ALLERGIC RHINITIS

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

ARIA Report 2001

Natural History of AR

Onset is common in childhood, adolescence and early adulthood Symptoms often wane in older adults, but may develop or persist at any age No apparent gender selectivity or predisposition for developing allergic rhinitis May contribute to other conditions such as Sleep disorders Fatigue Learning problems

Causes of AR

The Allergic Reaction

How are the symptoms caused?

Irritation of free nerve endings---- Itching and sneezing Increased mucus production -----Vasodilation -------- Congestion

Rhinorrhoea

Increased vascular permeability----

Oedema

Clinical Manifestations
Others

Repetitive sneezing Watery rhinorrhea Nasal pruritus

Eye symptoms Ear symptoms Postnasal drainage

Nasal congestion

ARIA Classification
Intermittent
< 4 days per week or < 4 weeks

Persistent
4 days per week and 4 weeks

Mild
normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms

Moderate-severe
one or more items

abnormal sleep impairment of daily activities, sport, leisure abnormal work and school troublesome symptoms

ARIA Report 2001

Minimal Persistent Inflammation

An underlying cause of chronicity

An inflammatory process which is actually present even in asymptomatic subjects who are exposed to allergens

Concept of "minimal persistent inflammation"

mite allergen (g/g of dust) 100

10
1

Threshold level for symptoms

12 Months

0,1

10

Symptoms inflammation

Minimal persistent inflammation

Ciprandi et al, J Allergy Clin Immunol 1996

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

Management of AR

Allergen Avoidance Pharmacotherapy Immunotherapy

Pharmacotherapy
Medications used to treat allergic rhinits:

Antihistamines Decongestants AH-D combinations Corticosteroids Mast Cell stabilizers Anticholinergics Antileukotrienes

Actions of Various Nasal Preparations in the Treatment of Rhinitis

Nasal Preparation Antihistamines Anticholinergics Sneezing +++++ 0 Itching ++++ 0 Rhinorrhoea +++ +++++ Congestion 0 0

Corticosteroids
Decongestants Mast cell stabiliser
Antileukotrienes

+++++
0 +++++

+++++
0 +++

+++
+ +

+++
+++++ 0

+++

++

++++

Anti-Histamines

Act by preventing histamine from binding to the H1-receptors Primarily helpful in controlling Sneezing, itching & rhinorrhoea; ineffective in releiving nasal blockage 1st generation anti-histamines - chlorpheniramine - diphenylhydramine 2nd generation anti-histamines - cetrizine - azelastine - fexofenadine - loratadine

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

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
JACI 1999; 103:S388

The Ideal Drugs Are

Corticosteroids are undoubtedly the
pharmacotherapeutic agents with the broadest

application for the treatment of many types of

rhinitis
Otolaryngol Head Neck Surg 1992, 107, 855-60

Management of Allergic Rhinitis

Allergen Avoidance
Intermittent Symptoms Mild
Oral H1 blocker Intranasal H1blocker and/or decongestant No Improvement : switch or add LTRA

Persistent Symptoms Mild

Oral H1 blocker and/or LTRA Intranasal H1 blocker and/or decongestant Intranasal CS Review patient after 2-4 weeks No improvement step up Improved: continue for 1 month If intranasal CS reduced by1/2 Rhinorrhea: add ipratropium

Moderate-severe
Oral H1 blocker and/or LTRA Intranasal H1 blocker and/or decongestant Intranasal CS

Moderate-severe
Intranasal CS If nose very blocked add oral CS or decongestant or LTRA

Improved Step-down and continue treatment for > 3 month

Not improved Review diagnosis, compliance, or other causes

Itch/sneeze/rhinorrhea add H1 blocker

Blockage: add LTRA or decongestant or oral CS (short term) or increase INCS

No improvement: refer to specialist