Transcript Allergic Rhinitis - Isfahan University of Medical Sciences

 The
nasal passages are lined with a membrane
that produces mucus
 Mucus is one of the body's defense systems:
• Thin clear liquid, traps small particles and bacteria
• The trapped bacteria usually remain harmless in
healthy individuals
• Even under normal circumstances, this produces a
cycle of congestion and decongestion that occurs
continuously throughout the day
 When
one side of the nose is congested, air
passes through the open, or decongested, side.
The sides alternate between being wide open
and being narrowed
 More
than 50 million Americans suffer
from allergies
 Sixth leading chronic disease in U.S.
 4.5 billion dollars in health care costs
annually
 3.8 million days lost yearly (from work
and school)
 People
with perennial allergic rhinitis, may
experience sleep disorders and daytime
fatigue.
• Often they attribute this to medication, but studies
suggest congestion may be the culprit in these
symptoms.
 Patients
with seasonal allergies experience
hundreds of brief, subtle awakenings, called
"microarousals", each night. In such cases,
people are not aware that they wake up, but
such events can cause fatigue the next day.

Children with severe allergies may have a higher risk for
behavioral problems than those without allergies

There have been reports that 30% to 45% of people with allergic
rhinitis also suffer from ear infections (otitis media)
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Chronic nasal obstruction can affect a child's appearance. If a
child can only breathe through the mouth, this might lead to an
elongated face and an overbite from teeth coming in at an
abnormal angle
Chronic rhinitis can cause headaches and also affect a child's
sleep, concentration, hearing, appetite, and growth
 Increasing
age, atopy, and high
socioeconomic status
 Parental history is also positively
associated with development of allergic
rhinitis. A maternal history of allergy was
significantly associated with a diagnosis
of rhinitis by age 6 years
 Other risk factors include indoor and
outdoor air pollution
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Rhinitis develops when congestion becomes severe or
other changes occur that irritate the nasal passage
Patient must experience at least two of the following
symptoms for an hour or more on most days:
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Runny nose
Obstruction in the nasal passage
Nasal itching
Sneezing
These symptoms may occur as a result of colds or
environmental irritants, such as allergens, cigarette
smoke, chemicals, changes in temperature, stress,
exercise, or other factors
 When
rhinitis lasts for a long period, it is
most often caused by allergies but can
also be caused by structural problems or
chronic infections.
 Aging
Process
 Mucous membranes become dry with age
 Cartilage supporting the nasal passages
weakens, causing changes in airflow
 Therapy:
Avoid possible allergens and airborne irritants
and keep the nasal passages moist.
Decongestants would not be appropriate
 Increased
parasympathetic stimulation
 Overreaction to irritants, cigarette smoke,
air pollutants, strong odors, alcoholic
beverages, stress, and exposure to cold
 Gustatory rhinitis
 Not the same as allergic reaction
 Foreign
Objects
 Blockage in young children is very often
caused by foreign objects
 If left in place, they may eventually cause
infection and nasal discharge, usually in
one side of the nose, which may be
yellow or green and foul smelling (very)
 One
in five pregnant women will
experience rhinitis symptoms (2nd or 3rd
trimester)
 Hormonally induced
 Spontaneously resolves within few weeks
after delivery
 Limited therapeutic options
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Medications and Illegal Drugs
overuse of decongestant sprays can, over time (three to
five days), cause inflammation in the nasal passages
and worsen rhinitis, Rhinitis Medicamentosa
Aspirin, Ibuprofen, and Naproxen
Oral contraceptives, hormone replacement therapy,
anti-anxiety agents, some antidepressants, and some
blood pressure medications, including beta-blockers
and vasodilators
Sniffing cocaine damages nasal passages and can
cause chronic rhinitis
 Patients
demonstrate Allergic Rhinitis
symptoms but without other systemic
manifestations
 Negative SPT and negative RAST
 Diagnosis: Nasal provocation and
detection of specific IgE in nasal mucosa
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Cystic fibrosis
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Mucociliary defects
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Cerebrospinal rhinorrhoea
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Anatomic abnormalities
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Foreign bodies
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Tumors
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Granulomas: Sarcoid, Wegener’s, Midline Granuloma
 Polyps
• soft, fluid-filled sacs
• impede mucus drainage and restrict airflow
• develop from sinus infections, do not regress on their
own and may multiply and cause considerable
obstruction
 Deviated
Septum
• A common structural abnormality that causes rhinitis
When deviated, it is not straight but shifted to one
side, usually the left
 Protrude
from the sinuses into the nasal
cavities, usually from the middle meatus
 Can be unilateral, or bilateral
 Anosmia, most common presentation
 Very common in CF
• 50% of children (4-16 y/o) w/ nasal polyps have
CF
 Routinely
ask for symptoms suggestive of
asthma
 Perform chest examination
 Consider lung function testing
 Consider tests for bronchial
hyperresponsiveness in selected cases
AR Classification
Intermittent
. < 4 days per week
. or < 4 weeks
Mild
normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and
school
& no troublesome
symptoms
in untreated patients
Persistent
. > 4 days per week
. and > 4 weeks
Moderatesevere
one or more items
. abnormal sleep
. impairment of daily
activities, sport,
leisure
. abnormal work and
school
. troublesome
symptoms
 Diagnosis
is clinical
Allergy Testing
Skin testing and in-vitro blood testing
• Testing is important to institute specific
avoidance measures
• Skin testing is slightly more sensitive
• Common allergens
 Outdoors: tree, grass, weed pollens, and mold
 Indoors: dust mites, pet dander, cockroaches and
mold
Skin prick test / positive result
 Nasal
secretion / scraping cytology
 Nasal allergen challenge
 Nasal endoscopy
 CT scan
• anatomic abnormalities
• concomitant presence of sinusitis
Immunoassay vs skin test for diagnosis
of allergy
Immunoassay
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Not influenced by
medication
Not influenced by skin
disease
Does not require expertise
Quality control possible
Expensive
Skin test
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Higher sensitivity
Immediate results
Requires expertise
Cheaper
 Imaging
studies
• X-rays have a limited value
• CT scans are preferred for evaluation of sinusitis
 Endoscopy
• Usually performed by an ENT physician, allows
easy evaluation of the nose, and throat areas
The management of allergic rhinitis involves the
following
components:
 Allergen avoidance
 Pharmacotherapy.
 Allergen immunotherapy. Of note, immunotherapy
helps prevent the development of asthma in children
with allergic rhinitis, and thus should be given special
consideration in the pediatric population.
 The
most logical strategy for disease that relates
to the indoor environment
 Effectiveness
requires comprehensive and
multifaceted measures
 More
studies are needed to also address the role
of indoor pollutants (e.g. NO2, tobacco smoke,
…)

Pets:
• If patient is allergic to pets, they should be given away or kept
outside
• If this isn't possible, they should at least be confined to carpetfree areas outside the bedroom
• Cats harbor significant allergens, which can even be carried on
clothing; dogs usually present fewer problems
• Washing animals once a week can reduce allergens. Dry
shampoos, such as Allerpet, are now available for pets that
remove allergens from skin and fur and are easier to administer
than wet shampoos.
 Dust
Control
• simply using a spray furniture polish is very effective
for reducing both dust and allergens
• Air cleaners, filters for air conditioners, and vacuum
cleaners with HEPA filters can help remove particles
and small allergens found indoors
• Neither vacuuming nor the use of anti-mite carpet
shampoo, however, is effective in removing mites in
house dust. In fact, vacuuming stirs up both mites
and cat allergens
• Carpets and rugs should be avoided if possible
 Bedding
and Curtains
• Using semipermeable coverings to fully encase
mattresses, and pillows is the most proven
effective step in reducing dust mite levels
• Curtains should be replaced with shades or
blinds
• Bedding should be washed using the highest
temperature setting
 Reducing
Humidity in the House
• Dust mites thrive in humidity and damp houses
increase the risk for mold
• On-going humidifiers, then, can be
counterproductive. If they are used, humidity
levels should not exceed 40% and they should
be cleaned daily with a vinegar solution
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The newer second-generation antihistamines do not
usually cause drowsiness to the extent that the first
generation antihistamines do.
Brand Names.
• Loratadine is approved for children age two and
over.
• Cetirizine is the only antihistamine to date
approved for infants as young as six months.
• Fexofenadine (Allegra)

Studies suggest that cetirizine is more effective than
either of these other agents in improving symptoms,
including in children, although cetirizine causes more
drowsiness at higher doses.
 Oral
decongestants come in many
brands, which mainly differ in their
ingredients.
 The most common active ingredient is
pseudoephedrine.
 Side
Effects of Decongestants
• Agitation and nervousness.
• Drowsiness (particularly with oral decongestants
and in combination with alcohol).
• Changes in heart rate and blood pressure.
• Avoid combinations of oral decongestants with
alcohol or sedatives.
Nasal corticosteroids
1
2
reduction of
mucosal mast cells
reduction of
mucosal inflammation
reduction of
late phase reactions
priming
nasal hyperresponsiveness
reduction of
acute allergic reactions
reduction of
symptoms and exacerbations
3
• suppression of
glandular activity
and vascular leakage
• induction of
vasoconstriction
 Benefits:
• The most effective agents currently available for
•
•
•
•
treating allergic rhinitis.
Blocks the inflammatory response that triggers an
allergic attack. They do not relieve symptoms
immediately but may take several hours before their
effects are felt.
They reduce inflammation and mucus production.
They improve night sleep and daytime alertness in
patients with perennial allergic rhinitis.
Beneficial in treating polyps in the nasal passages.
Nasal corticosteroids
• Overall safe to use
• Adverse Effects
– Nasal irritation
– Epistaxis
– Septal perforation (extremely rare)
– HPA axis suppression (inconsistent and not clinically
significant)
– Suppressed growth (only in one study with
beclomethasone)
 Corticosteroids
available in nasal spray
form include the following:
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Beclometazone (Beconaze). Approved for children
over six
Mometasone furoate (Nasonex). Approved for use in
patients as young as three.
Fluticasone (Flonase). Approved for children over
four.
Budesonide (Rhinocort). Approved for children over
six.
Medications for Allergic Rhinitis ARIA
sneezing rhinorrhea
obstruction itch
nasal
symptoms
nasal
eye
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0 to +
+
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++
++
0
intraocular
Corticosteroids
0
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0
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0
++
0
++
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+
Cromones
intranasal
+
+
+
+
0
0
0
0
0
++
intranasal
oral
0
0
0
0
++
+
0
0
0
0
Anti-cholinergics
Anti-leukotrienes
0
0
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+
0
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0
0
0
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H1-antihistamines
oral
intranasal
intraocular
Decongestants
 Efficacious
and equal to or superior to oral
antihistamines for treatment of SAR
 Clinically significant effect on nasal congestion
 Improved nasal symptoms in patients who
failed oral antihistamines
 Onset of action: 30 vs. 60-180 minutes for oral
antihistamine
 Side effects: Sedation, bitter taste
 Azelastine
 Olopatadine
(Patanase)
 Azelastine/Fluticasone (Dymista)
• Nasal glands are activated by muscarinic, cholinergic
receptors
• Ipratropium bromide is a nonselective muscarinic
receptor antagonist
• Ipratropium bromide applied intranasally blocks
rhinorrhea induced by
cholinergic stimulation
• Ipratropium bromide has negligent systemic
anticholinergic activity
• Topical adverse effects: excessive dryness, epistaxis
CysLT1 Receptor
5-Lipoxygenase
Antagonists
Inhibitors
Montelukast *
Zileuton
Pranlukast *
Zafirlukast
* Approved for allergic rhinitis
Anti-leukotriene treatment in
allergic rhinitis
Efficacy
•
•
•
Equipotent to H1 receptor antagonists but with onset of
action after 2 days
Reduce nasal and systemic eosinophilia
May be used for simultaneous treatment of allergic rhinitis and
asthma
Safety
•
Dyspepsia (approx. 2%)
 Criteria
for Allergen Immunotherapy
• Severity of rhinitis symptoms
• Duration of rhinitis symptoms
• Progression of rhinitis
• Failure to respond to medical treatment
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Administering Therapy
Immunotherapy requires a prolonged course of weekly
injections ("allergy shots"). The process generally
follows this course:
• Injections of diluted extracts of the allergen are given on a
regular schedule, usually weekly at first, then in increasing
doses until a maintenance dose has been reached. It usually
takes several months to reach a maintenance dose.
• At that time, intervals between shots can be two to four weeks,
and the treatment is continued for up to three to five years.
• Patients can experience some relief within three to six months;
if there is no benefit within 18-24 months, the shots should be
discontinued.
 Not
licensed to treat allergic rhinitis
 Could
be considered in severe cases unresponsive to
conventional treatment
 Could
cases
be an adjunct to immunotherapy in severe
 >4
years should be treated as for adults
 Children (>4) with AR and Asthma can be
treated with combination of newer topical and
inhaled corticosteroids
 Diagnosis in smaller children is difficult as can
have up to 6 to 8 colds per year
 Small children – oral antihistamines, saline
sprays and corticosteroids if symptoms severe
 <2 years fortunately rare
FDA considers no drugs are considered
completely safe
 FDA RISK Categories for drugs in pregnancy
(based on good studies in pregnant women)
A – safe to baby in 1st trimester
B – safe in pregnant animals, no human
studies
C – drugs show foetal problems in animal
studies
but benefits may outweigh the potential risks
D – clear risk to foetus but there may be
instances
X – should not be used in pregnancy

 Nasal
Saline
 Nasal corticosteroids – all Category C
except Budesonide which was recently
reassigned B – nasal steroid of choice
 Antihistamines – usually not very
effective but older antihistamine
chlorpheniramine, loratadineand
cetrizine are B
 Oral steroids C
 Decongestants - C
Capsaicin has been shown to be of
benefit to Idiopathic Rhinitis.
Nasal Capsaicin, results in rhinorrhea,
nasal blockage and sneezing through cfibers (pain receptors).
Repeated application of capsaicin,
however, lead to desensitization and
degeneration of C-fibers.
Dosage is five high dose treatments of intranasal
capsaisin over 1 day at 1 hr intervals after local
anesthesia or five treatments spread out over 2 wks.
Up to 75% of patients will show long lasting (from 4
month to over 1 yr.) relief of symptoms.
Even after symptom free period is over, a repeat dose
of capsaisin will most likely repeat itself.
Surgery is reserved for failed medical
therapy only.
Nasal polyps, inferior turbinate
hypertrophy and septal spurs may
obstruct nasal cavity and block the
action of topical medications.
What is the role of surgery?
•Sometimes effective
•Submucosal resection for good long term
results
Surgery is reserved for failed medical
therapy only.
Nasal polyps, inferior turbinate
hypertrophy and septal spurs may
obstruct nasal cavity and block the
action of topical medications.
 Allergic
disorders are on the rise and
have a significant impact on the quality of
life
 Allergic rhinitis can lead to other
comorbidities such as asthma and
sinusitis
 Treatment should focus on trigger
identification and avoidance, medications
and allergen immunotherapy
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Dykewicz MS, et al. Ann Allergy Asthma Immunol
1998;81(5 Pt 2):478-518
Rondon et al. J Investig Allergol Clin Immunol 2010;
20(5): 364-371
Wallace et al. J Allergy Asthma Clin Immunol 2008; 122:
S1-84
M. Varghese, M. C. Glaum and R. F. Lockey, Clinical &
Experimental Allergy, 2010 (40) 381–384