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Allergic Rhinitis.ppt

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					     ALLERGIC RHINITIS




Danilo R. Legita, M.D., DPBO-HNS
 Department of Otorhinolaryngology
       Davao Medical Center
                Objectives

   To provide updates on the diagnosis and
    management of allergic rhinitis
   To present ARIA protocol
       ALLERGIC RHINITIS


Definition:
 a symptomatic disorder of the nose
 induced by an IgE mediated inflammation
 after allergen exposure of the membranes
 of the nose
     Incidence of Allergic Rhinitis

    Allergic rhinitis affects ~20% of the population

                                  Malone et al. J Allergy Clin Immunol 1997




    n = 3558                    n = 3207
    age: 6-7 years old          age: 13-14 years old
    26.2% with AR               32.5% with AR


                          Cua-Lim et al: Phil J Alllerg Immunol; 1997;4:1;9-20
            ALLERGIC RHINITIS
   Symptoms develop in 1 of 5 children by
    2-3 years and in approximately 40% by age 6
   Symptoms develop before age 20 in 80% of
    cases
   Children with bilateral family history of allergy
    have symptoms before puberty

                                Wright et al. Pediatrics 1994
                                Aberg et al. Acta Paedistr Scand 1990
                                Tang et al; Clin Exp Allergy 1990
       ALLERGIC RHINITIS
           What is the percentage of
             developing Atopy?


Atopy                  Incidence
2 Parents              50%
1 Parent               25%
None                   12.5%
ALLERGIC RHINITIS
ALLERGIC RHINITIS
ALLERGIC RHINITIS
       ALLERGIC RHINITIS

Typical Symptoms:
 rhinorrhea

 nasal obstruction

 nasal itching

 sneezing

which are reversible
spontaneously or
with treatment
       ALLERGIC RHINITIS

Signs / Symptoms:
 Sinus headache

 Eustachian Tube
  dysfunction
 Mouth breathing or
  snoring
 Chronic postnasal drip
       ALLERGIC RHINITIS

Signs / Symptoms:
 Chronic,
  nonproductive cough
 Frequent throat
  clearing
 Sleep disturbance

 Daytime fatigue
   ALLERGIC RHINITIS




Facial Grimace   Allergic Shiner
ALLERGIC RHINITIS




   Allergic Hand Salute
Normal Inferior Turbinate
ALLERGIC RHINITIS
Pathogenesis of Allergic Rhinitis
          Sensitization



                          APC



                            Processed
                            allergen

                          CD4
                          T cell




        Plasma cell            IgE Ab
        The Allergic Response

       Minutes           Hours

Degranulation              Secretion


  Histamine                Cytokines
  Leukotrienes             Chemokines
  Proteases



Immediate Rxn           Late Phase Rxn
Allergic Response in Allergic Rhinitis


                 Immediate Rhinitis
                 •Sneezing
                 •Pruritus
                 •Rhinorrhea
                 “Runners”

                 Chronic Rhinitis
                 •Congestion
                 •Nasal hyperreactivity
                 •Loss of smell
                 “Blockers”
           ALLERGIC RHINITIS
   Allergic inflammation does not necessarily
    limit itself to the nasal passages

   Multiple co-morbidities have been
    associated with rhinitis
Comorbid Associations of
   Allergic Rhinitis
            Atopic     Otitis Media
            Dermatitis with Effusion

  Craniofacial                      Nasal
  Abnormalities                     Polyposis
                   Allergic
   Upper
                   Rhinitis
   Respiratory                      Sinusitis
   Infection

            Obstructive
            Sleep          Asthma
            Disorders

                                                Modified from C. Siegel
           ALLERGIC RHINITIS
   Allergic rhinitis is correlated to and
    constitutes a risk factor for the occurrence
    of asthma

   Strong epidemiologic, pathophysiological
    and clinical evidences of a relationship
    between rhinitis and asthma
    Allergic Rhinitis and Asthma


                               Allergic
                               rhinitis



                      Asthma




   Approximately 80% of asthmatics have allergic rhinitis
   Approximately 40% of allergic rhinitis patients have asthma
Treatment of allergic rhinitis improves asthma



                 6   p=0.001
                                     Untreated Rhinitis
                 5
                                     Treated Rhinitis
    Percent(%)




                 4

                 3
                                        p=0.001
                 2

                 1

                 0

                     ER Visits     Hospitalization


                                 Crystal-Peters et al. J Allergy Clin Immunol 2002
    Allergic Rhinitis and Sinusitis

   25-30%of Acute sinusitis linked to AR*
   Nasal allergy causes obstruction of the
    osteomeatal complex leading to sinusitis




                     *Savolainen et al.Allergy1989;44:116-22
Allergic Rhinitis and Otitis Media
   35-50% prevalence of AR in children with
    OME
   21% of allergic children have OME

   ET may also be target for allergy related OME


             -Hurst et al. Otolaryngol Head Neck Surg1993;108:711-22
                 -Fireman. J allergy Clin Immunol 1990;86:638-41

              -Tomonaga et al. 1988 Acta Otolaryngol458:S41-7
     Allergic Rhinitis and Respiratory
                 Infections
   Rhinovirus infection can accentuate the
    response to allergens or histamine
    challenge
   Allergen exposure can induce the
    expression of ICAM-1 which is the
    receptor for 90% of human rhinoviruses



                Porro et al:Int J Pedia Otolaryngol 1992;24:111-20
    Allergic Rhinitis and Nasal Polyps
   Presence of eosinophils, cytokines, and other
    allergic inflammatory cells in polyps
   Beneficial effects of steroids on polyps
   Recurrence is 36% in presence of allergy and
    only 18% in nonallergic patients
   Clinical observations that allergy control may
    decrease polyp recurrence

                 -Kim et al. J Clin Invest 1996
                 -Settipane GA. Rhinitis. Oceanside Pub, 1991;178-83
Nasal Polyps
Allergic Rhinitis and Sleep Disorders
   Congestion reduces size of airway with
    increased nasal resistance to airflow
   May exacerbate OSA with resultant drop in
    oxygen saturation during sleep
   Nasal obstruction is associated with sleep-
    disordered breathing including apnea,
    hypopnea, and snoring


                    Guilleminault et al. Pediatrics 1992;98:871-882
THE ARIA PROTOCOL
THE ARIA DOCUMENT
         THE ARIA PROTOCOL

   provide evidence-based approach to
    diagnosis
   provide evidence-based approach to
    treatment
   provide stepwise approach to the
    management of the disease
         ALLERGIC RHINITIS
Previous subdivision based on time of
exposure:
 Perennial - indoor allergens

  (dust mites, molds, insects, animal danders)
 Seasonal - outdoor allergens

  ( pollens and molds )
 Occupational
          ALLERGIC RHINITIS
     However….

   Pollens and molds in some areas are
    perennial allergens
   Symptoms of perennial rhinitis may not be
    present the whole year
   Majority of patients are sensitized to many
    allergens and have symptoms throughout
    the year
         ALLERGIC RHINITIS
New Subdivision in ARIA:
 based on duration

     intermittent
     persistent
 symptoms and quality of life parameters:

     mild
     moderate-severe
           Classification of
           Allergic Rhinitis
        Intermittent               Persistent
          symptoms                  symptoms
 • < 4 days per week        • > 4 days / week
 • or <4 weeks              • and >4 weeks

         Mild                    Moderate-Severe
                                    one or more items
•Normal sleep               •Abnormal sleep
•Normal daily activities,   •Impairment of daily
 sport, leisure              activities sport, leisure
•Normal work and school     •Problems caused at work
•No troublesome               or school
  symptoms                  •Troublesome symptoms
Treat in a stepwise approach (adolescents and adults)
                         Diagnosis of allergenic rhinitis
                         (history + skin prick tests or serum specific IgE)

                                     Allergen avoidance

                    Intermittent symptoms           Persistent symptoms

           mild                moderate severe            mild         moderate severe

Not in preferred order          Not in preferred order             Intranasal CS (300-400 ug daily)
•Oral H1 – blocker              •Oral H1 – blocker
•Intranasal H1 blocker          •Intranasal H1 blocker           review the patient
•And/or decongestant            •And/or decongestant              after 2-4 weeks
                                •(chromone)
                                •Intranasal CS
                                 (300-400 ug daily)     improved                failure
                                 (100-200 ug daily)
                                                                            review diagnosis
                                                         step-down         review compliance
                                                       and continue          query infections
                               in persistent rhinitis     treatment          or other causes
                                 review the patient     for 1 month
                                  after 2-4 weeks
                                                             increase          rhinorrhea     Blockage
                                                         intranasal CS             add        Add
                                                               dose                           Decongestant
                                  If failure: step-up                          ipatropium     Or oral CS
                              If improved; continue                                           Short term
                                      For 1 month                    Itch/sneeze
                                                                     Add H1 blocker
                                                                                               failure

                                                                                         Surgical referral
         Allergen Avoidance

   Prevention is the first therapeutic
    approach:
     Identification of causal allergens

       Skin   prick test
     Avoidance     of allergens
           Allergen Avoidance

   House dust mites
       remove carpets
       use allergen-impermeable covers
       vacuum-clean beds
       damp-cleaning of furniture
       wash bedclothes with warm water
     Treatment of Allergic Airway
             Diseases
•   ANTIHISTAMINES
       improvement due to restoration of
        filtration function of the nose
       dispels old belief that antihistamines have a
        negative effect on asthma
     Treatment of Allergic Airway
             Diseases
•   ANTIHISTAMINES
       1st generation
           sedation and anticholinergic effect
       2nd & 3rd generation
         Greater benefit risk ratio
         Less sedation and side effects

         Some with anti-inflammatory effects
Treatment of Allergic Airway
        Diseases
•   ANTIHISTAMINES

     No   satisfactory relief from nasal
     congestion
     Better results when taken routinely
Treatment of Allergic Airway
        Diseases
•   NASAL ANTIHISTAMINES
      decrease nasal congestion
     comparable with oral antihistamines

      but inferior to nasal steroids
     bitter taste

     not used < 5 years of age

     Azelastine and Levocabastine
     Treatment of Allergic Airway
             Diseases
•   ANTIHISTAMINES + DECONGESTANTS
       Effective in decreasing nasal congestion
       Decongestants alone may cause insomnia, anorexia
        and nervousness
       at recommended doses reduced asthma symptoms,
        improved pulmonary function and benefited asthma-
        specific quality of life
                            Storms WW et al : JACI 1989
                            Serra HA et al: Br J Clin Pharmacol 1998
     Treatment of Allergic Airway
             Diseases
   ANTILEUKOTRIENES
       Anti-inflammatory agents acting on the lipo-oxygenase
        pathway
       Significantly reduced sneezing, rhinorrhea, congestion,
        eye symptoms
       May be acting secondarily to reduce inflammation in
        the airway
       Level of efficacy comparable to antihistamines
       Eg. Monteleukast, zafirleukast
                                           Borish: JACI 2003
     Treatment of Allergic Airway
             Diseases
   NASAL CHROMONES
       Mast cell stabilizers
       Disodium cromoglycate and sodium nedocromil
       Acts on the cell wall of mast cell and/or intracellularly
       Effective and safe for children
       Major limitation to use is QID dosing
       Inferior to topical corticosteroids
                            Brown HM et al: Clinical Allergy 1981
                            Welsh PW et al: Mayo Clinic Proceedings 1987
     Treatment of Allergic Airway
             Diseases
   INTRANASAL STEROIDS
      reduction of asthma due to improvement
       of nasal function
      prevent increases in bronchial reactivity
       and asthma symptoms
     Treatment of Allergic Airway
             Diseases
   INTRANASAL STEROIDS
       Superior to oral antihistamines
                       Weiner JM et al:BMJ 1998

       Superior to nasal antihistamines
                       Munk Z et al:Pediat Asthma Allergy Immunol 1994

       May be given to as young as 3 years old
                       Dibildox J: JACI 2001

       Early therapeutic effect in 2-4 hrs after 1st dose
                       Meltzer EO et al: Ann Allergy Asthma Immunol 2001
Pharmacological Management of
       Allergic Rhinitis
Effect of therapies on rhinitis symptoms
                    sneezing   rhinorrhea     Nasal       Nasal      Eye
                                            obstruction    itch   symptoms
H1-antihistamines
 oral                 ++          ++            +         +++       ++
 intranasal           ++          ++            +         ++         0
 intraocular           0           0            0          0        +++
Corticosteroids
  intranasal         +++         +++           +++        ++        ++
Chromones
  intranasal           +           +            +          +         0
  intraocular          0           0            0          0        ++
Decongestants
  intranasal           0           0          ++++         0         0
  oral                 0           0            +          0         0
Anti-cholinergics      0          ++            0          0         0
Anti-leukotrienes      0           +           ++          0        ++
             Summary: Allergic Rhinitis


   Estimated worldwide prevalence of 20%
   Symptoms develop before age 20 in 80% of cases
   Associated with the development of co-morbid conditions
   Impairs patients quality of life
   Treatment in a stepwise approach, ARIA protocol
Thank you
   A SMALL
  TRUTH TO
MAKE LIFE 100%
         Hard Work
    H+A+R+D+W+O+R+K
8+1+18+4+23+15+18+11 = 98%

        Knowledge
    K+N+O+W+L+E+D+G+E
11+14+15+23+12+5+4+7+5 = 96%
                       Love
                   L+O+V+E
         12+15+22+5 = 54%

                       Luck
                  L+U+C+K
         12+21+3+11 = 47%
( don't most of us think this is the most important ??? )
 Then what makes 100% ?
   Is it Money ? ... NO ! ! !
        M+O+N+E+Y
   13+15+14+5+25 = 72%
   Leadership ? ... NO ! ! !
   L+E+A+D+E+R+S+H+I+P
12+5+1+4+5+18+19+9+16 = 89%
Every problem has a solution,
only if we perhaps change our
           attitude.
      To go to the top,
        to that 100%,
  what we really need to go
   further... a bit more...
        ATTITUDE
     A+T+T+I+T+U+D+E
1+20+20+9+20+21+4+5 = 100%


 It is OUR ATTITUDE towards
Life and Work that makes OUR
         Life 100% ! ! !
  Change Your Attitude …
And You Change Your Life ! ! !

				
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posted:9/28/2012
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