Objectives
Recognize allergic rhinitis (AR) in patients
Allergic Rhinitis Review current management strategies for
allergic rhinitis
Identify practical points to communicate to
Sandy Kapur, MD FRCPC patients to ensure optimal outcomes
Pediatric Allergy and Asthma
Case 1 Case 1
A 6 year old boy has symptoms of Assuming he has AR, what is the likely
sneezing, itchy eyes, and runny nose allergen causing his symptoms?
off and on from mid-June to mid-July. 1) Tree pollen
His symptoms are annoying, but do not 2) Grass pollen
distress him much. He has used no 3) Weed pollen
treatment for this. 4) Outdoor mold spores
Case 1 AR - Definition
What would be considered first line “Rhinitis is defined as an inflammation of the lining
of the nose and is characterised by nasal symptoms
pharmacotherapy for this patient? including anterior or posterior rhinorrhoea,
1) 1st generation antihistamine sneezing, nasal blockage and/or itching of the
nose…It is often associated with ocular symptoms.”
2) 2nd generation antihistamine
Traditional definition
3) Intranasal steroids
SAR – caused by seasonal (outdoor) allergens, ie.
4) Antihistamine eye drops pollens, molds
PAR –caused by perennial (indoor) allergens, ie.
house dust mite, pet dander
PAR, perennial allergic rhinitis
SAR, seasonal allergic rhinitis Bousquet J. et al. J Allergy Clin Immunol 2001;108:S147
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Diphenhydramine
Commonly Used Antihistamines
Once-daily Non-
Generic Name Brand Name dosing sedating
Cetirizine Reactine
Chlorpheniramine Chlor-Tripolon, others
Desloratadine Aerius
Diphenhydramine Benadryl, others
Fexofenadine Allegra
Loratidine Claritin
Compendium of Pharmaceuticals and Specialties
Diphenhydramine
Case 2
A 7 year old girl has a runny and stuffy
nose, as well as sneezing most days
from late April until early June. Her
nasal congestion is troublesome at
school and disturbs her sleep. She
seems tired during the day.
ARIA Classification
Case 2 Intermittent Persistent
< 4 days per week ≥ 4 days per week
What would be the best treatment or < 4 weeks and ≥ 4 weeks
option for her?
1) 1st generation antihistamine Mild Moderate-severe
normal sleep one or more items
2) 2nd generation antihistamine & no impairment of daily . abnormal sleep
3) Intranasal steroid activities, sport, leisure . impairment of daily
& normal work and activities, sport, leisure
4) Leukotriene receptor antagonist school . abnormal work and
& no troublesome school
symptoms . troublesome symptoms
2
Intranasal Steroids
Intranasal Steroids
Intranasal corticosteroids are gold standard first-line Steroid Trade Name Bioavailability
therapy for moderate-to-severe allergic rhinitis1 Fluticasone Avamys 0.5%
More effective than antihistamines against nasal furoate
symptoms in several studies1–3 Mometasone Nasonex 0.5%
furoate
Treatment may prevent development of co-
morbidities such as asthma, sinusitis or otitis media 4,5 Fluticasone Flonase 0.5%
proprionate
Also effective in non-allergic rhinitis
Budesonide Rhinocort 31%
Beclomethasone (Beconase) 44%
1. Bousquet J et al. J Allergy Clin Immunol 2001;108(Suppl 5):S147–S334
2. Long A et al. Evidence Report/Technology Assessment Number 54, 2002
3.Ratner R et al. J Allergy Clin Immunol 1997;99:S439
4.Settipane R. Allergy Asthma Proc 1999;20:209–213
5. Crystal-Peters J et al. J Allergy Clin Immunol 2002;109:57–62
Current Nasal Delivery Systems
Case 3
A 3 year old boy has a stuffy nose and
white nasal discharge most days from
September to April. He sometimes can
not sleep because of his nose. He goes
through a lot of Kleenex (and shirt
sleeves) at daycare. He has no personal
or family history of allergy.
Case 3 Case 3
What is the most likely cause of his What is the best treatment option for
symptoms? this patient?
1) Allergic rhinitis 1) Oral antihistamine
2) Infectious rhinitis 2) Leukotriene receptor antagonist
3) Autonomic rhinitis 3) Intranasal steroid
4) Idiopathic rhinitis 4) Antibiotics
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Rhinitis Classification
Rhinitis – Canadian Guidelines
Allergic
Intermittent vs persistent
Autonomic
Vasomotor
Infectious
Idiopathic
Small et al, 2007
World Allergy Organization
Case 4 Case 4
A ten year old girl has symptoms of nasal What is the likely allergen causing her
congestion, sneezing, and runny nose at least symptoms?
5 days/week, year around. In the spring, her
1) Tree pollen
symptoms become worse and her eyes also
become red and itchy. She has tried Benadryl 2) Cat
with some benefit. Her symptoms are worse 3) House Dust Mite
at night and in the morning. She seems tired 4) All of the above
at school. She has a cat at home.
Case 4 Allergic Rhinitis Treatment
What is the best treatment option for Avoidance of triggers
this patient? Medical therapy:
1) Oral antihistamines Antihistamines
Nasal steroids
2) Intranasal steroids
Others
3) Antihistamine eye drops
Immunotherapy
4) All of the above
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Allergens True or False
The most effective way to reduce house dust
Indoor Outdoor mite (HDM) exposure is to remove carpeting
house dust mite tree pollen from bedroom
grass pollen HEPA filters in furnaces significantly decrease
animals (cat, dog)
allergen loads in the home
cockroach weed pollen
HEPA filter units in bedrooms are not helpful
mold (Alternaria,
mold (Penicillium,
in decreasing HDM exposure
Cladosporium)
Aspergillus) Keeping cat/dog out of bedroom significantly
reduces exposure to pet allergen
Indoor Allergen Control
House Dust Mite
Mattress/pillow encasings
Wash bedding in hot water
Cat/dog
Remove from home
Molds
Clean with chlorine
Dehumidify/avoid excess moisture
AR - Therapeutic Options
Outdoor Allergen Control
Effects on symptoms
Pollens (tree,grass,weed), mold spores Drug
Itch/ Nasal Nasal Sense Ocular
sneeze discharge congestion of smell symptoms
Know season for planning
INS +++ +++ ++ + ++
Do not use clothesline Oral
+++ ++ ± – +++
Air conditioning antihistamine
– – –
Avoid high exposure activities Topical
decongestant
+++ +
Do not keep children indoors Chromone + + ± – ++a
Anticholinergic – +++ – – –
Oral
+++ +++ +++ ++ ±
corticosteroid
a Alleviates ocular symptoms only when administered as eye drops
1. Bousquet J et al. J Allergy Clin Immunol 2001;108:S147–S334
2. Scadding G. J Allergy Clin Immunol 2001;108:S59
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ARIA: Treatment recommendations
Allergic Rhinitis
moderate Other Treatment Options
moderate mild severe
severe persistent
Leukotriene receptor antagonists
persistent
mild intermittent Nasal irrigation
intermittent Sinus rinse
intra-nasal steroid
local cromone Netti pot
oral or local non-sedating H1-blocker
intranasal (<5 days) or oral decongestant
allergen and irritant avoidance
immunotherapy
Prevalence of hay fever: 13-14 yr olds
Immunotherapy
Reserved for patients not controlled with
avoidance and pharmacotherapy
Good for pollen and house dust mites; limited
usefulness for molds and animal dander
Perennial vs preseasonal
Subcutaneous vs sublingual
Must be performed in a medical facility
≥20%
prepared to treat anaphylaxis 10-20%
<10%
Small et al. 2007 Strachan et al, Pediatr Allergy
Immunology 1997
Allergic rhinitis is poorly controlled Ocular symptoms play a key
in clinical practice role in the experience of allergy
A study comparing the symptomatic burden on UK allergic rhinitis
(AR) patients seen in primary care and specialist settings 70 Adults
experiencing symptoms
Primary care 60 Children
Allergists
physicians
(n=202 AR sufferers) 50
(n=265 AR sufferers)
40
Percent (%)
Severe AR (P=0.004) 5% 15%
30
Already receiving at 20
least one prescription 98% 97%
for AR 10
AR not well controlled 0
56% 64% Nasal Sneezing Ocular
(P=0.097)
congestion symptoms
Despite treatment a significant proportion of patients in both primary
and specialist treatment settings are not well controlled
Scadding G et al. EAACI 2006 Scadding G et al. EAACI 2006; Scadding G et al. EAACI 2006
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AR - Quality of Life True or False
Moderate-severe AR associated with:
Fatigue and daytime somnolence 1–3 50% of patients with AR have asthma
Daily activity impairment4,5
95% of patients with asthma have AR
Reduced work productivity4–8
Disturbed cognitive functions9 Rhinitis is a risk factor for developing
Reduced learning abilities including exam asthma
performance10,11
Adverse effects on adolescent behaviour 6 Treating AR has little effect on asthma
Treating asthma has little effect on AR
1. Borres MP et al. Ann Allergy Asthma Immunol 1997;78:29–34;
2. Craig TJ et al. J Allergy Clin Immunol 2005;116:1264–1266; 3. Young T et al. J Allergy Clin Immunol
1997;99:S757–S762; 4. Reilly MC et al. Clin Drug Invest 1996;11:278–288; 5. Tanner et al. Am J Manag Care 1999;
5(Suppl 4):S235–S247; 6. Juniper EF et al. J Allergy Clin Immunol 1994;93:413–423; 7. Corey JP et al. Otolaryngol
Head Neck Surg 2000;122:681–685; 8. Blanc PD et al. J Clin Epidemiol 2001;54:610–618;
9. Marshall PS and Colon EA. Ann Allergy 1993;71:251–258; 10. Vuurman EF et al. ARIA, 2007
Ann Allergy Asthma Immunol 1996;76:247–252; 11. Walker S et al. Eur Respir J 2005;26(Suppl 49):134s.
First Description of Hay Fever
John Bostock, Med Chir Trans, 1819;10:161 Treatment of AR with INS in patients with mild
asthma : effect on lower airway responsiveness
"About the beginning or middle of
June in every year …..
…. A sensation of heat and fulness is
experienced in the eyes ….
…. To this succeeds irritation of the
nose producing sneezing ….
…. To the sneezings are added a
further sensation of tightness of the
chest, and a difficulty of breathing" Watson et al. JACI 1993;91:97-101
The ARIA initiative Resources
was
developed ARIA
(in collaboration with the WHO) www.whiar.org
The Canadian Rhinitis Guidelines
Small et al. Journal of Otolaryngology, Volume 36,
To translate evolving science on rhinitis into Supplement 1, April 2007
recommendations for the management and
prevention of the disease.
To better assess the interactions between
rhinitis and asthma.
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