Eosinophilic rhinitis (NARES) management
Eosinophilic nonallergic rhinitis with nasal eosinophilia (NARES) is characterized by prominent perennial rhinorrhea and sneezing with nasal eosinophilia and without evidence of IgE-mediated allergy. [1] Management is based on confirmation of the diagnosis, exclusion of important alternative causes of persistent nasal eosinophilia, and treatment with corticosteroids because NARES is particularly corticosteroid responsive. [1]
Diagnostic clarification to guide treatment
NARES should be considered in patients with nonallergic symptoms with prominent perennial rhinorrhea and sneezing in the absence of facial pain, nasal obstruction, and rhinosinusitis with nasal polyps, with sinus mucosal thickening not present at the time of evaluation. [1] The differential diagnosis for persistent nasal eosinophilia includes allergic rhinitis with positive skin or serum IgE testing, local allergic rhinitis, rhinosinusitis with nasal polyps, chronic rhinosinusitis without polyps, eosinophilic granuloma, allergic fungal rhinosinusitis, and NSAID-exacerbated respiratory disease. [1] NARES diagnostic criteria in guidelines have not converged on a single required eosinophil threshold for nasal eosinophilia, with proposed lower limits ranging from 5% to 25% depending on specimen type. [1]
Medication selection algorithm
Intranasal corticosteroids are the primary pharmacologic therapy for NARES due to corticosteroid responsiveness. [1] Oral leukotriene receptor antagonists may be considered based on limited evidence showing symptom improvement in a small uncontrolled study in subjects with NARES and asthma. [1] Intranasal cromolyn is not recommended for NARES due to lack of benefit in a study of NARES. [1]
Corticosteroid-based therapy
NARES is particularly responsive to corticosteroids. [1] Topical nasal corticosteroids are first-line therapy for moderate to severe persistent rhinitis in general rhinitis management frameworks, including allergic and non-allergic phenotypes. [2]
Adjunct and alternative pharmacotherapy
Montelukast 10 mg daily reduced nasal obstruction, rhinorrhea, sneezing, and nasal pruritus in an uncontrolled study that included subjects with NARES and asthma. [1] Intranasal cromolyn was studied in NARES and found to have no benefit. [1]
Initiation criteria and clinical triggers for treatment escalation
Corticosteroid therapy should be initiated when symptoms are consistent with NARES (nonallergic persistent rhinorrhea and sneezing) and when NARES is supported by nasal eosinophilia or notable response to nasal steroids. [1] Escalation toward additional therapies (for example, an adjunct leukotriene receptor antagonist) is considered when symptoms persist despite corticosteroid therapy, and when comorbid asthma and a NARES phenotype are present. [1]
Common pitfalls to avoid
NARES should not be diagnosed without exclusion of alternative causes of persistent nasal eosinophilia, including chronic rhinosinusitis with or without nasal polyps and NSAID-exacerbated respiratory disease. [1] Intranasal cromolyn should not be used as a disease-specific therapy for NARES because it has not demonstrated benefit. [1]
Treatment goals for symptom control and disease linkage
The primary clinical objective is reduction of NARES-associated nasal symptoms, including rhinorrhea, sneezing, and nasal congestion, with documented corticosteroid responsiveness supporting this approach. [1] Ongoing evaluation for comorbid or evolving airway disease is relevant because NARES has associations with asthma and chronic rhinosinusitis with nasal polyps in systematic evaluations. [1]