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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References:

 

Skoner DP.  Allergic Rhinitis: Definition, epidemiology, pathophysiology, detection and diagnosis.  J Allergy Clin Immunol, 2001;108:S2-8.

 

Fletcher RH.  An overview of rhinitis. UpToDate.  Online version 17.2 last updated: Dec 7, 2007.

 

Whitton RC.  Medical disqualification in USAF pilots and navigators.  Aviation Space Environ Med. 1984;55(4):332-6.

 

Edwards RJ, Price DR.  Descriptive analysis of medical attrition in US Army aviation.  Aviation Space Environ Med. 1989;60(7):A92-7.

 

Mason KT.  US Army aviation epidemiology data register: Descriptive analysis of medical disqualifications among female army aviator training applicants. USAARL Report No. 95-16. February 1995:1-19.

 

6.  Ungs TJ.  Extent and etiology of duty restriction at a US Coast Guard air station.  Aviation Space Environ Med. 1991;62:974-7.

 

Quillen DM, Feller DB.   Diagnosing rhinitis: Allergic vs. nonallergic.  Am Fam Physician. 2006;73:1583-90.

 

Lambert M.  Practice parameters for managing allergic rhinitis.  Am Fam Physician. 2009;80:79-85.

 

Weber RW.  Allergic rhinitis.  Prim Care Clin Office Practice. 2008;35:1-10.

 

Abramowicz MD(ed).  Drugs for allergic disorders.  Treatment Guidelines from the Med Letter. 2007;5(60):71-80.

 

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