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Allergic rhinitis

Highlights

Allergic Rhinitis

Allergic rhinitis is the way some people respond to outdoor or indoor allergens:

Allergic rhinitis tends to run in families. If one or both parents have allergic rhinitis, there is a high likelihood that their children will also have allergic rhinitis. People with allergic rhinitis have an increased risk of developing asthma and other allergies. They are also at risk for developing sinusitis, sleep disorders (including snoring), nasal polyps, and ear infections.

Symptoms

Common symptoms of allergic rhinitis include:

Treatment

Home remedies for allergic rhinitis include nasal washes with saline solution. Many different over-the-counter and prescription drugs are used to treat allergic rhinitis. These medications include oral and nasal antihistamines, corticosteroid nasal sprays, cromolyn, leukotriene antagonists such as montelukast (Singulair, generic), and decongestants. Many of these drugs have side effects. Immunotherapy (allergy shots or under-the-tongue tablets) may also be an option for some patients.

Prevention

In addition to avoiding exposure to allergy triggers, people with allergic rhinitis can take precautions to control their environment. These measures include bathing pets weekly, using vacuum cleaners and air conditioners with high-efficiency particulate air (HEPA) filters, frequent washing of bedding and curtains, reducing humidity in the house, and removing sources of mold.

Sublingual Immunotherapy Approved in the United States

Sublingual therapy uses under-the-tongue dissolving tablets that contain allergen extracts. It is an alternative to subcutaneous immunotherapy (allergy shots) and is widely used in many countries, but until recently was not approved in the United States.

In 2014, the FDA approved the first three sublingual immunotherapy products for treating allergic rhinitis:

Drug Approval

In 2013, the FDA approved triamcinolone (Nasacort Allergy 24H), the first over-the counter (OTC) nasal steroid spray for the treatment of allergic rhinitis. It will be available without a prescription for patients age 2 and older.

Introduction

Rhinitis is inflammation of the mucous membranes of the nasal passages. It results from severe nasal congestion or other changes that irritate the nose.

Allergic rhinitis is caused by a substance (allergen) that triggers an allergic response. As part of the allergic response, the body's immune system launches a defensive attack by releasing histamine and other chemicals.

Allergic rhinitis is generally classified as either:

Allergens involved in allergic rhinitis come from either outdoor or indoor substances:

Rhinitis can also be due to non-allergic causes, such as infections, temperature changes, hormonal changes, certain medications, cigarette smoke, stress, exercise, structural problems in the nose, or other factors. In non-allergic rhinitis, the immune system does not play a role in the body's response to these factors.

Basic symptoms of both allergic and non-allergic rhinitis include:

Allergic rhinitis

Causes

The allergic process, called atopy, occurs when the body overreacts to a substance that it senses as a foreign invader. The immune system works continuously to protect the body from potentially dangerous intruders such as bacteria, viruses, and toxins. However, for reasons not completely understood, some people are hypersensitive to substances that are typically harmless.

When the immune system inaccurately identifies these substances (allergens) as harmful, an allergic reaction and inflammatory response occurs.

There are many types of IgE antibodies, and each is associated with a specific allergen. This is why some people are allergic to cat dander, while others are not bothered by cats yet are allergic to pollen. In allergic rhinitis, the allergic reaction begins when an allergen comes into contact with the mucous membranes in the lining of the nose.

Seasonal allergic rhinitis occurs only during periods of intense airborne pollen or spores. It is commonly, although inaccurately, called hay fever. No fever accompanies this condition, and the allergic response is not dependent on hay. In general, triggers of seasonal allergy in the U.S. include:

Allergies

Allergens in the House. Allergens in the home are the most common triggers of perennial (year-round) allergic rhinitis. Household allergens include:

Risk Factors

Allergic rhinitis usually first appears in childhood or early adulthood but it can affect people of all ages.

Allergic rhinitis appears to have a genetic component. People with a parent who has allergic rhinitis have an increased risk of developing allergic rhinitis themselves. The risk increases significantly if both parents have allergic rhinitis.

Home or workplace environments can increase the risk for exposure to allergens (mold spores, dust mites, and animal dander) associated with allergic rhinitis.

Exclusively breastfeeding for the first 4 months of life appears to help prevent or delay allergies in high-risk infants. It is not clear whether breastfeeding helps prevent the development of allergic rhinitis. There is some evidence that breastfeeding may help prevent wheezing and other symptoms of asthma, a condition that is sometimes associated with allergic rhinitis.

Prognosis

Seasonal allergic rhinitis tends to diminish as a person ages. The earlier the symptoms start, the greater the chances for improvement. People who develop seasonal allergic rhinitis in early childhood tend not to have the allergy in adulthood. In some cases, allergies go into remission for years and then return later in life. People who develop allergies after age 20, however, tend to continue to have allergic rhinitis at least into middle age.

Complications

Asthma and allergies often coexist. Patients with allergic rhinitis often have asthma or are at increased risk of developing it. Allergic rhinitis is also associated with eczema (atopic dermatitis), an allergic skin reaction characterized by itching, scaling, and red swollen skin. Chronic uncontrolled allergic rhinitis can worsen asthma attacks and eczema.

Although allergic rhinitis is not considered a serious condition, it can interfere with many important aspects of life. Nasal allergy sufferers often feel tired, miserable, or irritable. Allergic rhinitis can interfere with work or school performance.

People with allergic rhinitis, particularly those with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. Often they attribute this to allergy medication, but congestion may be the cause of these symptoms. Patients who have severe allergic rhinitis tend to have worse sleep problems, including snoring, than those with mild allergic rhinitis.

Any chronic rhinitis, whether allergic or non-allergic, can cause swelling in the turbinates, which may become persistent (turbinate hypertrophy). The turbinates are tiny, shelf-like bony structures that project into the nasal passageways. They help warm, humidify, and clean the air that passes over them. If turbinate hypertrophy develops, it causes persistent nasal congestion and, sometimes, pressure and headache in the middle of the face and forehead. This condition may require surgery.

Other possible complications of allergic rhinitis include:

Symptoms

Symptoms of allergic rhinitis often occur in two phases, early and late.

Early Phase Symptoms. The early phase occurs within minutes of exposure to the allergen and includes:

Late-Phase Symptoms. Symptoms that may develop several hours or later after exposure include:

A newer classification system groups allergic rhinitis by how long symptoms last and how severe they are:

Diagnosis

In most cases, a doctor can diagnose allergic rhinitis based on the patient's symptoms. Your doctor will take your medical history and will ask about:

The doctor may examine the inside of the nose with an instrument called a speculum. This is a painless procedure that allows the doctor to check for redness and other signs of inflammation. The doctor will also usually check the eyes, ears, and chest.

Allergy testing may be used to confirm an allergic trigger identified by symptoms. A skin test is a simple method for detecting common allergens. Patients are usually tested for a panel of common allergens. Skin tests are rarely needed to diagnose milder seasonal allergic symptoms before treatment is tried. Skin tests are not completely accurate and are not appropriate for children younger than age 3.

The procedure is as follows:

In most situations, before getting tested, patients will try to avoid their known allergens. They also will try medications, including nasal corticosteroid sprays. Patients with more severe symptoms, particularly those with asthma, significant eczema, or nasal polyps, may benefit from earlier skin testing.

Nasal Smear. The doctor may take a nasal smear. The nasal secretion is examined under a microscope for increased white blood cell counts (indicating infection), or high eosinophil counts (indicating an allergic condition -- but low counts do not rule out allergic rhinitis).

Tests for IgE. Blood tests for IgE immunoglobulin production may also be performed. Newer enzyme-based assays using IgE antibodies have replaced the older radioallergosorbent test (RAST). IgE tests detect increased levels of allergen-specific IgE in response to particular allergens. Blood tests for IgE may be less accurate than skin tests. They should be performed only on patients who cannot undergo skin testing or when skin test results are uncertain.

In some cases of chronic or unresponsive seasonal rhinitis, a doctor may use endoscopy to look for irregularities in the nose structure. Endoscopy inserts a tube containing a miniature camera through the nose to view the passageways.

Rhinitis always precedes and accompanies sinusitis, which is inflammation or infection of the mucous lining of the sinuses. Acute sinusitis usually clears up on its own. Chronic sinusitis can be more difficult to treat.

Allergic rhinitis also needs to be distinguished from the cold or flu:

Treatment

Patients with allergic rhinitis have many treatment options available to them:

All drug treatments have side effects. Some side effects are very unpleasant and, in rare cases, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Treating mild allergy attacks usually involves little more than reducing exposure to allergens and using a nasal wash. Medications may also be used. Most medications for mild allergic rhinitis are available without a prescription.

Treatments for mild allergic rhinitis include:

For people with moderate-to-severe seasonal allergies, doctors recommend:

Patients with perennial (year-round) allergic rhinitis or those who have bothersome symptoms that are active during most of the year may require daily medications. This is especially true if patients also have asthma.

Drug treatments for moderate-to-severe allergic rhinitis include:

For mild allergic rhinitis, a nasal wash can help remove mucus from the nose. You can purchase a saline solution at a drug store or make one at home (2 cups of warm water, a teaspoon salt, and a pinch of baking soda). If you prepare your own saline solution, use bottled or boiled water, not plain tap water.

Here is a simple method for administering a nasal wash:

Neti pots have also become popular in recent years for prevention and treatment of allergic rhinitis. To do nasal irrigation with a saline solution through a Neti pot:

Antihistamine pills can sometimes help itching and redness in the eyes. Eye drops provide faster relief, and a combination of the two may be best. Eye drops for itchy eyes include:

General Side Effects and Warnings:

Some patients with allergies report symptom relief through modalities such as acupuncture and Chinese herbal medicine. While some studies have reported symptom improvement with these therapies, it is not clear if this is due to a placebo effect.

Medications

Histamine is one of the chemicals released when antibodies overreact to allergens. It is the cause of many symptoms of allergic rhinitis. Antihistamine drugs can help relieve:

If possible, take an antihistamine before an anticipated allergy attack.

Many antihistamines are available. They include short-acting and long-acting forms, and come in oral pill and nasal spray forms.

Antihistamines are generally categorized as first and second generation. First-generation antihistamines, which include diphenhydramine (Benadryl, generic) and clemastine (Tavist, generic) cause more side effects (such as drowsiness) than most newer second-generation antihistamines. For this reason, second-generation antihistamines are generally preferred and recommended over first-generation antihistamines.

Here are some notes of caution when taking any antihistamine:

Second-generation antihistamines are sometimes referred to collectively as nonsedating antihistamines. However, cetirizine (Zyrtec, generic) and the nasal spray antihistamines (Astelin, Patanase) may cause drowsiness when taken at recommended doses. Loratadine (Claritin, generic) and desloratadine (Clarinex) can cause drowsiness when taken at doses exceeding the recommended dose.

Brand Names. Second-generation antihistamines in pill form include:

Second-generation antihistamines in nasal form are as good as, or better than the oral forms for treating seasonal allergic rhinitis. However, they can cause drowsiness, and they are not as effective for allergic rhinitis as nasal corticosteroids. Nasal spray antihistamines are available by prescription and include:

In 2013, the FDA approved a liquid form of antihistamine for treatment of seasonal and perennial allergic rhinitis. Carbinoxamine maleate (Karbinal ER) is approved for patients age 2 and older.

Side Effects and Precautions.

Corticosteroids help reduce the inflammatory response associated with allergic reactions. Nasal-spray corticosteroids (commonly called steroids) are considered the most effective drugs for controlling the symptoms of moderate-to-severe allergic rhinitis. They are often used alone or in combination with second-generation oral antihistamines.

The benefits of nasal spray steroids include:

Nasal-Spray Brands. Corticosteroids available in nasal spray form include:

Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas and has less risk for widespread side effects, unless the drug is used excessively. Side effects of nasal steroids may include:

Possible Long-Term Complications. All corticosteroids suppress stress hormones. This effect can produce some serious long-term complications in people who take oral steroids. Researchers have found far fewer concerns with nasal administration or inhaled forms, but there may still be certain problems, including:

Cromolyn is both an anti-inflammatory drug and a specific blocker for allergens. The standard cromolyn nasal spray (NasalCrom, generic) is not as effective as steroid nasal sprays, but it does work well for many people with mild allergies. It is one of the preferred first-line therapies for pregnant women with mild allergic rhinitis. It may take up to 3 weeks to experience the full benefit.

Side Effects. Cromolyn has no major side effects, but minor ones include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat. The spray can cause burning or irritation.

Leukotriene antagonists are oral drugs that block leukotrienes, powerful immune system factors that cause airway constriction and mucus production in allergy-related asthma. They appear to work as well as antihistamines for treatment of allergic rhinitis, but are not as effective as nasal corticosteroids.

Leukotriene antagonists include zafirlukast (Accolate, generic) and montelukast (Singulair, generic). These drugs are mainly used to treat asthma. Montelukast is also approved to treat seasonal allergies and indoor allergies.

The FDA warns that these drugs have been associated with behavior and mood changes, including agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking and behavior. Patients who take a leukotriene antagonist drug such as montelukast should be monitored for signs of behavioral and mood changes. Doctors should consider discontinuing the drug if patients exhibit any of these symptoms.

Decongestants work by shrinking blood vessels in the nose. Many over-the-counter decongestants are available, which can be either taken by mouth or applied to the nose.

Nasal Decongestants. Nasal-delivery decongestants are applied directly into the nasal passages with a spray, gel, drops, or vapors. Nasal decongestants come in long-acting or short-acting forms. The effects of short-acting decongestants last about 4 hours. Long-acting decongestants last 6 to 12 hours. The active ingredients in nasal decongestants include oxymetazoline, xylometazoline, and phenylephrine. Nasal forms work faster than oral decongestants and may not cause as much drowsiness. However, they can cause dependency and rebound congestion.

The major problem with nasal-delivery decongestants, particularly long-acting forms, is the cycle of dependency and rebound effects. The 12-hour brands pose a particular risk for this effect.

The following precautions are important for people taking nasal decongestants:

Oral Decongestants. Oral decongestants also come in many brands, which have similar ingredients. The most common active ingredients are pseudoephedrine (Sudafed, other brands, generic) and phenylephrine, sometimes in combination with an antihistamine. Oral decongestants can cause side effects such as insomnia, irritability, nervousness, and heart palpitations. Taking pseudoephedrine in the morning, as opposed to later in the day or before bedtime, can help patients avoid these side effects.

Individuals at Risk for Complications from Decongestants. People who may be at higher risk for complications are those with certain medical conditions, including disorders that make blood vessels highly susceptible to contraction. Such conditions include:

No one with these conditions should use oral or nasal decongestants without a doctor's guidance. Other people who should not use decongestants without first consulting a doctor include:

Decongestants can cause dangerous interactions when combined with certain types of medications, such as the antidepressant MAO inhibitors. They can also cause serious problems when combined with methamphetamines or diet pills. Be sure to tell your doctor about any drug or herbal remedy you are taking. Caffeine can also increase the stimulant side effects of pseudoephedrine.

Ipratropium bromide (Atrovent, generic) is a prescription nasal spray that can help relieve runny nose. It works best when given in combination with a nasal corticosteroid. Side effects include nasal dryness, nosebleeds, and sore throat. It should not be used by people who have glaucoma or men who have an enlarged prostate gland.

Immunotherapy

Immunotherapy is a safe and effective treatment for patients with allergies. It is based on the premise that people who receive injections of a specific allergen will lose sensitivity to that allergen. Immunotherapy is given either as subcutaneous (under the skin) injections or as sublingual (under the tongue) tablets.

The most common allergens for which allergy shots are given are house dust, cat dander, grass pollen, and mold. Sublingual tablets are approved for grass pollen and ragweed. (Tablets for house dust mite allergens are being studied in clinical trials.)

Immunotherapy benefits include:

Candidates for Immunotherapy. Immunotherapy may be given to anyone with allergies who does not get better with medication and who has had a positive allergy test to specific allergens.

The latest guidelines indicate that immunotherapy injections are safe for young children. Some, but not all, sublingual tablets are approved for children. Immunotherapy is safe for pregnant women who are already receiving it, although half-strength doses are generally recommended, and it should not be started during pregnancy.

Individuals at Risk for Complications. People who should probably avoid immunotherapy include those who have:

Everyone's health status should be determined before starting treatment.

Subcutaneous immunotherapy (SCIT), also called allergy shots, uses a prolonged course of weekly injections:

The use of an injection series is effective, but patients often have difficulty complying with the regimens. For some patients, rush immunotherapy may be an alternative option. Rush immunotherapy uses several shots a day over a period of 3 to 5 days to achieve the full dose. Studies suggest that it is effective and safe, but anaphylaxis and severe reactions can occur. Patients must be selected carefully and must be monitored closely during this period for severe reactions.

Sublingual immunotherapy (SLIT) is an oral form of immunotherapy that uses a fast-dissolving under-the-tongue tablet. It has been prescribed for many years in Europe and South America, but until recently was not available in the United States.

In 2014, the FDA approved the first three sublingual immunotherapy products for treating allergic rhinitis:

A sublingual tablet is taken once daily. Treatment starts 3 to 4 months before pollen season begins and continues until the season ends.

Injections for ragweed and dust mites are more likely to cause allergic reactions and side effects than other allergy shots. If complications or allergic reactions develop, they usually occur within 20 minutes, although some can develop up to 2 hours after the shot is given. Side effects may include swelling and soreness at the injection site.

Sublingual tablets may cause throat irritation and itching in the mouth or ears. The first dose is given at a doctor's office to make sure an allergic reaction does not occur. Subsequent doses are taken at home. Patients with severe or uncontrolled asthma should not use this treatment. These pills are very expensive, but may be covered by insurance.

Lifestyle Changes

People with existing allergies should avoid irritants or allergens. These triggers include:

Some studies suggest that early exposure to some of these allergens, including dust mites and pets, may actually prevent allergies from developing in children.

Controlling Pets. People who already have pets and are not allergic to them are probably at low risk for developing such allergies later on. When children are exposed to more than one dog or cat during their first year, they have a much lower risk for not only pet allergies, but also seasonal allergies and asthma. (Pet exposure does not protect them from other allergens, notably dust mites and cockroaches).

For children who have an existing allergy to pets:

Preventing Exposure to Cigarette and Cooking Smoke. Although cigarette smoke is not a trigger for allergic rhinitis, parents who smoke should quit. Studies show that exposure to secondhand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children.

Controlling Dust. Spray furniture polish is very effective for reducing both dust and allergens. Air purifiers and vacuum cleaners with High Efficiency Particulate Air (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo is effective in removing mites in house dust. Vacuuming actually stirs up both mites and cat allergens. People with these types of allergies should avoid having carpets or rugs in their homes. For children with allergies, vacuuming should be performed when the child is not around.

Bedding and Curtains:

Reducing Humidity in the House. Living in a damp environment can lead to allergy problems:

Exterminating Pests (Cockroaches and Mice):

Avoiding Outdoor Allergens. The following are recommendations for avoiding allergens outside:

Some evidence suggests that people with allergic rhinitis and asthma may benefit from a diet rich in omega-3 fatty acids (found in fish, almonds, walnuts, pumpkin, and flax seeds) and fruits and vegetables (at least 5 servings a day). Researchers are also studying probiotics -- good bacteria such as lactobacillus and Bifidobacterium -- which can be obtained in supplements. Some studies have found that probiotics may help reduce allergic rhinitis symptom severity and medication use.

Resources

References

Al Sayyad JJ, Fedorowicz Z, Alhashimi D, Jamal A. Topical nasal steroids for intermittent and persistent allergic rhinitis in children. Cochrane Database Syst Rev. 2007;(1):CD003163.

Bahls C. In the clinic. Allergic rhinitis. Ann Intern Med. 2007;146(7):ITC4-1-ITC4-16.

Bergmann KC, Demoly P, Worm M, Fokkens WJ, Carrillo T, Tabar AI, et al. Efficacy and safety of sublingual tablets of house dust mite allergen extracts in adults with allergic rhinitis. J Allergy Clin Immunol. 2014;133(6):1608-1614.e6. Epub 2013 Dec 31.

Blaiss MS. Safety considerations of intranasal corticosteroids for the treatment of allergic rhinitis. Allergy Asthma Proc. 2007;28(2):145-152.

Brinkhaus B, Ortiz M, Witt CM, et al. Acupuncture in patients with seasonal allergic rhinitis: a randomized trial. Ann Intern Med. 2013;158(4):225-234.

Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466-476.

Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011;127(1 Suppl):S1-S55.

Di Bona D, Plaia A, Leto-Barone MS, La Piana S, Di Lorenzo G. Efficacy of subcutaneous and sublingual immunotherapy with grass allergens for seasonal allergic rhinitis: a meta-analysis-based comparison. J Allergy Clin Immunol. 2012;130(5):1097-1107.e2.

Dretzke J, Meadows A, Novielli N, Huissoon A, Fry-Smith A, Meads C. Subcutaneous and sublingual immunotherapy for seasonal allergic rhinitis: a systematic review and indirect comparison. J Allergy Clin Immunol. 2013;131(5):1361-6. Epub 2013 Apr 1.

Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S103-S115.

Frew AJ. Allergen immunotherapy. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S306-S313.

Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet. 2011;378(9809):2112-2122.

Jaakkola MS, Quansah R, Hugg TT, Heikkinen SA, Jaakkola JJ. Association of indoor dampness and molds with rhinitis risk: a systematic review and meta-analysis. J Allergy Clin Immunol. 2013;132(5):1099-1110.e18. Epub 2013 Sep 10.

Lin SY, Erekosima N, Kim JM, et al. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013;309(12):1278-1288.

Matricardi PM, Kuna P, Panetta V, Wahn U, Narkus A. Subcutaneous immunotherapy and pharmacotherapy in seasonal allergic rhinitis: a comparison based on meta-analyses. J Allergy Clin Immunol. 2011;128(4):791-799.e6.

Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117-1119.

Scow DT, Luttermoser GK, Dickerson KS. Leukotriene inhibitors in the treatment of allergy and asthma. Am Fam Physician. 2007;75(1):65-70.

Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. 2007;(1):CD001563.

Sicherer SH, Wood RA; American Academy of Pediatrics Section On Allergy And Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2012;129(1):193-197.

Smits WL, Giese JK, Letz KL, Inglefield JT, Schlie AR. Safety of rush immunotherapy using a modified schedule: a cumulative experience of 893 patients receiving multiple aeroallergens. Allergy Asthma Proc. 2007;28(3):305-312.

Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician. 2010;81(12):1440-1446.

Vliagoftis H, Kouranos VD, Betsi GI, Falagas ME. Probiotics for the treatment of allergic rhinitis and asthma: systematic review of randomized controlled trials. Ann Allergy Asthma Immunol. 2008;101(6):570-579.

Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1-S84.



Review Date: 6/24/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital, Boston, MA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team. A.D.A.M. Editorial Update: 09/29/2014.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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