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
Pollens
Fungi Grass

Occupational
Bakery,Dust Washing powder Latex,Drugs

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)

1.

Leukotrienes
hypersecretion of mucus oedema (Increased vascular permeability)

2.

Histamine
itching, rhinorrhea (Allergic rhinitis)

3.

Cytokines
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:

PERENNIAL
--Skin allergy test Symptoms include: itching, nasal block, Hyposmia, palatl itch, facial pain

Runny nose, itching, sneezing, nasal block

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 +++ ++ + _ AZELASTINE Nasal preparations

Anticholinergics
Decongestants Mast Cell Stabilizers Topical Corticosteroids

_
_ +

+++
+ +

_
+++ +

_
_ _

Ipratropium
Xylometazoline Oxymetazoline Sodium cromoglycate 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

Moderate-Severe Intermittent AR Nasal H1 blocker / Spray

Oral H1 blocker
Decongestants LTRA
LTRA= Leukotriene Receptor Antagonists

Oral H1 blocker Decongestants/LTRA/Chromone FLUTICASONE - 2

sprays/nostril OD

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

THANK YOU