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ARIF DERMAWAN
ALLERGIC RHINITIS
A symptomatic disorder of the nose, induced after
allergen exposure, by an IgE-mediated
inflammation of the nasal membranes
It was defined in 1929.1:
The three cardinal symptoms in nasal reactions occurring
in allergy are :
a. sneezing,
b. nasal obstruction, and
c. mucous discharge
ARIA 2008 Update (in collaboration with the World Health Organization, GA2LEN* and Allergen
ALLERGIC RHINITIS
Represent a Global Health Problem
10 - 25% world population
The prevalence is increasing (into 40%)
Alter the social life of patients:
school performance/work productivity
The costs of incurred by rhinitis are substantial
Asthma and rhinitis are common co-morbidities
one airway one disease
Maxillary sinusitis is the common complication
Triggers
Allergens
Aeroallergens
mites, pollens, animal
danders, insects, plant origin,
moulds
Food allergens
Occupational rhinitis
Latex allergy
Pollutants
Indoor air pollution
domestic allergens,
indoor gas pollutants
(tobacco smoke)
ALLERGIC MANIFESTATION
Allergy = Systemic Disease
Asthma
Allergic
Rhinitis
Urticaria
Conjunctivitis
Allergy
Atopic
Dermatitis
Otitis
Media
OSAS
Laryngitis
Sneezing
Anterior rhinorrhea
Nasal itch
Posterior rhinorrhea
Congestion
Nasal Cavity:
Normal vs Allergic Rhinitis
NASOENDOSKOPI
85.7%
80
65.7%
% patients
70
60
50.0%
50
23.0%
40
30
20
10
0
Asthma
Chronic
sinusitis
Otitis media
with effusion
Recurrent
nasal polyposis
DAILY ACTIVITIES
IMPAIRED2,3
Impact of
allergic
rhinitis
WORK AND SCHOOL PRODUCTIVITY
90% effectiveness at work4
93% impaired classroom performance3,5
EMBARRASSMENT
Adolescents embarrassed to use
inhalers6
1. Scadding G et al. EAACI 2007, Abstract 1408. 2. Reilly MC et al. Clin Drug Invest 1996;11:27888. 3. Tanner LA et al. Am J Manag Care 1999;5(Suppl 4):S235S247. 4. Blanc PD et al. J Clin
Epidemiol 2001;54:61018. 5. Juniper EF et al. J Allergy Clin Immunol 1994;93:41323. 6. Marshall PS, Colon EA. Ann Allergy 1993;71:2518.
Histamine
Proteases
Late-Phase Response
Cellular Infiltration/Inflammation
Eosinophil
Basophil
Chemotactic
factors
Monocyte
Mast cell
Other
Inflam.
mediators
Lymphocyte
Early-Phase Response
Mast Cell
Allergen
Pearlman. J Allergy Clin Immunol. 1999;104:S132. Bascom et al. Am Rev Respir Dis. 1988;138:406. Bascom et al. J Allergy
Clin Immunol. 1988;81:580. Quraishi et al. J Am Osteopath Assoc. 2004;104(suppl 5):S7. Minshall et al. Otolaryngol Head
Neck Surg. 1998;118:648.
Allergic Rhinitis:
Classification and
Management
Guideline
INTERMITTENT
PERSISTENT
MILD
MODERATESEVERE
In untreated patients
ARIA, Allergic Rhinitis and its Impact on Asthma
Bousquet J et al. J Allergy Clin Immunol 2001;108(Suppl 5):S147336; ARIA: at a glance pocket reference 2007.
Symptoms suggestive
of allergic rhinitis
- unilateral symptoms
- nasal obstruction without other
symptoms
- mucopurulent rhinorrhea
- posterior rhinorrhea (post nasal drip)
- with thick mocous
- and / or no anterior rhinorhea
- pain
- recurrent epistaxis
- anosmia
Diagnosis
Typical History
General ENT examination
Diagnostic Test
Skin tests
Allergen-specific IgE
Endoscopy
Cytology
Nasal challenge test
Imaging
(ARIA WHO Consensus 2001)
16
Immunotherapy
Pharmacotherapy
effectiveness
specialist prescription
may alter the natural
course of the disease
safety
effectiveness
easy administration
Patient
education
always indicated
18
Establish diagnosis
Define goals, consider quality of life
Educate and counsel
Treat appropriately
Follow-up and adherence
Evaluate further options
INS added to
non-sedating AH
decongestant
Non-sedating AH
decongestant
Mild intermittent
symptoms
Moderate severe
persistent symptoms,
bothersome
Immunotherapy if symptoms:
Show inadequate response to therapy
Prolonged
Impact upon HRQoL
Lead to co-morbid conditions
AH, antihistamine; HRQoL, health-related quality of
life; INS, intranasal corticosteroids
Short course of
corticosteroids added
to INS,
non-sedating AH
decongestant
Inadequate response to
therapy, symptoms
impact of HRQoL,
comorbidities
Step-down
as symptoms improve:
Reduce number of drugs
Reduce dose
Change therapy
Sneezing
Rhinorrhea
Nasal
obstruction
Itchy nose
Level of
evidence
Oral H1-antihistamine
++
++
+++
Intranasal
H1-antihistamine
++
++
++
+++
+++
+++
++
Oral decongestant
Intranasal decogestant
++++
Intranasal chomones
Intranasal CS
Oral H1-Antihistamine
Reduced
Symptoms Alergic
Rhinitis
(50-70%)
Quality of life
Effective
IAR / PER
Nasal symptom
Asthma symptom
Preventive
No
Sedation/cognitive
psychomotor
impairment
Anticholinergic
Cardiac side effects
Weight gain
Safety in young/
elderly
Safety in pregnant
& breast feeding
Post marketing
safety analysis
Rapid onset
Long duration of
action (once daily
preferred)
No tachyphylaxis
EAACI = European Academy of Allergy and Clinical Immunology; ARIA = Allergic Rhinitis and its Impact on Asthma.
1. Bousquet J et al. Allergy. 2004;59(suppl 77):416.
30
ANTI
HISTAMINE
Oral
Antihistamine
FIRST GENERATION
- H1 receptor
antagonist
- Sedation/
drowsiness
- Anti Cholinergic
- Cross blood brain
barrier
- CTM, Diphen
Hydramine
SECOND
GENERATION
- H1 receptor
antagonist
Local
Antihistamine
New/Next
Generation
- Non sedating
- Eliminating /
- Less Sedation
- Once daily
- Anti Inflamatory
- Rapid onset
- Do not cross blood
Activity
- Reducing nasal
brain barrier
- Terfenadine
astemizole cetirizine
loratadine,Fexo
Fenadine
congestion
-
Desloratadine
- Levocetirizine
- Rupatadine
- Effective < 30
- Controlling Sneezing
Rhinorea Nasal
Itching
- Blocking H1 receptor
- More Effective than
oral AH
- Less Effective than
INS
- Minor Local side
effect
- Azelastine / Levo Cabastine
31
New-generation oral H1-antihistamines are suggested rather than intranasal H1antihistamines in adults with seasonal AR (conditional recommendation/moderatequality evidence) and in adults with persistent AR (conditional
recommendation/very-low-quality evidence)
New-generation oral H1-antihistamines are suggested rather than intranasal H1antihistamines in children with intermittent or persistent AR (conditional
recommendation/very-low-quality evidence)
In many patients with different values and preferences or those who experience
adverse effects, an alternative choice may be equally reasonable
Agent
EAACI
Consensus on Allergic
Rhinitis2
ARIA
2001 Guidelines3
Oral antihistamines
Effective for
reducing symptoms of itching,
sneezing, and rhinorrhea, but
have little objective effect on
nasal congestion
Effective on rhinorrhea,
sneezing, and itch, but
have limited effects on
nasal congestion
Oral decongestants
Effectively reduce
nasal congestion produced
by rhinitis
Effective on nasal
congestion
EAACI = European Academy of Allergology and Clinical Immunology; ARIA = Allergic Rhinitis and its Impact on Asthma.
1. Dykewicz MS et al. Ann Allergy Asthma Immunol. 1998;81:474477.
2. van Cauwenberge P et al. Allergy. 2000;55:116134.
3. Bousquet J et al. J Allergy Clin Immunol. 2001;108(suppl):S147334.
Nasal Corticosteroid
Systemic VS Topical Corticosteroid
Intranasal
Systemic
Decrease potential of
systemic side effect
High concentration can be
achieved at receptor sites
Limited contraindications
Nasal Polyps
Ref : PI BPOM
Conclusion