Rinitis alergy

8/11/2019 Rinitis alergy

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ALLERGIC RHINITIS

An inflammatory disorder of the nose

induced by an IgE-mediated inflammation

following allergen exposure of the mucous

membrane lining the nose; characterized by

sneezing, and nasal obstruction


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WHO Classification of allergic rhinitis

Intermittent

symptoms

< 4 days/ week

or < 4 weeks

Persistent

Symptoms

* > 4 days/ week

* and > 4 weeks

Moderate-severeone or more items

Abnormal sleep Impairment of daily activities,

sport, leisure

Problems at work or school

Troublesome symptoms

Mildnormal sleep

normal daily activities,Sport, leisure

normal work or school

no troublesome symptoms


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Epidemiology of allergic rhinitis :

Children

Prevalence of rhinitis symptoms in the

ISAAC in Childhood, (Asher et al, 1995)

0.8% - 14,95% ( 6-7 year old)1.4% - 39.7% ( 13-14 years old)

Low prevalence : Indonesia,Georgia, Greece

High prevalence : Australia, UK and Latin America

Semarang (ISAAC 2002) : rhinitis symptoms in

13-14 years old students 18.6%


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Diagnosis of allergic rhinitis : 1

EssentialDetail personal and family history and

physical examination

Nasal examination

History of eye symptoms

Allergy skin tests and/ormeasurement of

allergen specific IgE antibody


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Allergy skin prick testing

Skin prick test :

positive result

wheal > 3mm diameter

Flare reaction


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Globally important allergens

mites

pollen

mites sources

weed cockroaches

pets : dogs


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Diagnosis of allergic rhinitis :

Additional diagnostic tests which may beperformed if required :

Total IgE

Fibreoptic rhinoscopy Nasal secretions/scraping for cytology

Nasal challenge with allergen, including

rhinomanometry CT scan


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Differential diagnosis

Infectious : viral, bacterial, fungal

Drug induced : aspirin, other medications

Occupational (allergic and non-allergic)

Hormonal : puberty, pregnancy, menstruation,endocrine disorders

Other causes : foods, irritants, emotions,

NARES, gastroesophageal reflux, atropicIdiopathic

Non Allergic Rhinitis


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Treatment of allergic disease :

Allergen avoidance is the firststep in the management of

allergic disease

Allergen avoidance


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Allergen avoidance

House dust mite

Wash bedding weekly at 600C

Encase pillow, mattress and quilt in

allergen impermeable covers

Dispose of feather beddingUse vacuum cleaner with HEPA filter

Replace carpets with wooden floors

Remove curtain, pets and soft toys frombedroom

Provide adequate ventilation to decrease

humidity


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Treatment of allergic rhinitis :

Azelastine & levocobastine

Rapid onset of action

Recommended for organ limited disese

May be used in demandin addition to a

continuous medication

Good safety profile

Topical antihistamines


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Chlorpheniramine, diphenhydramine,

promethazine, tripolidine

Limited by sedative and anticholinergic

effects

First generation oral antihistamines


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Acrivastine, astemizole *, azelastine,

cetirizine,ebastine, epinastine, terfenadine*,

ketotifen, levocetirizine, loratadine,mizolastine

Greatly reduced unwanted effect

First line treatment for intermittent or mild

persistent AR

Second generation oral antihistamines


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Decongestants

Topical sprays

Very effective treating

nasal obstructionLimit treatment to 10

days

Application > 10 days

may lead to unwanted

effect

Oral tablets

Less effective than sprays ;

no rhinitis medicamentosaEffective when combined

with antihistamines

Avoid in : < 1year,

pregnancy, hypertension,

cardiopathy, glaucoma,

prostatism


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Potent-anti-inflammatory

Effective in treatment of all nasal symptoms

Superior to antihistamine for all nasalsymptoms

Firstline pharmacotherapy for moderate

severe persistent AR

Topical-corticosteroids -1


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Occasional unwanted effects

Rarely affect HPA axis

Anecdotally, perforation of the nasal

septum has been reported

One study reports decrease in growth inchildren ( Beclomethasone)

Topical-corticosteroids-2


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Short-course of oral corticosteroids

(< 3weeks) can be prescribe for severe

refractory symptoms

Can be repeated every 3 months

May be used with caution in children and in

pregnancy, if no alternative available

Intramuscular injection of corticosteroid

suspensions should be avoided

Systemic-corticosteroids


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Recommended for clinically relevant Ig E

mediated disease. May involve multiple

allergens; usually restricted to two allergensin Europe.

Risk : benefit ratio must be considered in all

cases

Highly effective in carefully selected patients

Injection allergen immunotherapy


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Evidence-based step-wise guidelines

for the management of allergic

rhinitis

The stepwise guidelines do offer a rational

basis

The guidelines are based on the assumption

that all treatments are readily available andaffordable to the patient

I i AR Ad l & hild


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Intermittent AR : Adults & children

Is therapy needed ? If yes

Non-pharmacological therapy:

Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/nasal AH

or cromon

Nasal

corticosteroids

Nasal CS & oral/

nasal AH

Add further symptomatic

treatment

Or

Short course oral CS

Or

Consider IT

If inadequate

control

P i t t AR Ad lt


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Persistent AR : Adults


Non-pharmacological therapy

Alergen avoidance measure

Environment control


Mild disease Moderate disease Severe disease

Oral/ nasal

antihistamine

Nasal

corticosteroids

Nasal CS &

Oral antihistamine

If inadequate

control If resistent


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I f resistent

Nasal blockage

RhinorrheaAntihistamine and

Oral / nasal

decongestant

OrShort course oral

steroid

Nasal ipratropium

bromide

I f persistent

Consider

Immunotherapy

I f inadequate control

Further examination &

consider immunotherapy

Or

Surgical turbinate reduction

P i t t AR hild


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Persistent AR : children


Non-pharmacological therapy

Allergen avoidance measure

Environment control


If inadequate control

Oral/ nasal antihistmaines or

nasal cromon

Nasal corticosteroids in adequate dosis

If inadequate control

Review diagnosis

Consider immunotherapy


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Documents

Rinitis alergy