Allergic Rhinitis

Definition
Allergic rhinitis (AR) = inflammation of the lining of the nose, characterized by one or more of the following nasal sx:
Nasal congestion Nasal pruritis Rhinorrhea Sneezing Nasal sx lasting > 1 hr on most days.

Ages affected
Not seen until after age 4 or 5.
(Takes approx 3 pollen season exposures).

10-15% in adolescents (adolescents and young adults). Peak age 30 (decades 2, 3 and 4).

Predisposition
Genetic:
Positive FHx (polygenic inheritance) Negative FHx does not rule out dx of AR

Atopic dermatitis:
Early sign of predisposition to allergy. 13% -/- parent, 30% +/- parent/sibling, 50% +/+ parent.

Previous exposure/environmental factors

Comorbid Associations of Allergic Rhinitis

Otitis Media Atopic Dermatitis with Effusion
Craniofacial Abnormalities

Nasal Polyposis

Upper Respiratory Infection

Allergic Rhinitis
Sinusitis

Obstructive Sleep Disorders

Asthma

Modified from C. Siegel

Airway inflammation
Allergen Dendritic cell
IL-1 IgE MBP ECP LTs PGs PAF

Th0-cell B-cell
IL-4 IL-10 IL-13 Eotaxin IL-5 RANTES

Eosinophil

Mast cell

IFN-

Th1-cell

Th2-cell

histamine VCAM-1 ICAM-1 E-selectin Systemic circulation

The Allergic Response

Minutes Degranulation
Histamine Leukotrienes Proteases

Hours Secretion

Cytokines Chemokines

Immediate Rxn

Late Phase Rxn

Pathogenesis allergic airway disease

Environmental factors Atopic sensitization Mucosal inflammation

Phenotype

Genetic factors Structural changes

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 symptoms < 4 days per week or <4 weeks
Mild Normal sleep Normal daily activities, sport, leisure Normal work and school No troublesome symptoms

Persistent symptoms > 4 days / week and >4 weeks

Moderate-Severe
one or more items

Abnormal sleep Impairment of daily activities sport, leisure Problems caused at work or school Troublesome symptoms

Skin Prick Testing

IgE-mediated rxn (Type I). Small, but significant potentail for anaphylactic rxn.

Wheal & flare response (15-20 minutes)

Includes a positive and control soln.

Positive rxn = over 3cm wheal with assd flare and pruritis (no rxn to neg control).

Skin Prick Testing (cont.)

# of skin test allergens limited to common aeroallergens in pts environment. False positives (dermatographism)

False negatives ( interference by meds, i.e. antihistamines)

Skin Prick Test (cont.)

Discontinue antihistamine use prior to skin testing:
Benadryl, CTM: 48 hrs Claritin: 96 hrs Atarax: 120 hrs Hismanal: 6 weeks

TCAs and some antipsychotics may also block skin test results.

Treat in a stepwise approach (adolescents and adults)

Diagnosis of allergenic rhinitis
(history + skin prick tests or serum specific IgE)

Allergen avoidance Intermittent symptoms mild Not in preferred order Oral H1 blocker Intranasal H1 blocker And/or decongestant moderate severe Persistent symptoms mild moderate severe

Intranasal CS (300-400 ug daily) Not in preferred order Oral H1 blocker Intranasal H1 blocker review the patient 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 treatment in persistent rhinitis or other causes for 1 month review the patient after 2-4 weeks Blockage rhinorrhea increase Add intranasal CS add Decongestant dose ipatropium Or oral CS If failure: step-up Short term If improved; continue Itch/sneeze For 1 month 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 asthmaspecific 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 H1-antihistamines oral intranasal intraocular Corticosteroids intranasal Chromones intranasal intraocular Decongestants intranasal oral Anti-cholinergics Anti-leukotrienes ++ ++ 0 +++ + 0 0 0 0 0 rhinorrhea ++ ++ 0 +++ + 0 0 0 ++ + Nasal obstruction + + 0 +++ + 0 ++++ + 0 ++ Nasal itch +++ ++ 0 ++ + 0 0 0 0 0 Eye symptoms ++ 0 +++ ++ 0 ++ 0 0 0 ++

Immunotherapy (ITX)
Should be considered if: pharmacotherapy insufficiently controls sx or produces undesirable side effects. appropriate avoidance measures fail to control sx. h/o AR for at least 2 seasons (seasonal) or 6 months (perennial). positive skin tests correlate with rhinitis sx.

Immunotherapy (cont.)
Contraindications: age < 5-6 yrs. use of beta-blockers. contraindication to epinephrine. pt non-compliance. autoimmune dz. induction during pregnancy (maintenance OK). uncontrolled asthma, FEV1<70%

Immunotherapy (cont.)
80-85% pts derive long-lasting symptomatic relief. After 3-5 seasons with adequate relief, stopping should be considered. ~60% pts will continue to derive symptomatic benefit with reduced need for medication. All pts on ITX should be encouraged to maintain environmental avoidance and may have to use concomitant medication (i.e.: antihistamines).

Who/when to refer to an Allergist

The need to assess allergen-specific IgEmediated mechanisms of sx causation. When pt does not respond to indicated tx (may need rhinoscopy, imaging studies or eval of immunocompetence). Any pt with a treatable complication of allergic dz may benefit from a specialized referral.

TERIMA KASIH