ALLERGIC RHINITIS

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Allergic Rhinitis: Definition

Allergic rhinitis (AR) is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen IgEexposure of the membranes lining the nose

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ARIA Report 2010

Natural History of AR
Onset is common in childhood, adolescence and early adulthood Symptoms often wane in older adults, but may develop or persist at any age No apparent gender selectivity or predisposition for developing allergic rhinitis May contribute to other conditions such as Sleep disorders Fatigue Learning problems
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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 free nerve endings---- Itching and sneezing endings---Increased mucus production -----Vasodilation -------- Congestion Increased vascular permeability---permeability---Provided as a service by CiplaMed

Rhinorrhoea

Oedema

Role Of Leukotrienes In AR
Dilatation of nasal blood vessels, increase vascular permeability with edema formation congestion Increase mucus production Recruitment of inflammatory cells into the tissue Promote inflammation by enhancing the activity of inflammatory cells 5000 times more potent than histamine
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Clinical Manifestations
Others Repetitive sneezing Watery rhinorrhea Nasal pruritus Nasal congestion Eye symptoms Ear symptoms Postnasal drainage

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ARIA Classification
Intermittent
< 4 days per week or < 4 weeks

Persistent
4 days per week and 4 weeks

Mild
normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms

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

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ARIA Report 2001

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"

mite allergen (g/g of dust) 100 10 1

Threshold level for symptoms

12 Months

0,1

10

Symptoms inflammation

Minimal persistent inflammation

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Ciprandi et al, J Allergy Clin Immunol 1996

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: 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: rhinits: Antihistamines Decongestants AH-D combinations AHCorticosteroids Mast Cell stabilizers Anticholinergics Antileukotrienes
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Actions of Various Nasal Preparations in the Treatment of Rhinitis

Nasal Preparation Antihistamines Anticholinergics Corticosteroids Sneezing +++++ 0 +++++ Itching ++++ 0 +++++ Rhinorrhoea +++ +++++ +++ Congestion 0 0 +++

Decongestants Mast cell stabiliser

Antileukotrienes
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0 +++++

0 +++

+ +

+++++ 0

+++

++

++++

AntiAnti-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 anti- chlorpheniramine - diphenylhydramine 2nd generation anti-histamines anti- cetrizine - azelastine - fexofenadine - loratadine
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Role Of Montelukast In AR
It belongs to that class of drug which specifically blocks leukotrienes, leukotrienes, an underlying cause of allergy symptoms Blocks LTC4 which is approximately 10 times as potent as histamine Blocks LTD4 which was shown to be 5000 times as potent as histamine Offers relief from congestion and stuffiness Gives day-time as well as night-time symptom relief daynightProvided as a service by CiplaMed

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 firstabsorbed 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 FastFast-acting, to control the early phase DosingDosing-od or bd for compliance No side effects Manage all symptoms Intranasal administration
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JACI 1999; 103:S388

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, 855-60 855-

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Management of Allergic Rhinitis

Allergen Avoidance Intermittent Symptoms Mild
Oral H1 blocker Intranasal H1blocker and/or decongestant No Improvement : switch or add LTRA

Persistent Symptoms Mild

Oral H1 blocker and/or LTRA Intranasal H1 blocker and/or decongestant Intranasal CS Review patient after 2-4 weeks No improvement step up Improved: continue for 1 month If intranasal CS reduced by 1/2 Rhinorrhea: add ipratropium

ModerateModerate-severe
Oral H1 blocker and/or LTRA Intranasal H1 blocker and/or decongestant Intranasal CS

ModerateModerate-severe
Intranasal CS If nose very blocked add oral CS or decongestant or LTRA

Improved Step-down and continue treatment for > 3 months

Not improved Review diagnosis, compliance, or other causes

Itch/sneeze/rhinorrhea add H1 blocker

Blockage: add LTRA or decongestant or oral CS (short term) or increase INCS

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No improvement: refer to specialist