Prevalence of Allergic Rhinitis by Age Group

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Prevalence of Allergic Rhinitisby Age Group
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Related Anatomic StructuresCompromised by
Allergic Rhinitis
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Differential Diagnosis of Rhinitis and Nasal
Obstruction

• Rhinitis
• Allergic, seasonal, or perennial
• Infectious, chronic, or acute (frequent
  recurrences)
• Obstructive foreign body
• Secondary to topical decongestants (eg,
  rhinitis medicamentosa)
• Nonallergic with eosinophilia (NARES)
• Nonallergic vasomotor
• Atrophic (eg, cocaine abuse)
• Due to hormonal changes (eg, pregnancy)

• Nasal Obstruction
• Allergic or nonallergic rhinitis
• Rhinosinusitis
• Anatomic abnormality (eg, deviated septum)
• Nasal polyps
• Tumor (eg, angiofibroma)
• Cerebrospinal fluid leakage secondary to
  perforation of the cribriform plate by
  fracture or tumor
• Granulomatous disorders (eg, Wegeners
  granulomatosis, sarcoidosis)
• Foreign body

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Seasonal Allergic Rhinitis Mechanism of
Therapeutic Agents

• Cells in Nasal Mucosa Mediators Cytokines
• Antihistamines Decrease eosinophils Inhibit
  histamine
• and neutrophils release by blocking H1
• receptors
• Reduce expression of ICAM-1 Reduce PGD2 in nasal
  
• on epithelial cells secretions
• Nasal Decrease T cells (CD3, Decrease ECP,
• corticosteroids CD4, CD8), Langerhans
  cells, histamine, tryptase,
• mast cells, basophils, and IL-3, IL-5, and
  GM-CSF
• activated (EG2) eosinophils
• Attenuation in cell numbers after allergen
  challenge
• ECPeosinophil cationic protein
  GM-CSFgranulocyte macrophage colony-stimulating
  factor

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First-generation Antihistamines

• H1 Sedative Anticholinergic GI
  Blockade Effects Effects Effects
• Ethylenediamines (tripelennamine)
• Ethanolamines (diphenhydramine)
• Alkylamines (chlorpheniramine)
• Piperazines (hydroxyzine)
• Piperidines (azatadine)
• Strongly positive effec

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Second-generation Antihistamines

• H1 Sedative Anticholinergic GI
  Blockade Effects Effects Effects
• Fexofenadine (60 mg bid)
• Astemizole (10 mg qd)
• Loratadine (10 mg qd)
• Cetirizine (10 mg qd)
• Negative effect
• Strongly positive effect

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Advantages of Second-generation Nonsedating
Antihistamines

• Bind strongly to histamine (H1) receptors
• negligible affinity for nonhistamine receptors
• no anticholinergic effects
• Do not cross the blood-brain barrier
• do not affect cognitive functions or
  psychomotor performance
• do not potentiate impairment caused by alcohol
  or benzodiazepines
• do not impair driving skills

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Treatment of SAR With Fexofenadine Safety
(N575)

• No sedation
• No ECG abnormalities
• including no prolongation of QTc at 60, 120, or
  240 mg bid
• 60-mg bid dose optimal
• frequency of adverse events similar among all
  groups

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Safety and Efficacy of Once-a-day Dosage for
Adult SAR
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Once-a-day Fexofenadine for Adult SARAdverse
Events (gt2)

• Fexofenadine HCI, N
  ()
• Placebo 120 mg 180 mg Total Active N293 N287 N
  283 N570
• EffectOverall occurrence 88 (30.0) 86 (30.0) 86
  (30.4) 172 (30.2)
• Headache 22 (7.5) 21 (7.3) 30 (10.6) 51 (8.9)
• Upper respiratory 9 (3.1) 6 (2.1) 9 (3.2) 15
  (2.6)tract infection
• Pharyngitis 9 (3.1) 8 (2.8) 6 (2.1) 14 (2.5)
• Back pain 4 (1.4) 8 (2.8) 8 (2.8) 16 (2.8)
• Pain 10 (3.4) 7 (2.4) 5 (1.8) 12 (2.1)

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Decongestants

• Actions
• Constrict mucous membranes shrinkage promotes
  drainage, improves ventilation, relieves
  nasal stuffiness
• Routes of administration
• Systemic, topical
• Indications
• Allergic rhinitis, vasomotor rhinitis, sinusitis,
  eustachian tube congestion
• Side effects
• Systemic stimulation (CNS, cardiovascular)
• Topical rhinitis medicamentosa, CNS stimulation,
  local irritation

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Drugs for Pediatric Allergy (lt12 years)

• Antihistamines
• Brompheniramine maleate
• Cetirizine
• Chlorpheniramine maleate
• Clemastine fumarate (12-hour liquid)
• Diphenhydramine HCl
• Loratadine
• Decongestants
• Phenylephrine HCl
• Phenylpropanolamine
• Pseudoephedrine

• Antihistamine/decongestants
• Chlorpheniramine maleate/
  phenylpropanolamine
• Brompheniramine maleate/ pseudoephedrine
• Intranasal preparations
• Nonsteroid Cromolyn sodium
• Corticosteroid Beclomethasone (AQ and
  aerosol) Budesonide (aerosol) Flunisolide
  (AQ) Fluticasone (AQ)

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Safety of a Second-generation Antihistamine in
Children
Most Frequently Reported (?2) Adverse Even
Fexofenadine HCl (bid)
Placebo N () N () 15 mg 30 mg 60
mg Total (N229) (N224) (N209) (N213) (N646)
Total occurrence 83 (36.2) 79 (35.3) 77 (36.8) 73
(34.7) 230 (35.6) Headache 15 (6.6) 18 (8.0) 15
(7.2) 20 (9.4) 53 (8.2) URTI 4 (1.7) 11 (4.9) 9
(4.3) 3 (1.4) 23 (3.6) Pharyngitis 9 (3.9) 9
(4.0) 6 (2.9) 6 (2.8) 21 (3.3) Coughing 3 (1.3) 3
(1.3) 8 (3.8) 5 (2.3) 16 (2.5) Injury, accident 3
(1.3) 4 (1.8) 6 (2.9) 9 (4.2) 19 (2.9) Abdominal
pain 8 (3.5) 6 (2.7) 4 (1.9) 5 (2.3) 15
(2.3) Fever 2 (0.9) 4 (1.8) 5 (2.4) 4 (1.9) 13
(2.0)
URTI upper respiratory tract infection
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Safety of a Second-generation Antihistamine in
Children
Frequency of ECG Outliers

• 
  Fexofenadine HCl (bid)
• Placebo N ()
• N () 15 mg 30 mg 60 mg
• ECG Parameter (N229) (N224) (N209) (N213)
• PR (gt200 msec and 0 0 0 1 increase gt20 msec)
• QTc (gt450 msec and 7 6 6 3 increase gt10 msec)

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Symptoms of Chronic Sinusitis in Children

• Symptom Occurrence ()
• Chronic nasal obstruction 100
• Purulent nasal discharge 90
• Headache 90
• Cough 71
• Fetid breath 67
• Postnasal drainage 63
• Behavioral changes 63

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Sinus Areas Susceptible to Infection
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Allergy vs Infectious Sinusitis Symptoms in
Children

• Allergy
• Itching of eyes, nose, and palate
• Clear rhinorrhea
• Sneezing
• Other symptoms
• eczema
• food allergy
• Infection
• Purulent anterior rhinorrhea or postnasal drip
• Frequent head pain
• Other
• intractable cough
• sore throat
• purulent sputum

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Treatment of Pediatric Chronic Sinusitis

• Decongestants
• Antihistamines
• Antibiotics
• Amoxicillin (40 mg/kg tid 14-21 days)
• Amoxicillin-clavulanate (40 mg/kg tid)
• Azithromycin (10 mg/kg day 1 5 mg/kg days 2
  to 5)
• Cefixime (8 mg/kg qd or bid)
• Cefuroxime axetil (20-30 mg/kg bid)
• Clarithromycin (15 mg/kg bid)
• Loracarbef (30 mg/kg bid)
• Trimethoprim/sulfamethoxazole (8 mg/kg TMP and 40
  mg/kg SMX bid)
• Functional endoscopic sinus surgery
• Immunotherapy

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Pathogenesis of Otitis Media With Effusion
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Pathogenesis of Otitis Media With Effusion
(contd)
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Risk Factors Associated With Otitis Media

• Viral URT infection
• Allergic rhinitis
• Eustachian tube dysfunction
• Cigarette smoking by parents (especially
  mother)
• Bottle feeding (questionable)

• Male gender
• Immunologic deficiency
• Ciliary dysfunction
• Adenoidal hypertrophy
• Cleft palate disorders
• Genetic predisposition

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Tympanic Membrane Changes and Symptoms

• A. Normal

B. Affected by OME
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Treatment of Otitis Media

• Antibiotics
• First choice amoxicillin
• Amoxicillin/clavulanate
• Erythromycin/sulfisoxazole
• Cephalosporin (for ?-lactamase- producing H
  influenzae or M catarrhalis)
• Clarithromycin or azithromycin (for suspected
  penicillin-resistant S pneumoniae)
• Decongestants

• For coexisting allergic rhinitis
• Antihistamine/decongestants
• Intranasal corticosteroids
• Intranasal cromolyn
• Allergen immunotherapy
• Follow-up physical examination
• Other measures
• Tympanometry (persistent OME)
• Antibiotic prophylaxis

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Asthma and Allergic Rhinitis
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Environmental Allergens and Childhood Asthma

• Dust mites
• Furry pets
• Molds
• Cockroaches

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Compliance With Environmental Control Measures

• Response
• Dust my house frequently 34.1
• Do not have pets inside my house 20.8
• Avoid outdoor activities 18.7
• Wash bedding in hot water 15.0
• Wrap mattresses in plastic cover 6.0
• Do not have carpeting (or rugs) in my house 2.1
• No measures 25.4
• Note Respondents (481 patients with
  self-reported allergic rhinitis) were asked to
  check all items that apply.

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Drug Compliance Rates Allergy and Asthma

• Noncompliance rates significantly high
• estimated 50 to 80 noncompliance
• Factors in treatment success
• education/clear communication write it down
• simplicity of dosing schedule
• minimal adverse effects, especially
  cognitive/behavioral

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Noncompliance Among Pediatric Patients

• Poor physician communication with
  parents/caregivers
• Inconvenient or complex dosing schedules
• Troublesome adverse effects
• Cost not affordable

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Strategies to Encourage Compliance in Pediatric
Patients

• Educate regarding allergen avoidance measures
• Promote the need for medication compliance
• Enlist parental support
• Seek allergy specialist care