Transcript Allergic and Non-Allergic Rhinitis

Allergic and Non-Allergic Rhinitis
Objectives
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Who cares?
Why?
What else could it be?
Gazoontite
Can’t we just give them Allegra and
Flonase?
• Do they really need an Allergy consult?
Allergic Rhinitis: Epidemiology
• In US, affects 80 million people annually
– 10-30% adults affected
– Up to 40% children
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80% cases develop before age 20
In childhood, males > females
In adulthood, males = females
Prevalence is increasing
Allergic Rhinitis: The Impact
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28 million restricted activity days each year
2 million missed school days each year
3.4 million missed work days each year
Decreased productivity in US labor force
– $2.4 billion for men
– $1.4 billion for women
• Estimated $3 billion per year on Rx meds
Rhinitis: The Definition
• Inflammation of the membranes lining the
nose characterized by:
– Nasal congestion
– Rhinorrhea
– Sneezing
– Pruritis
– Postnasal drainage
Rhinitis: Classification
• Allergic
– ~ 50% cases
– IgE-mediated reaction due to exposure to
airborne allergens
– Seasonal, perennial, episodic, occupational
• Non-allergic
– Infectious
– Non-infectious
• Vasomotor, atrophic, hormonal, exercise, drug,
reflex-induced, occupational
Allergic Rhinitis: Risk Factors
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Family history of atopy
Serum IgE > 100 IU/ml before 6 yo
Higher socioeconomic class
Non-Caucasians
First born children
Exposure to cigarette smoking in infancy
Exposure to indoor allergens
Presence of positive allergy prick skin tests
Sensitization
Re-exposure
Allergic Rhinitis: Pathophysiology
• Early allergic response, within minutes
– Mast cell degranulation
• Preformed: Histamine, tryptase, chymase
• Newly formed: Prostaglandins, cysteinyl leukotrienes
– Vascular leakage – edema, watery rhinorrhea
– Exocytosis of mucosal glands
– Vasodilation – nasal obstruction
– Stimulation of sensory nerves – nasal itch,
congestion
– Systemic reflexes – sneezing paroxyms
Allergic Rhinitis: Pathophysiology
• Late phase response
– Within 4-8 hours
– Inflammatory cells attracted - basophils,
eosinophils, neutrophils, mononuclear cells, T
helper lymphocytes
– Nasal congestion predominates
– Sneezing, rhinorrhea, pruritis
Symptoms of Allergic Rhinitis
Classic
• Sneezing paroxysms
• Nasal pruritis
• Nasal congestion
• Clear rhinorrhea
• Palatal itching
Associated
• 20% asthma sx
• Post nasal drip
• Itchy, watery eyes
• Ear fullness, popping
• Itchy throat
• Sinus pressure
• Mouth breathing,
snoring
Priming
• Exposed to allergen for days to weeks
• Significant inflammation
– Increase numbers of mast cells
– Upregulation of IgE receptors and surface
bound IgE on mast cells
– Nonspecific nasal hyperreactivity
– Influx of eosinophils, other inflammatory cells
• As allergy season progresses, 10-100 fold
less allergen needed to cause sx
Progression of Symptoms During
Allergy Season
• Symptoms related to infiltration of
inflammatory cells
– Mucus hypersecretion
– Tissue edema
– Goblet cell hyperplasia
– Tissue damage
• Primed mast cells
• Role of histamine diminishes
• Antihistamines less effective
Which plant is more allergenic?
Seasonal Allergic Rhinitis (SAR)
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Trees - Spring
Grasses - Summer
Weeds - Fall
Outdoor molds – Summer and Fall
Perennial allergic rhinitis (PAR)
• Usually indoor
allergens
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Dust mites
Cockroach
Perennial molds
Animal danders
• Nasal congestion and
post nasal drip may
predominate
Associated Conditions
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Asthma
Sinusitis
Otitis media
Nasal polyposis
Lower respiratory tract infections
Dental occlusions
Allergic Rhinitis and its Impact on
Asthma (ARIA)
"One airway, one disease "
Bousquet J. et al. JACI 2001;108:S147-334.
ARIA “One airway, one disease”
• Rhinitis and asthma are co-morbidities
– Linked by epidemiologic, pathologic, and physiologic
characteristics
• AR considered a risk factor for asthma
• Patients with AR should be screened for asthma
and vice versa
• Combined strategy to treat upper and lower
airway disease
• New classification system for AR
• Stepwise therapeutic approach
ARIA Classification
Intermittent
Persistent
. < 4 days per week
. or < 4 weeks
. ≥ 4 days per week
. and ≥ 4 weeks
Mild
normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and
school
& no troublesome
symptoms
in untreated patients
Moderatesevere
one or more items
. abnormal sleep
. impairment of daily
activities, sport, leisure
. abnormal work and
school
. troublesome symptoms
Non-Allergic Rhinitis (NAR)
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Sporadic or persistent perennial rhinitis sx
Not IgE-mediated
Infectious
Hormonal
Vasomotor
Non-allergic rhinitis with eosinophilia (NARES)
Occupational
Gustatory
Drug-induced
Non-Allergic Rhinitis
• Vasomotor rhinitis
– Variable sx, nasal obstruction and rhinorrhea
– Provoked by nonspecific irritant stimuli
– Cold dry air, changes in relative humidity
– Strong odors, tobacco smoke, dust, fumes
– Alcohol, spicy foods, bright lights
• Food allergy rarely presents with rhinitis
alone
Non-Allergic Rhinitis
• Drug induced rhinitis
– Nasal congestion and/or rhinorrhea
– Antihypertensives, OCPs, NSAIDs, Viagra
• Hormonal rhinitis
– Hormone induced intranasal vascular
engorgement
– Nasal congestion and/or hypersecretion
– Pregnancy, conjugated estrogens, OCPs,
hypothyroidism
Non-Allergic Rhinitis
• Occupational rhinitis
– Sneezing, nasal discharge and/or congestion
– Exposure to airborne agent in workplace
– Sx improve away from workplace
– Non IgE mediated - irritant, cold air, chemical
– IgE mediated – animals, grain, wood dusts
– Frequently co-exists with occupational asthma
Non-Allergic Rhinitis
• Rhinitis medicamentosa
– > 5-10 days of topical nasal decongestant use
– Rebound nasal congestion after d/c
– Hypertrophy of nasal mucosa
– Downregulation of nasal mucosal alphaadrenergic receptors
Other Conditions to Consider
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Anatomic abnormalities
Benign and malignant tumors
CSF leak – refractory clear rhinorrhea
Atrophic rhinitis
– Elderly patient, nasal congestion, constant
bad smell in nose (ozena), thick crusts
• Systemic diseases
– Uremia, diabetes
– Wegener’s, sarcoidosis, infections causing
granulomatous nasal lesions
Rhinitis History
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Frequency, duration, and severity of Sx
Provoking or aggravating triggers
Environment – home, job, school
Current/past treatments
PMH, incl trauma
FH, incl atopic disease
Review of systems
Physical Examination
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Allergic facies (shiners, nasal crease)
Allergic salute
Injected conjunctiva with tearing
Nose wrinkling, grimacing, or other facial
mannerisms
Physical Exam cont.
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Long and narrow facies, high cheek bones
Injected sclera, edematous eyelids
Nasal mucosa, turbinate size, polyps
Nasal discharge, post-nasal drainage
Posterior pharyngeal cobblestoning
TM mobility, retraction, effusion
Other organ systems: eczema, wheezing
Testing for Specific IgE
• Allergen-specific IgE
• In vivo testing
– Prick skin tests
– Trees, grasses,
weeds, molds, dust
mite, cat, dog,
cockroach
• In vitro testing
– RAST
Management
• Allergen Avoidance
• Pharmacotherapy
• Immunotherapy
Avoidance
• Minimize exposure to outdoor allergens
– Decrease exposure during high pollen counts
– Keep house and car windows closed, use A/C
– Do not dry laundry outdoors
– Make the bed daily
– Do not lay on a bed in clothes worn outside
– Hire lawn service
– Keep the pets out of the bedroom
Dust Mite Avoidance
• Encase bedding in allergen-impermeable covers
• Wash sheets in water >130° F every 7-10 days
• Remove stuffed animals, down pillows, draperies,
upholstered furniture, rugs from bedrooms
• Maintain humidity <50%
• Replace curtains with blinds
• Vacuum weekly
Avoidance Measures cont.
• Indoor animal allergens
– Get rid of the pet
– Keep animals away from bedrooms
– Bathe pet weekly and brush frequently
– Vacuum with HEPA filter
– Room air cleaners
Environmental Controls cont.
• Indoor molds and pests
– Exterminate
– Decrease dampness
– Improve ventilation
– Increase exposure to sunlight
– Use weak bleach solution to wash
baseboards and walls
Antihistamines
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Competitively bind to H1 receptor
Prevent histamine release
Reduce sneezing, pruritis, and rhinorrhea
Little effect on nasal congestion
First generation antihistamines
• Eg: diphenhydramine (Benadryl), hydroxyzine (Atarax),
chlorpheniramine (Chlor-Trimetron)
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Highly lipophilic, cross blood-brain barrier
Sedation, somnolence, incoordination
Anticholinergic side effects
Legally considered “under the influence of
drugs” in many states
• Evening doses impair performance and
cognition in morning without the appreciation of
sedation
Second generation
antihistamines
• Eg., fexofenadine (Allegra), cetirizine (Zyrtec),
loratadine (Claritin)
• May inhibit release of mast cell and
basophil mediators
• Prolonged duration of action
• Lipophobic, poor penetration of CNS
• Minimal, if any sedative effects
They’re not all the same
• Loratadine
– Metabolized through cytochrome P450 system
– Half life prolonged in elderly pts, co-admin with macrolide abx or
imidazole antifungals
• Cetirizine
– Metabolite of hydroxyzine
– Excreted unchanged in urine and feces
• Fexofenadine
– Metabolite of terfenadine
– Only 5% metabolized
– Co-admin with ketoconazole and erythromycin increase GI
absorption, increased plasma levels
– No sedative effects seen at doses up to 480 mg/day
Fexofenadine vs Cetirizine
Incidence of Drowsiness + Fatigue
10
p= 0.018
8
p=0.
018
%
6
Patients
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17/421
18/209
0
Fexofenadine
Howarth et al. JACI 1999.
Cetirizine
Intranasal Antihistamine
• Azelastine hydrochloride (Astelin)
– 0.1% aqueous solution
– 2 sprays/nostril twice daily
– Onset of action 3 hours
– Efficacy equal to oral antihistamines
– Improves rhinitis symptoms incl congestion
– Bitter taste, somnolence
Intranasal Corticosteroids
• Most effective med at controlling rhinitis sx
• First line for moderate-severe SAR/PAR
– Reduce inflammation
– Mild vasoconstriction
– Suppress late phase response
• Adverse effects
– No evidence of atrophy
– Local irritation, epistaxis, septal perforation
Leukotriene Antagonists
• Decrease vascular permeability
• Level of efficacy comparable to
antihistamines
• FDA approved for AR and asthma
Oral and Nasal Decongestants
• Stimulate α-adrenergic receptors
• Reduce nasal congestion
• Side effects: elevated BP, nervousness,
insomnia, loss of appetite, palpitations,
urinary retention
• Topical preparation < 3-5 days
Intranasal Anticholinergics
• Ipratropium Nasal (Atrovent)
• Effective at reducing rhinorrhea
• 0.03% and 0.06%
– Allergic/nonallergic perennial rhinitis
• 0.06%
– Common cold
Nasal Saline Lavage
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Lavage with nasal irrigator or bulb syringe
Hydrates mucosa
Removal of mucous and debris
Improves sx of rhinitis
Intranasal Cromolyn
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Prevents mast cell degranulation
Helpful for sneezing, rhinorrhea, pruritus
Not helpful for congestion
Protective effect lasts 4-8 hours
Use as pre-treatment prior to exposure
Treatment of allergic rhinitis (ARIA)
Allergic Rhinitis and its Impact on Asthma
moderate
severe
intermittent
mild
persistent
moderate
severe
persistent
mild
intermittent intra-nasal steroid
local cromone
oral or local non-sedative H1-blocker
intra-nasal decongestant (<10 days) or oral decongestant
allergen and irritant avoidance
immunotherapy
Aeroallergen Immunotherapy (AIT)
• Immunomodulation
• Candidates
– Continuous pharmacotherapy required
– Continued moderate-severe symptoms
despite maximal medical therapy
– Multi-season symptoms
– Adverse effects of pharmacotherapy
Evidence Based Medicine
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Trees (birch, mountain cedar)
Grasses (timothy, orchard, rye, bermuda)
Weeds (ragweed)
Dust mites (D. pteronyssinus)
Molds (Cladosporium, Alternaria)
Animals (cat)
Immunotherapy cont.
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Can take several months to work
Is specific against allergens used in AIT
Treatment for 3-5 years
Relative contraindications – uncontrolled
asthma, ß-blocker therapy, co-morbid
conditions
• Risk for anaphylaxis
Allergy Referrals
• Clarification and identification of
allergic/nonallergic triggers
• Unsatisfactory management of symptoms
– Suboptimal control
– Adverse effects
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Consideration for immunotherapy
Moderate/severe persistent symptoms
Complications of rhinitis symptoms
Patient request for further evaluation
Education/counseling
Internet Sites
• National Allergy Bureau – daily pollen count
– www.aaaai.org/nab
• American Academy of Allergy, Asthma, and
Immunology
– www.aaaai.org
• American College of Allergy, Asthma, and
Immunology
– www.acaai.org