VIEWS: 226 PAGES: 62 POSTED ON: 9/28/2012
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 ! ! !
Pages to are hidden for
"Allergic Rhinitis.ppt"Please download to view full document