

:B.t.w, it's also technically incorrect to say that an allergy to hay, to pollen, and to grass, are three different things, since hay is made of grass, and the allergic reaction is to the pollen of the grass. Certainly though, there could be different reactions to different kinds of pollen and other allergens such as dust, and different ways they come into contact with the body.
:[[User:IamNotU|IamNotU]] ([[User talk:IamNotU|talk]]) 15:28, 29 April 2013 (UTC)

== Anti-histamines ==

The source for this information: 

"First generation antihistamine drugs such as diphenhydramine cause drowsiness, but not second- and third-generation antihistamines such as cetirizine and loratadine.[15]" 

must be suspect as I can truthfully state that cetirizine reduced me to a useless, depressed, sleep-lusting zombie (but a dry-nosed one!) for the several days that I took it this week while living in a pine forest. [[User:EdX20|EdX20]] ([[User talk:EdX20|talk]]) 21:59, 27 May 2012 (UTC)

:I agree, I think drowsiness is mentioned as a possible side effect for "nonsedating" antihistamines, cetirizine is especially bad for that.  Go ahead and find a good reference and modify the article! [[User:Puffysphere|Puffysphere]] ([[User talk:Puffysphere|talk]]) 13:56, 12 February 2013 (UTC)

:: It can be hard to sleep with Hayfever... This might not be a bad thing... There is also a lot of other things that can cause you to become a "zombie"... Tiredness has a lot of Differentials you know... [[Special:Contributions/134.148.64.206|134.148.64.206]] ([[User talk:134.148.64.206|talk]]) 11:58, 9 October 2014 (UTC)

== "Hay fever" NOT "Hayfever" - Be careful! ==

Never ever write "Hayfever" because Google is currently showing that, when Google itself autocorrects to "Hay fever" with a space. Remember EVERYONE looks to Dr Wikipedia so it's important to get it right on here :) [[Special:Contributions/134.148.64.206|134.148.64.206]] ([[User talk:134.148.64.206|talk]]) 12:09, 9 October 2014 (UTC)

== NEJM review ==

[[doi:10.1056/NEJMcp1412282]] [[User:Jfdwolff|JFW]]&nbsp;&#124;&nbsp;[[User_talk:Jfdwolff|<small>T@lk</small>]] 10:08, 3 February 2015 (UTC)

== Causation ==

I would question the statement in the introduction that "Allergic rhinitis is typically caused by environmental allergens". Hay fever is not caused by allergens, it is a reaction to allergens. The evidence appears to be that exposure to allergens when a child reduces the incidence of hay fever in later life. So rather than being caused by allergens, it is more accurate to say that the absence of exposure to environmental allergens when a child can result in a hyper reaction to allergens in adulthood.[[User:Royalcourtier|Royalcourtier]] ([[User talk:Royalcourtier|talk]]) 00:33, 10 November 2015 (UTC)
::Yes good point. Should be triggered rather than caused. [[User:Doc James|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Doc James|talk]] · [[Special:Contributions/Doc James|contribs]] · [[Special:EmailUser/Doc James|email]]) 07:49, 10 November 2015 (UTC)

== Problem in Treatment section ==

This sentence in the ''[[Allergic rhinitis#Treatment|Treatment]]'' section is incorrect: ''Intranasal corticosteroids are the preferred treatment if medications are required, with other options used only if these are not effective.'' I've tried to change it but it's been reverted twice. As I don't wish to edit-war, {{ping|Doc James}} could you comment on how we can solve this issue? I appreciate that ''Antihistamines by mouth are suitable for occasional use with mild symptoms'' has been added, but that now seems somewhat contradictory to the first sentence.

The problem to me is that it's a rather black-and-white and over-general statement that antihistamines are in all cases ''only'' used after a corticosteroid spray has been tried and failed. That doesn't reflect the real-world situation - nor does it accurately reflect the source. The source does give the recommendation that "The initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone, with the use of second-line therapies for moderate to severe disease."<ref name=AFP10>{{cite journal |vauthors =Sur DK, Scandale S |title=Treatment of allergic rhinitis |journal=Am Fam Physician |volume=81 |issue=12 |pages=1440–6 |date=June 2010 |pmid=20540482 |url=http://www.aafp.org/link_out?pmid=20540482}}</ref> However, at the end of the source article, there is a chart that clearly shows second-generation antihistamines being the ''first'' choice for mild intermittent symptoms. This is also the case in other treatment recommendations such as from the British Society for Allergy and Clinical Immunology,<ref>{{cite journal |last1=Angier |first1=Elizabeth |last2=Willington |first2=Jenny |last3=Scadding |first3=Glenis |last4=Holmes |first4=Steve |last5=Walker |first5=Samantha |title=Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline |journal=Primary Care Respiratory Journal |date=2 August 2010 |volume=19 |issue=3 |pages=217–222 |doi=10.4104/pcrj.2010.00044 |url=https://www.siaip.it/upload/BSACIsummary-rhinitis.pdf|accessdate=12 April 2018}}</ref> which the source cites in giving its recommendation. It's likely that for more persistent symptoms like hay fever, nasal steroid spray should be the first-line treatment. But consider someone with pet dander allergies, who is normally not exposed to the allergen. If they visit a friend or family with a pet, antihistamine tablets may well be the preferred treatment. In addition to rapid action, there may be factors of cost, availability, and convenience.

Second, the source is describing a treatment ''recommendation'' supported by the [[AAFP]]. It is not universally accepted, and does not necessarily reflect actual practice. At least one study concluded that, although it may be misguided, "Physicians prefer and more often use combination treatment with oral antihistamines and intranasal corticosteroids, regardless of the frequency and intensity of allergic rhinitis".<ref>{{cite journal |first1=A. |last1=Navarro |first2=A. |last2=Valero |first3=M. J. |last3=Rosales |first4=J. |last4=Mullol |title=Clinical use of oral antihistamines and intranasal corticosteroids in patients with allergic rhinitis |url=http://www.jiaci.org/issues/vol21issue5/4.pdf |journal=Journal of Investigational Allergology & Clinical Immunology |date=2011 |issn=1018-9068 |pages=363–369 |volume=21 |issue=5 |pmid=21905499}}</ref> The sentence presents one recommendation about how nasal allergies ''should'' be treated, as a fact about how they ''are'' treated in general. --[[User:IamNotU|IamNotU]] ([[User talk:IamNotU|talk]]) 01:22, 12 April 2018 (UTC)

::Ref says "Intranasal corticosteroids are the most effective treatment and '''should be first-line therapy for mild to moderate disease'''. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation)."[https://www.aafp.org/afp/2010/0615/p1440.html]
::We should stick to review articles per [[WP:MEDRS]].
::The ref does say "In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Because their onset of action is typically within 15 to 30 minutes and they are considered safe for children older than six months, antihistamines are useful for many patients with mild symptoms requiring “as needed” treatment."
::Does not contradict that steroids are first line. [[User:Doc James|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Doc James|talk]] · [[Special:Contributions/Doc James|contribs]] · [[Special:EmailUser/Doc James|email]]) 14:50, 12 April 2018 (UTC)

:::In addition to the mild-moderate-severe axis, there is the intermittent-persistent axis. The ref also gives an "algorithm for the treatment of allergic rhinitis", which shows '''Mild intermittent symptoms --> Second-generation oral or intranasal antihistamine, as needed'''. [[WP:MEDRS]] also lists as "ideal sources", "medical guidelines and position statements from national or international expert bodies" such as the BSACI guidelines cited by the AAFP source. Reliance on a single source when there are other reliable ones that contradict it (and certainly when the ''source itself'' contradicts the statement in the article!) may violate [[WP:NPOV]] in presenting medical/scientific consensus per [[WP:MEDSCI]] - especially when ''all three'' guidelines (BSACI, IPCRG, and JTFPP) cited by the AAFP, in support of the "initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone" recommendation, in fact say that for mild ''intermittent'' symptoms, antihistamines are first line - as does the AAFP guideline itself... --[[User:IamNotU|IamNotU]] ([[User talk:IamNotU|talk]]) 15:44, 21 April 2018 (UTC)

:::Actually, I found that there's an updated version of the reference, which now reads "Intranasal corticosteroids are the most effective treatment and '''should be first-line therapy for persistent symptoms affecting quality of life.''' More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation."[https://www.aafp.org/afp/2015/1201/p985.html] Exactly what I was saying. Also, the algorithm chart showing antihistamines as first line treatment for mild intermittent symptoms is much more prominent. I've replaced the citation in the article and edited the text accordingly. --[[User:IamNotU|IamNotU]] ([[User talk:IamNotU|talk]]) 20:57, 21 April 2018 (UTC)


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== Local allergenic rhinitis and nasal challenge ==

Updated the article to mention that this is mostly a European thing [https://en.wikipedia.org/enwiki/w/index.php?title=Allergic_rhinitis&diff=893247741&oldid=893066975]. Spoke to an practicing allergenist loosely affiliated with the top West Coast United States hospital ([[University of California, San Francisco]]) in the United States (San Francisco) and he had never heard of nasal challenges, altho he was kind enough to peruse some of the material I provided. From reading something like [https://onlinelibrary.wiley.com/doi/full/10.1111/all.13416 EAACI Position paper on the standardization of nasal allergen challenges] you'd think this was pretty standard ("In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental", but apparently not. The lack of use in the United States was also noted in 2005 at [https://www.ncbi.nlm.nih.gov/pubmed/15744168 Nasal provocation testing as an international standard for evaluation of allergic and nonallergic rhinitis.]. Further, [[The Regence Group]] won't cover it as it is listed in [http://blue.regence.com/trgmedpol/lab/lab01.pdf "Allergy Tests of Uncertain Efficacy"]. Aetna similarly considers it investigational [http://www.aetna.com/cpb/medical/data/1_99/0038.html]. Not that insurers are the best authorities on medical evidence. [[User:ImperfectlyInformed|<span style="font-family: Times">II</span>]] | ([[User_talk:ImperfectlyInformed|t]] - [[Special:Contributions/ImperfectlyInformed|c]]) 02:21, 20 April 2019 (UTC)

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