Allergic Rhinitis

OTC 2015

References
Practice guideline for the treatment of allergic rhinitis. American

Academy of OtolaryngologyHead and Neck Surgery Feb.2015,

Vol. 152(1S) S1S43
Treatment of Allergic Rhinitis. Am Fam Physician.
2010;81(12):1440-1446.
Allergic rhinitis management pocket reference 2008. Allergy 2008:

63: 990996.
Pharmacotherapy: A pathophysiologic Approach. 7 th Edition 2008.
Safety of Antihistamines in Children. Drug Safety 2001; 24 (2): 119-

147.
Second-Generation Antihistamines Actions and Efficacy in the

Management of Allergic Disorders. Drugs 2005; 65 (3): 341-384

2

Allergic RhinitisOverview
The most common atopic disease
The hallmark of ~: a temporal relationship

between the exposure to allergens & the

development of nasal symptoms
It takes at least 2 years of exposure to
aeroallergens
(airborne
environmental
allergens) to develop AR (thus, very rare in
children <1 year)
The prevalence of AR: lowest in children < 5

yrs
highest 2nd---- 4th decades
Genetic predisposition (60%)

In a sensitized individual, allergic

rhinitis occurs when mucous
membranes
are
exposed
to
inhaled allergenic materials that
elicit a specific response mediated
by immunoglobulin E (IgE).

Definitions.
Allergic Rhinitis (AR) is an inflammatory, IgEmediated disease characterized by nasal
congestion,
rhinorrhea
(nasal
drainage),
sneezing, and/or nasal itching. It can also be
defined as inflammation of the inside lining of
the nose that occurs when a person inhales
something he or she is allergic to, such as
animal dander or pollen; examples of the
symptoms of AR are sneezing, stuffy nose,
runny nose, post nasal drip, and itchy nose.

AR may be classified by:

(1) the temporal pattern of exposure to a triggering
allergen, such as seasonal (eg, pollens), perennial/
year-round
(eg,
dust
mites),
or
episodic
(environmental from exposures not normally
encountered in the patients environment, eg,
visiting a home with pets);
(2) frequency of symptoms; and
(3) severity of symptoms. Classifying AR in this
manner may
assist in choosing the most appropriate treatment
strategies for an individual patient.

Allergen
sensitization and
the allergic
response. A.
Exposure to
antigen stimulates
IgE production and
sensitization of
mast cells with
antigen specific
IgE antibodies. B.
Subsequent
exposure to the
same antigen
produces an
allergic reaction
when mast cell
mediators are
released.
9

Mast cells degranulating and releasing vasoactive

amines.

Mast Cell Mediators

11

Allergic Rhinitis
Most patients develop symptoms before age

30
Asthma develops in about 19% of children
with rhinitis (more likely with perrenial allergic
rhinitis)
The term rhinitis refers to the inflammation

of the nasal mucous membranes. Whenever a

a causative allergen can be identified
allergic rhinitis
It is difficult sometimes to distinguish
between different types of rhinitis
Comparison between different types of

Features of Common Rhinitis Symptoms

Allergic
rhinitis

Infectious
rhinitis

Vasomotor rhinitis

Rhinitis
Medicamentosa

Etiology

Allergen

Viral or
bacterial

Unknown

Tachyphylaxis to
topical decongestants

Symptoms

Rhinorrhea,
congestion,
sneezing,
pruritis, cough
with postnasal
drip ocular
itching etc

Fever (more
common in
children),
mucupurulent
rhinorrhea,
scratchy throat,
congestion,
cough

Rhinorrhea,
congestion

Congestion

Pattern

Perennial or
seasonal

Any time

Any time

Temporal relationship
with use of topical
decongestant

Associated
Factors

Concurrent
None
atopic disease,
family history

Affects women
primarily, strong
odours, alcohol, stress,
change in humidity
and temperature

Overuse of topical
decongestants,
concurrent use of
antihypertensive
therapy

Perennial Allergic Rhinitis

Caused by continuous exposure to many

different types of allergens

Dust Mite the most common cause of
perennial allergic rhinitis
Commonly: household dust mites, molds,
cockroaches, house pets
Less commonly: cottonseed & flaxseed (found
in fertilizers, hair setting preparations and
foods); some vegetable gums (found in hair
setting prep & foods)

Caused by:

Dust mites

Perennial Allergic Rhinitis

Dust mite: thrive in carpets, beddings & reproduce

best in warm (18-21C) humid (>50%)

environment found in most homes
Mites feed on human skin scales and their own
faeces.
Mite itself is not allergen, the main allergen is the
glycoprotein that coats their faeces.
Dust mite remain airborne for about 30 minutes
after being disturbed
Molds: grow best in warm, moist environment
Cat-derived allergens: light small proteins secreted
through the sebaceous glands in the skin. May
remain airborne for up to 6 hrs. Can be detected at
home even 6 months after removal of the cat.

Seasonal Allergic Rhinitis

Caused by wind-borne plant pollens

(e.g. tree, grass. etc)

hay fever, and rose fever are
terms related to seasons associated
grass pollinosis and NOT associated
with FEVER!

Complications
1.
2.
3.
.
.
.
.

Sinusitis
Recurrent otitis media & hearing loss
Patients who develop:
fever,
purulent nasal discharge,
refer to Dr. for evaluation
frequent HA,
and treatment
earache

Symptoms of Allergic
Rhinitis
Ocular: itching, lacrimation, mild soreness,

puffiness & conjuctival erythema

Nasal: congestion, watery rhinorrhea, itching,
sneezing, postnasal drip and nasal pruritus
Head & Neck: loss of taste and smell, mild sore
throat due to postnasal drip, earache, sinus HA,
itching of the palate and throat
Systemic: malaise & fatigue:

Physical Assessment
allergic shiners venous/lymphatic

congestion
Chronic mouth breathing highly arched
palate
A horizontal crease across the lower third of
the nose (in patients repeatedly rub their
noses upward) called nasal salute
Nasal mucosa: pale & swollen
Nasal secretions: clear & watery
Eyes: watery with scleral & conjuctival
erythema and periorbital edema

Allergic shiners
Arched palate because of mouth
breathing

Periorbital edema

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Update: April 2013

The US Food and Drug Administration (FDA) has approved
carbinoxamine maleate extended-release (Karbinal ER, Tris
Pharma), the first liquid, sustained-release histamine-H1
receptor blocker indicated for the treatment of seasonal and
perennial allergic rhinitis in children aged 2 years and older.
The drug will be available in a 4 mg/5 mL oral suspension.
It is dosed once every 12 hours, "making it an attractive
treatment option" for allergy sufferers who do not respond to
second-generation antihistamines and are not satisfied with
dosing schedules associated with the first-generation
antihistamines.
Carbinoxamine is a mildly sedating antihistamine. Before
2006, it was widely used in carbinoxamine-containing
combination products. However, most of these older drugs
had not gone through the FDA's approval process.