The truth on Allergic Rhinitis

							A Quick Tour Of
ALLERGIC RHINITIS
Manjul Dixit, M.D.
     Allergic Rhinits: Definition
Allergic rhinitis is clinically defined as a symptomatic
disorder of the nose induced by an IgE-mediated
inflammation after allergen exposure of the membranes
lining the nose
                Interesting Facts
• 10% to 20% of population have intermittent rhinitis
• 30% to 50% of patients have persistent rhinitis
• Up to 15% of patients are children 6 to 7 years of age
• Up to 40% of patients are adolescents 13 to 14 years of age
• 18% to 21% of patients are young adults 15 to 24 years of age
• less than 8% of patients are adults over 65 years of age
• Allergic rhinitis is one of the major 10 conditions that lead to
medical consultation in U.S. managed-case populations
        Clinical Manifestations


   Repetitive sneezing      Eye symptoms
   Watery rhinorrhea        Ear symptoms
   Nasal pruritus           Postnasal drainage
   Nasal congestion
            Quality Of Life
• Fatigue
• Sleep Disorders
• Learning Problems
• Chronic Rhinosinusitis
• Dental Abnormalities
• Speech Disorders
• Emotional problems
• Impaired activity and social functioning
• Poor perception of general health
• > 800,000 missed days of work, school, and
decreased productivity days
• $5.4 to $7.7 billion dollars lost
Types of Rhinitis
Conditions that mimic rhinitis
The Allergic Reaction
                 ARIA Classification

Intermittent                  Persistent
• < 4 days per week           • ≥ 4 days per week
• or < 4 weeks                • and ≥ 4 weeks


Mild                              Moderate-severe
 normal sleep                 one or more items
& no impairment of daily         abnormal sleep
 activities, sport, leisure      impairment of daily
& normal work and school          activities, sport, leisure
& no troublesome symptoms        abnormal work and school
                                 troublesome symptoms


                                                  ARIA Report 2001
              Diagnosis of AR
   History
   Physical / Nasal Examination
   Laboratory Testing
    - Skin Prick Test
    - Peak Nasal Inspiratory Flow Rate
    - Rhinomanometry
              PHYSICAL EXAMINATION
   Allergic shiner
   Dennie Morgan line
   Allergic crease
   Allergic salute
   Nasal mucosa may appear normal or pale bluish,
    swollen with watery secretions but only if patient is
    symptomatic
   Exclude structural problems (polyps, deflected nasal
    septum)

Others:
    nasal voice, constant mouth breathing, frequent
    snoring, coughing, repetitive sneezing, chronic open
    gape of the mouth, weakness, malaise, irritability
                                      Why?
-Trees: Spring and Fall
       Oak, Maple, Cedar, Olive and Elm

- Grasses: Early Summer and Fall
          Kentucky Blue Grass, Orchard, Redtop, Timothy, and Bermuda

-Weed: Late Summer and Fall
       Pigweed, Sage, Mugwort, lamb’s quarters

-Outdoor Molds: Summer and Early Fall
       Alternaria and Cladosporium
       Dry and Windy days

-Indoor Molds:
        Aspergillus and Penicillium
-Pets
-Cockroaches
           Management of AR
   Allergen Avoidance
   Pharmacotherapy
   Immunotherapy
     - Subcutaneous
     - Sublingual
Pharmacotherapy
Actions of Various Nasal Preparations in
       the Treatment of Rhinitis

Nasal              Sneezing   Itching   Rhinorrhea   Congestion
Preparation
Antihistamines     +++++      ++++      +++          0

Anticholinergics   0          0         +++++        0
Corticosteroids    +++++      +++++     +++          +++


Decongestants      0          0         +            +++++

Antileukotrienes   +++            ++    0            ++++
The “Ideal” Drug For Allergic Rhinitis
Should Have The Following Features:
   Inhibit both early and late phases
   Be an H1 blocker
   Counter effects of other mediators
   Fast-acting, to control the early phase
   Dosing-od or bd for compliance
   No side effects
   Manage all symptoms
   Intranasal administration
   The “Ideal” Drugs Are……
“Corticosteroids are undoubtedly the
pharmacotherapeutic agents with the broadest
application for the treatment of many types of
rhinitis”
    Intranasal corticosteroid therapy
   Potent topical activity
   Administration of low doses directly at site of action
   Considerable efficacy at low doses
   High topical: systemic activity ratios
   Rapid first-pass hepatic metabolism of any systemically
    absorbed drug, to compounds with negligible activity
   Markedly greater inhibition of EAR than with oral
    steroids
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