Clinical Practice Guideline
for
ALLERGIC RHINITIS
Developed for the
Aerospace
Medical Association
by their constituent organization
American
Society of Aerospace Medicine Specialists
Overview: Allergic rhinitis is usually
considered a relatively minor health condition.
However, it can result in major adverse effects in aviators in light of
the unique environmental and physical stresses of flight. It is the most common of allergic disorders,
affecting an estimated 20 to 40 million people in the United States and up to
30% of adults worldwide. For the average
person, allergic rhinitis is a nuisance; for aircrew it can be a serious and
potentially fatal condition. For the
period from 1980 to 1981, allergic rhinitis represented 2% of disqualifying
defects in a study of 304 USAF aircrew removed from flying status and 9% of
disqualifications in the 20-29 year age group.
A similar study in the US Army aviation corps demonstrated a 2.2%
rejection rate for initial flying training and 0.8% disqualification of trained
aviators. Additionally, in a population
of US Army female aviator applicants between 1987 and 1990, 4.1% were
disqualified due to allergic rhinitis.
Qualified aircrew can also be adversely affected by allergic rhinitis;
the condition can diminish active flying operations and readiness through
temporary flying duty restrictions. One
study at a US Coast Guard air station found 5.7% of total days restricted
attributed to allergic causes (allergic rhinitis and asthma). Currently, the modes of therapy acceptable
for flying duty (intranasal steroids and mast-cell stabilizers, some
second-generation antihistamines, leukotriene modifier [montelukast] and
immunotherapy) are generally effective.
However, the actual impact of allergic rhinitis on mission effectiveness
in terms of temporary flying duty restriction is unknown.
Allergic
rhinitis often occurs seasonally in direct response to elevated airborne
pollens but can also exist perennially. A family history of allergies is often
present. The symptoms of common “hay
fever” include nasal pruritus, congestion, rhinorrhea, sneezing, eye irritation
and pruritus, and coughing. Clinical
findings include edematous or inflamed nasal mucosa, increased nasal secretion
(which is typically clear), and conjunctival edema and erythema. Difficult cases may require skin tests to
allergens and examination of nasal secretions for eosinophilia. However, in most cases the appropriate
diagnosis can be made on the basis of a careful medical history, thorough
clinical exam, and a documented response to appropriate therapeutic
intervention. The differential diagnosis
includes viral upper respiratory infection (URI), non-allergic rhinitis,
sinusitis and side effects of medications including ovarian hormones and
nonsteroidal anti-inflammatory agents.
Abuse of decongestant nasal sprays and anatomic deformity should also be
excluded as a cause of chronic congestion and obstruction. In cases of prolonged or moderate to severe
symptoms a formal allergy consultation may be appropriate.
Topical
drug therapy for mild to moderate symptoms of allergic rhinitis consists of
intranasal delivery of topical steroids or cromolyn sodium. The steroids act as local anti-inflammatory
agents and cromolyn stabilizes mast cells.
These agents are very effective but may take several days to reach the
desired effect. Intranasal steroids are
widely accepted as the most effective and preferred first-line treatment for
allergic rhinitis. Oral antihistamines
are another choice for acute and chronic control of allergic rhinitis. Antihistamines competitively inhibit binding
of histamine to H1 receptors.
Fexofenadine (Allegra®), or loratadine
(Claritin®) (10mg dose only) are the only aeromedically approved
second-generation antihistamines.
Because these medications are larger molecules they do not cross the
blood-brain barrier and are considered non-sedating antihistamines. Loratadine at doses higher then 10mg per day
can cross the blood-brain barrier and is therefore not approved at these doses
for use in USAF aviators. Montelukast
(Singulair®) has shown modest control of allergic rhinitis and is a safe
drug. If a patient responds poorly to
nasal spray, antihistamines or montelukast, immunotherapy may then be
considered. Immunotherapy carries a
higher risk of serious adverse reaction and the initiation and maintenance of
treatment are more complicated than with nasal spray or antihistamine.
Aeromedical Concerns: Potential hazards include:
ear and sinus barotrauma with potential in-flight incapacitation; airway
compromise; discomfort and distraction; reduced sense of smell; and possible
use of easily accessible, unauthorized over the counter medication. Symptomatic allergies with sneezing could be
a particular hazard in high speed, low level flight. Barotrauma as well as infectious
complications can lead to prolonged periods of flying restriction, reducing
operational effectiveness and mission effectiveness.
Antihistamines
may adversely influence cognition and performance; hence, ground testing prior to
acceptance for operational use is required.
Idiosyncratic reactions need to be excluded for any selected mode of
therapy. Additionally, symptomatic
control should be achieved. Because of
the risk of an allergic reaction to an immunotherapy injection, the flyer
should remain in the physician’s office for approximately 30 minutes
post-injection. Grounding is required
until potential idiosyncratic reaction is ruled out and adequate control is
maintained before submission for a waiver.
Once a waiver has been granted a 4-hour verbal grounding may be required
for aircrew after each injection.
Medical
Work-up: Proper evaluation for an aviator prior to
consideration of a waiver includes a good history of symptoms to include all
treatments (to include any possible skin testing and allergy shots) and effect
of symptoms on their everyday life and job, particularly the aviation-related
duties. The physical examination should
focus on ears, nose, eyes, pharynx and lungs.
The aviator needs to assure that he or she is using medication that is
approved by their military service or the FAA.
There needs to be documentation that the allergic symptoms are greatly
improved or resolved on therapy and that there are no side effects from
therapy. If applicable, a report from
the treating allergist would be very helpful.
Aeromedical
Disposition:
Air
Force: Historically,
the waiver approval rate for allergic rhinitis has exceeded 99%. The AFMOA Policy Letter, “Nasal Steroids and
Nasal Cromolyn Sodium Use in Aviators”, dated May 2001, approved the use of topical
nasal steroids or cromolyn for the treatment of mild allergic,
non-allergic or vasomotor rhinitis without
a waiver. The length of DNIF is
dictated by the time required for control of underlying symptoms. In July 2004, the HQ USAF/SGOP Policy Letter,
“Medication Changes for Aviators and Special Duty Personnel”, approved the use of loratadine (Claritin®) or fexofenadine
(Allegra®) for the treatment of mild allergic rhinitis without a waiver. A minimum of 72 hours as a ground trial at
initiation of therapy to ensure adequate symptom control and to exclude
idiosyncratic reactions is required.
Loratadine is limited to a maximum dosage of 10 mg per day. In Sep 2006, the ACS released a memorandum
for AFMOA in support of the leukotriene modifier, montelukast, for use in
allergic rhinitis. However, despite its
favorable safety profile, local waiver delegation was not recommended because
its primary indication is for asthma.
IAW
AFI 48-123, a waiver is required for FC
II, IIU and III duties for allergic rhinitis unless it is mild in
degree. For seasonal cases only
requiring approved antihistamines, montelukast, or nasal steroids, a waiver is
not required. A waiver for medical
therapy is necessary only for the use of immunotherapy (desensitization) and these will not be indefinite. A verified history of allergic, non-allergic
and vasomotor rhinitis after age 12, unless symptoms are mild and controlled by
a single approved medication, is disqualifying for FC I/IA. Therefore, a waiver is required for FC I and IA duties for allergic rhinitis
successfully treated with approved second-generation antihistamines, topical
medications, montelukast or immunotherapy.
The use of Claritin-D® or Allegra-D® is not approved for flying duties.
Army: History of allergic rhinitis or
vasomotor rhinitis requiring the use of antihistamines for a cumulative period
greater than 30 days per year is disqualifying according to AR 40-501 Standards
of Medical Fitness. The aeromedical
disposition for Army aircrew is discussed in the Aeromedical Policy Letter
Allergic/Nonallergic Rhinitis. Mild
seasonal or perennial allergic rhinitis, treated successfully with short acting
decongestants, non-sedating antihistamines, leukotriene modifiers, and/or intranasal
steroids without side effects or adverse reactions will be noted, but not
require waiver. Waivers must be
requested for applicants and rated crew who have required systemic steroids,
immunotherapy within a 5-year period to application, or have a history of sinus
surgery to include polyp removal.
Fexofenadine (Allegra), and Loratadine (Claritin) constitute the
recommended first line treatment for mild disease (all other antihistamines are
non-waiverable including Cetirizine (Zyrtec)). Immunotherapy
may be used while the aviator remains on flight status provided he (or
she) remains relatively asymptomatic without the use of antihistamines. Aviation personnel should be grounded 12 hours
following immunotherapy injection.
Navy: Information required:
1.
Documentation of diagnosis on SF 88/93
2.
Nasal speculum exam
3.
Waters’ view x-ray (only x-ray report needs to be submitted, not actual films)
If the conditions outlined above conditions aren't met, then
the allergic rhinitis is presumably more complicated and the member is not
physically qualified (NPQ). Depending on the reason for disqualification, a
waiver may or may not be considered. In these cases, the following information
is also required for waiver consideration:
1.
ENT and/or Allergy consultation
2.
Results of any further tests that have been performed, such as sinus CT
Vasomotor
rhinitis, which causes significant disability, will require the same
documentation as for allergic rhinitis. If the member is felt to be NPQ, then
the Allergic Rhinitis Worksheet (available on the US Navy Aeromedical
Reference and Waiver Guide) may be helpful in assuring that all useful
information is collected for waiver.
Civilian:
The FAA allows allergic rhinitis as a condition. If the condition was severe and absolutely
required the use of daily sedating type antihistamines then they would not
permit the airman to obtain an authorization for special issuance. The FAA
permits the use of desensitization injections.
They accept the use of the medications Claritin (loratadine) and
Clarinex (desloratadine) as they are non-sedating. Nasal steroids are also acceptable. If the condition is controlled an
authorization is not generally required.
Waiver
Experience:
Air Force: A
review of AIMWTS revealed 1,049 submitted cases with a history of allergic
rhinitis. There were 169 FC I cases, 478
FC II cases and 402 FC III cases. There
were a total of 54 disqualifications. Of
those disqualified, 14 (26%) were trained assets. None of the disqualifications were due to the
allergic rhinitis but rather some other medical or administrative condition.
Army:
The
Aeromedical Epidemiological Data Repository (AEDR) catalogs all Army flight
physicals since 1960.
There have been approximately 160,000 individual aircrew entered
in this database. During this period of
time, there have been 531 aeromedical summaries submitted for allergic rhinitis
on behalf of applicants. Of those 69
were denied exceptions to policy. There
were an additional 607 rated aviators with this disease of which 10 were denied
waiver.
Navy: Precise
statistics are not available at this time.
Civilian:
As of June 30, 2010 there are currently issued: 3,153 first-, 1, 942
second-, and 5,739 third-class airmen with this condition for a total of 10,834.
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RH. An overview of
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RJ, Price DR. Descriptive
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KT. US Army aviation epidemiology data
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rhinitis. Am Fam Physician. 2009;80:79-85.
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RW. Allergic rhinitis. Prim Care Clin Office Practice. 2008;35:1-10.
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Kay
GG. The effects of
antihistamines on cognition and performace. J Allergy Clin Immunol. 2000;105:S622-7.
AFMOA
Policy Letter, “Nasal Steroids and Nasal Cromolyn Sodium Use in Aviators,” 31
May 2001.
HQ
USAF/SGOP Policy Letter, “Medication Changes for Aviators and Special Duty
Personnel,” 15 July 2004.
USAFSAM/FECI
Memorandum, “Montelukast (Singulair®),” 20 September 2006.
Prepared
by Drs. Valerie Johnson and Dan Van Syoc
Date:
September 26, 2010