Transcript Allergic Rhinitis in Children - Asia Pacific Association

Allergic Rhinitis in Children
Alfred Tam
MBBS(HK), FRCP(Edin., London, Glasg.)
FHKCPaed, FHKAM(Paediatrics)
Department of Paediatrics and Adolescent
Medicine, University of Hong Kong
Allergic Rhinitis in Children
•
•
•
•
•
•
What is allergic rhinitis?
Diagnosis and differential diagnosis
Assessment and classification of AR
What can make AR worse or better?
Health effects of AR
What can we do to make AR better?
What is allergic rhinitis?
•
•
•
•
•
•
Rhinorhoea
Nasal blockage
Postnasal drip
Itchiness
Sneezing
Associated health
effects
‼ IgE mediated
Allergic rhinitis is increasing
Lee SL et al. Pediatr Allergy Immunol 2004; 15: 72-8.
Prevelance Rates 1995-2001
45
40
35
30
25
%
20
15
10
5
0
Ever rhinitis
Current rhinitis
Current
rhinoconjunctivitis
Ever eczema
1995 (3618)
2001(4448)
AR prevalence varies in different cities
Wong G et al. Clin Exp Allergy 2001; 31: 1225.
Past 12 mths
%(95%CI)
HK
BJ
GZ
Numbers
3110
4227
3565
Wheeze
5.8(5.0-6.7)
3.8(3.3-4.4)
3.4(2.8-4.1)
15.0(13.9-16.4)
6.7(5.9-7.5)
7.4(6.6-8.3)
3.8(3.1-4.5)
2.2(1.8-2.7)
1.8(1.4-2.3)
Rhinoconjunctivitis
Flexural eczema
Atopic sensitization is not that different!
Wong G et al. BMJ 2004; 329:486-9.
%(95%CI)
HK
BJ
GZ
Numbers
1341
1044
1098
Atopic
41.2(38.5-43.8)
23.9(21.3-26.4)
30.8(28.1-33.5)
D. pter
34.1(31.5-36.6)
7.5(5.9-9.1)
20.0(17.6-22.4)
D. far
25.9(23.5-28.2)
5.7(4.3-7.1)
17.9(15.6-20.2)
3.7(2.7-4.7)
5.6(4.2-6.9)
4.3(3.1-5.5)
11.5(9.8-13.2)
13.3(11.3-15.4)
17.8(14.8-19.2)
Cat
Cockroach
Allergic Rhinitis in Hanoi
Nguyen et al. Pediatr Allergy Immunol 2003; 14:272-9.
Symptoms
%
n
Ever allergic rhinitis
34.9
338
Allergic rhinitis in past 12 months
27.6
267
Allergic rhinoconjunctivitis in past 12 months
10.7
104
AR limiting activities
17
165
Ever hay fever
7.8
76
Doctor diagnosed hay fever
11.2
109
Diagnosis of Allergic Rhinitis
1. Clinical symptoms of recurrent or
persistent rhinitis and/or associated
health effects
2. Signs of atopy and recurrent or
persistent rhinitis
3. Demonstration of IgE allergy
4. Exclusion of other causes of rhinitis
Diagnosis of Allergic Rhinitis
1. Clinical symptoms of recurrent or persistent
rhinitis and/or associated health effects
–
–
–
–
–
–
Rhinorhoea
Nasal blockage
Postnasal drip
Itchiness
Sneezing
Others: conjunctivitis, eczema, asthma, chronic
rhinosinusitis, otitis media with effusion, sleep
obstruction…
Diagnosis of Allergic Rhinitis
2. Signs of atopy and recurrent or
persistent rhinitis
Diagnosis in Primary Care Setting
Diagnosis of Allergic Rhinitis
3. Demonstration of IgE allergy
Immunoassay vs Skin Test for
Diagnosis of Allergy
Immunoassay
• Not influenced by
medication
• Not influenced by skin
disease
• Does not require
expertise
• Quality control
possible
• Expensive
Skin test
•
•
•
•
Higher sensitivity
Immediate results
Requires expertise
Cheaper
Other Causes of Rhinitis in Children
• Infection
– Viral, bacterial,
– Rhinosinusitis
• Foreign body in the nose
• Rhinitis associated with physical or chemical
factors
• Drug, food induced rhinitis
• NARES, aspirin sensitivity
• Vasomotor rhinitis
Health Effects of Allergic Rhinitis
•
•
•
•
•
•
•
Social inconvenience
Sleep disturbances/obstruction
Learning difficulties
Impaired maxillary growth
Dental problems
Infection: nose and sinuses
Co-morbidities: conjunctivitis, asthma,
rhinosinusitis, otitis media
Short Form Health Survey (SF-36)
Profiles of Patients with Allergic Rhinitis
controls (n=139)
90
allergic rhinitis (n=312)
85
*
†
scale: 0 to 100
80
Declining
health
status
*
75
*
70
*
*
65
60
*
55
50
Physical
Functioning
Role–
Physical
Bodily
Pain
General
Health
Vitality
Domains
Adapted from Meltzer EO et al. J Allergy Clin Immunol.
1997;99:S815
Social
Functioning
Role–
Emotional
Mental
Health
Change in
Health
Perennial Rhinitis: an Independent Risk
Factor for Asthma
(European Community Respiratory Health Survey)
25
20
OR=11
no rhinitis, N=5198
rhinitis, N=1412
15
Asthma (%)
OR=17
10
5
0
Atopic
Adapted from Leynaert B et al. J Allergy Clin Immunol
1999; 104:301
Non atopic
Looking for asthma…
In Patients with Rhinitis:
• Routinely ask for symptoms suggestive of
asthma
• Perform chest examination
• Consider lung function testing
• Consider tests for bronchial
hyperresponsiveness in selected cases
ARIA Classification
Intermittent
. Š 4 days per week
. or Š 4 weeks
Mild
normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and school
& no troublesome
symptoms
in untreated patients
Persistent
. > 4 days per week
. and > 4 weeks
Moderatesevere
one or more items
. abnormal sleep
. impairment of daily
activities, sport,
leisure
. abnormal work and
school
. troublesome
symptoms
Medications for Allergic Rhinitis ARIA
sneezing
rhinorrhea
eye
symptoms
nasal
obstruction
nasal
itch
+++
+++
0 to +
+++
++
+++
0
+
0
++
0
0
Corticosteroids
++
0
+++
+++
+++
++
++
+
Cromones
intranasal
+
+
+
+
0
0
0
0
0
++
0
0
0
0
++
+
0
0
0
0
0
0
+++
+
0
++
0
0
0
++
H1-antihistamines
oral
intranasal
intraocular
intraocular
Decongestants
intranasal
oral
Anti-cholinergics
Anti-leukotrienes
Oral Antihistamines
• First generation agents
• Newer agents
Chlorpheniramine
Acrivastine
Brompheniramine
Azelastine
Diphenydramine
Cetirizine
Promethazine
Desloratadine Fexofenadine
Tripolidine
Levocetirizine Loratadine
Hydroxyzine
Mizolastine
Azatadine
Nasal Antihistamines
• Azelastine
• Levocabastine
• Olopatadine
Efficacy of an Antihistamine over 6 Months in
Persistent Allergic Rhinitis
Sneezing
*
0.8
Pruritus Nose
Pruritus Eyes
*
*
*
*
1.0
mean
Individual
symptom
score
improvement
Rhinorrhea
*
*
*
*
*
*
*
0.6
Congestion
*
0.4
0.2
0
* P<0.05
1 wk
6 mo
4 wk
1 wk
6 mo
4 wk
1 wk
6 mo
4 wk
1 wk
6 mo
4 wk
1 wk
6 mo
4 wk
Baseline total symptom score: 8.95
Levocetirizine, 5 mg, N = 276
Placebo, N = 271
Bachert C et al. J Allergy Clin Immunol 2004:114:838
Efficacy of an Antihistamine in the Treatment of
Allergic Rhinitis with Perennial Symptoms
(n= 337)
(n= 339)
Simons FER et al., J Allergy Clin Immunol 2003;111:617
Newer Generation Oral Antihistamines
Somnolence/Drowsiness
Active
Placebo
Data Source
Cetirizine
10 mg qd
13.7%
6.3%
www.PDR.net
Desloratadine
5 mg qd
2.1%
1.8%
www.PDR.net
Fexofenadine
60 mg bid
1.3%
0.9%
www.PDR.net
Levocetirizine
5 mg qd
6.8%
1.8%
Bachert et al
JACI
2004;114:838
Loratadine
10 mg qd
8%
6%
www.PDR.net
Newer Generation Oral Antihistamines
•
First line treatment for mild allergic rhinitis
•
Effective for
– Rhinorrhea
– Nasal pruritus
– Sneezing
•
Less effective for
– Nasal blockage
•
Possible additional anti-allergic and anti-inflammatory effect
• In-vitro effect > in-vivo effect
•
Minimal or no sedative effects
•
Once daily administration
•
Rapid onset and 24 hour duration of action
Decongestants: Alpha-2
Adrenergic Agonists
• Oral
Pseudoephedrine
• Nasal
Phenylephrine
Oxymetazoline
Xylometazoline
Decongestants: Alpha-2
Adrenergic Agonists
nasal septum
nasal
turbinates
nasal airway lumen
vasoconstriction
Decongestants
EFFICACY:
•
Oral decongestants: moderate
•
Nasal decongestants: high
ADVERSE EFFECTS:
•
Oral decongestants: insomnia, tachycardia, hyperkinesia
tremor, increased blood pressure, stroke (?)
•
Nasal decongestants: tachyphylaxis, rebound congestion, nasal
hyperresponsiveness, rhinitis medicamentosa
Cysteinyl-Leukotriene Production and
the CysLT1 Receptor
CysLT1
receptor
cytosolic
phospholipase A2
leukotriene C4
arachidonic
nucleus
acid
+
5-lipoxygenase
activating
protein
5-lipoxygenase
leukotriene A4
leukotriene C4
leukotriene D4
leukotriene E4
leukotriene C4
synthase
mast cells
basophils
eosinophils
macrophages
Efficacy of a CysLT1 Receptor Antagonist
in Allergic Rhinitis with Seasonal Symptoms
Daytime Nasal Symptoms Score
(0-3 point scale)
0
Change from
baseline
(mean, 95% CI)
-0.2
-0.4
-0.6
*
*
placebo, N=149
montelukast, N=155
mean baseline=2.0
*p<0.01 vs placebo
Adapted from Nayak, et al. Ann Allergy Asthma Immunol.
2002;88: 592
loratadine, N=301
Anti-Leukotriene Treatment in
Allergic Rhinitis
Efficacy
•
•
•
Equipotent to H1 receptor antagonists but with onset of
action after 2 days
Reduce nasal and systemic eosinophilia
May be used for simultaneous treatment of allergic
rhinitis and asthma
Safety
•
Dyspepsia (approx. 2%)
Nasal Corticosteroids
Beclomethasone dipropionate
Budesonide
Ciclesonide*
Flunisolide
Fluticasone propionate
Mometasone furoate
Triamcinolone acetonide
* Currently only approved for asthma
Nasal Corticosteroids
1
2
reduction of
mucosal mast cells
reduction of
mucosal inflammation
reduction of
late phase reactions
priming
nasal hyperresponsiveness
reduction of
acute allergic reactions
reduction of
symptoms and exacerbations
3
• suppression of
glandular activity
and vascular leakage
• induction of
vasoconstriction
Efficacy of Nasal Corticosteroid Sprays in Children with
Allergic Rhinitis and Seasonal Symptoms
Meltzer E. et al. J Allergy Clin Immunol. 1999;104:107.
Comparative Efficacy of Nasal
Corticosteroids
Mandl M. et al. Ann Allergy Asthma Immunol 1997;79:370
Nasal Corticosteroids
• Most potent anti-inflammatory agents
• Effective in treatment of all nasal symptoms
including obstruction
• Superior to anti-histamines and anti-leukotienes
• First line pharmacotherapy for persistent allergic
rhinitis
Nasal Corticosteroids
• Overall safe to use
• Adverse Effects
– Nasal irritation
– Epistaxis
– Septal perforation (extremely rare)
– HPA axis suppression (inconsistent and not
clinically
significant)
– Suppressed growth (only in one study with
beclomethasone)
Nasal Corticosteroid vs Placebo: Effects on 12-Hour
Urinary Free Cortisol in 2-3 Year-Old Children
6-week treatment
Value of 1 indicates
no change from baseline
1.0
0.8
Adjusted Geometric Mean 0.6
of the Change from Baseline 0.4
0.98
0.94
SE=1.14
SE=1.15
N=31
N=29
Fluticasone
Proprionate
Nasal Spray
200 µg daily
Placebo
0.2
0
Adapted from Galant, S. P. et al. Pediatrics 2003;112:96
Other Management Aspects
• Manage other co-morbidities:
– Allergic conjunctivitis
– Asthma
– Sinusitis…
• Environmental manipulations:
– allergen avoidance
– Pollution treatment
• Nutritional support
• Activities and sports
Environmental Control
1. Allergens
•
•
•
•
•
House dust mites
Pets
Cockroaches
Molds
Pollen
2. Pollutants and Irritants
House dust mite allergen avoidance
– Provide adequate ventilation to decrease humidity
– Wash bedding regularly at 60°C
– Encase pillow, mattress and quilt in allergen
impermeable covers
– Use vacuum cleaner with HEPA filter
– Dispose of feather bedding
– Remove carpets
– Remove curtains, pets and stuffed toys from
bedroom
Allergen Avoidance
•
Pets
• Remove pets from bedrooms and, even better, from the entire home
• Vacuum carpets, mattresses and upholstery regularly
• Wash pets regularly (±)
•
Molds
• Ensure dry indoor conditions
• Use ammonia to remove mold from bathrooms and other wet spaces
•
Cockroaches
• Eradicate cockroaches with appropriate gel-type, non-volatile, insecticides
• Eliminate dampness, cracks in floors, ceilings, cover food; wash surfaces, fabrics
to remove allergen
•
Pollen
• Remain indoors with windows closed at peak pollen times
• Wear sunglasses
• Use air-conditioning, where possible
• Install car pollen filter
To Conclude…
• Allergic rhinitis is very common and
causes considerable morbidity
• Adequate and appropriate treatment leads
to significant improvement in quality of life
• Co-morbid conditions are common and
warrants special attention and treatment
for optimal results
• Environmental manipulations is also
important in the control of disease
Thank you for staying awake!
Or, you may now wake up and ask
questions!