Transcript Document

ALLERGIC RHINITIS
 Definition
 Types
 Etiology
-Genetic
-Atopy
-pollution
Asthma and Allergic Rhinitis
Prevalence of Allergic Rhinitis
by Age Group
 10-20% of world
 Allergy+Asthma
50-58%
 Asthma+Non
eosinophillic rhinitis 14%
Allergic Rhinitis (AR): Risk Factor for
ASTHMA
 Prevalence of AR:
Adults
31.5%
Children
40%
 About 50-80% of asthmatics have AR
 About 40% of allergic rhinitis cases have Bronchial Asthma
 Untreated nasal allergy leads to other airway diseases
including Asthma (post-nasal drip as trigger, irritant
receptors in upper AW, mouth breathing)
Related Anatomic Structures
Compromised by Allergic Rhinitis
ALLERGENS
SEASONAL
Occupational
 Pollens
Bakery,Dust
Washing powder
Latex,Drugs
 Fungi
 Grass
Perennial
 House dust mite
 Cat-Fel d l
 Cockroaches
Food
Tartazine,Sulphate,Cheese
Fish,Nuts,Eggs
Citrus fruits
Environmental Allergens and
Childhood Asthma
 Dust mites
 Furry pets
 Molds
 Cockroach
es
Allergic Rhinitis
First exposure – Phase of sensitization
On re-exposure- Mast cell degranulation
Exposure of genetically predisposed individuals to
allergens (pollen, animal dander, fur)
Activation of T-lymphocytes
Stimulates IgE production by B-lymphocytes
IgE coat mast cells [on re-exposure mast cell
degranulation]
Allergin Rhinitis: Inflammatory cells
1. Mast cells
 Contain


Granules (histamine)
Other mediators (leukotrienes and PGs)
2. Lymphocytes
 T cells
 Increased mobilisation of inflammatory cells

Eosinophils, macrophages, neutrophils
3. Eosinophils
 Major basic protein, Eosinophilic Cationic Protein
(epithelial injury, nasal block)
Allergic Rhinitis: Inflammatory
mediators
Released by inflammatory cells (mast cells, eosinophils,
lymphocytes)
Leukotrienes
1.


hypersecretion of mucus
oedema (Increased vascular permeability)
Histamine
2.

itching, rhinorrhea (Allergic rhinitis)
Cytokines
3.



Interleukins (IL)
IL-4 (IgE production)
IL-3 and IL-5 (eosinophil, mast cell recruitment /
activation)
ALLERGIC RHINITIS PATHOGENESIS
 EAR- Early Allergic Reaction
– Within 15 - 30 minutes after exposure
 Mast cell degranulation: histamine
 LAR- Late Allergic Reaction
 6-12 hours after exposure
 Eosinophils, Basophils.
 Epithelial damage, increased mucus secretion.
ALLERGIC RHINITIS
SYMPTOMS
 SEASONAL
 Pollen
 Eye symptoms
 Skin allergy test +
 Symptoms include:
Runny nose, itching,
sneezing, nasal block
 PERENNIAL
--Skin allergy test  Symptoms include:
itching, nasal block,
Hyposmia, palatl itch,
facial pain
ARIA GUIDELINES
DIAGNOSIS
 History
 Skin prick test
 Nasal smear
 RAST
 ELISA
CLASSIFICATION OF ALLERGIC RHINITIS (AR)
Intermittent AR
• < 4 days per week
• or < 4 weeks
Mild Intermittent AR
• Normal Sleep
• No impairment
of daily activities
• Normal work and
school
• No troublesome
symptoms
Moderate-Severe Intermittent AR
• Abnormal Sleep
• Impairment
of daily activities
• Problem at work
and school
• Troublesome
symptoms
CLASSIFICATION OF ALLERGIC RHINITIS (AR)
Persistent AR
• > 4 days per week
• or > 4 weeks
Mild Persistent AR
• Normal Sleep
• No impairment
of daily activities
• Normal work and
school
• No troublesome
symptoms
Moderate-Severe Persistent AR
• Abnormal Sleep
• Impairment
of daily activities
• Problem at work
and school
• Troublesome
symptoms
ARIA GUIDELINES
TREATMENT
Allergic Rhinitis: Treatment
 Avoid contact with allergen
 Hyposensitization (Allergy tests / vaccines )
 Drug therapy
 Antihistamines / Relievers: Nasal sprays (Superior) / Oral
 Steroids / Preventers: Nasal (Superior) / Oral / Drops
 Other preparations (Na Cromoglycate or Chromone,
Ipratropium, Decongestants, LTRA or Montelukast)
Drug options for Allergic Rhinitis
Drug type
Antihistamines
Itch /
Discharge Blockage Impaired
sneezing
smell
+++
++
+
Nasal
preparations
_
AZELASTINE
Anticholinergics
_
+++
_
_
Ipratropium
Decongestants
_
+
+++
_
Xylometazoline
Oxymetazoline
+
+
+
_
Sodium
cromoglycate
Mast Cell
Stabilizers
Topical
Corticosteroids
+++
+++
++
+
Fluticasone
Nometasone
2 sprays/nostril
OD
Treatment Options: Allergic Rhinitis
 Antihistamines
 Oral: Most common form of Treatment. (Drowsiness /
Dryness of mouth / Urinary retention / Blurred vision /
appetite +).Cetrizine, Rupatidine
 Nasal Spray : Azelastine. Potent H1 blocker with
immediate effect / Also blocks other mediators (LT, PAF)
 Corticosteroids
 Nasal Sprays: Most effective treatment of AR / certain
types of perennial rhinitis (Beclomethasone / Budesonide
/ Fluticasone / Mometasone.
 Block both EAR / LAR : Reduce swelling & secretions in
nasal mucosa (anti-inflammatory)
 Oral Corticosteroids: Short term
TREATMENT OF POLYPOSIS
 Topical nasal
corticosteroids are
mainstay of treatment
for ethmoidal polyposis
Fluticasone Nasal Spray
 Fluticasone (50 mcg / spray) 120 doses
 Dose: 2 sprays / nostril once daily (Adults).
 Used for Prophylaxis & treatment of AR/perennial
rhinitis/Vasomotor rhinitis/ Symptomatic relief of
Nasal polyps/ Prevent recurrence of polyps (postpolypectomy)
 Potent anti-inflammatory action (Block both EAR /
LAR : Reduce swelling & secretions in nasal mucosa)
 Safe: No HPA axis suppression/systemic absorption.
Can be used for long periods even in children
Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines
Management of Intermittent AR
Avoid Allergens
Mild Intermittent AR
Nasal H1 blocker / Spray
Oral H1 blocker
Decongestants
LTRA
Moderate-Severe Intermittent AR
Nasal H1 blocker / Spray
Oral H1 blocker
Decongestants/LTRA/Chromone
FLUTICASONE - 2
sprays/nostril OD
LTRA= Leukotriene Receptor Antagonists
Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines
Management of Persistent AR
Avoid Allergens
Nasal H1 blocker
Oral H1 blocker / LTRA
Decongestants / Chromone
Intranasal CS / NOMETASONE/
/FLUTICASONE
Review patients after 2-4 weeks
Step up if no improvement
Continue: 1 month if improvement
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