ALLERGIC RHINITIS

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ALLERGIC RHINITIS
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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
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(No Transcript)
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Causes of AR
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The Allergic Reaction
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How are the symptoms caused?

• Irritation of freenerve endings---- Itching and
  sneezing
  
• Increasedmucus production ------ Rhinorrhoea
• Vasodilation -------- Congestion
• Increasedvascular permeability---- Oedema

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Clinical Manifestations
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ARIA Classification

• Persistent
• 4 days per week
• and 4 weeks

• Intermittent
• or

• Moderate-severe
• one or more items
• abnormal sleep
• impairment of daily activities, sport, leisure
• abnormal work and school
• troublesome symptoms

Mild normal sleep no impairment of daily a
ctivities, sport, leisure normal work and schoo
l
no troublesome symptoms
ARIA Report 2001
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Minimal Persistent Inflammation An underlying
cause of chronicity

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

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Concept of "minimal persistent inflammation"
Threshold level for symptoms
Symptoms inflammation
Ciprandi et al, J Allergy Clin Immunol 1996
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Diagnosis of AR

• History
• Physical / Nasal Examination
• Laboratory Testing
• - Skin Prick Test
• - Peak Nasal Inspiratory Flow Rate
• - Rhinomanometry

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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

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Management of AR

• Allergen Avoidance
• Pharmacotherapy
• Immunotherapy

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Pharmacotherapy

• Medications used to treat allergic rhinits
• Antihistamines
• Decongestants
• AH-D combinations
• Corticosteroids
• Mast Cell stabilizers
• Anticholinergics
• Antileukotrienes

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Actions of Various Nasal Preparations in the
Treatment of Rhinitis
Antileukotrienes

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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

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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

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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 103S388

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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

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Management of Allergic Rhinitis
Allergen Avoidance
Intermittent Symptoms
Persistent Symptoms
Mild
Moderate-severe
Mild
Moderate-severe
Oral H1 blocker Intranasal H1blocker and/or deco
ngestant
No Improvement switch or addLTRA
Oral H1 blockerand/or LTRA Intranasal H1blocker
and/ordecongestant
Intranasal CS
Oral H1 blockerand/or LTRA Intranasal H1 blocker
and/ordecongestant Intranasal CS Review patie
ntafter 2-4 weeks No improvementstep up Improv
ed continue for1 month If intranasal CSreduced
by1/2
Intranasal CS If nose very blockedadd oral CS or
decongestantor LTRA
Improved
Not improved
Step-down and continue treatment for 3 month
Review diagnosis, compliance, or other causes
Blockage add LTRA or decongestant or oral CS
(short term) or increase INCS
Rhinorrheaadd ipratropium
Itch/sneeze/rhinorrheaadd H1 blocker
No improvement refer to specialist