22-Sep-16

1

Allergic Rhinitis, Asthma

& Dust Mite Allergy:Suspecting, Subduing & Solving

Dr Kymble Spriggs MBBS, MPH, DTMH, FRACP

Specialist Allergist & Immunologist

HealthEd Conference 2016

Take Home

Messages

• 1. Dust mite allergy is an important cause of

chronic allergic rhinitis and asthma - with persistent

unrecognised associated morbidity

• 2. Allergen Avoidance, Nasal Steroids and

Immunotherapy are all under-utilised.

• 3. GP’s are key! Patients rely on you to consider the

diagnosis and assist by educating, managing and

referring appropriately. Suspect, Subdue, Solve.

Myths &

Misconceptions:

No Treatment is necessary(!)

• Persistent Allergic Rhinitis and (mild) asthma is

seen as a minor complaint

• Not recognising to subacute effects on sleep,

cognition, and effects on other allergic disease

• Not aware of substantial disease modifying

treatments available

What is Allergic Rhinitis?

• “Inflammation of the lining of the nose”

• Allergic process: Stimulus —> Reaction

• Ambient Allergens

• Commonly called “hay fever”

Causes of

Allergic Rhinitis

• Exposure to allergen in those with sensitised

immune system.

• Main Allergen causes:

• House Dust Mite - usually persistent

• Grass Pollen - usually seasonal

• Animal Epithelia (cats, dogs & horses) - usually episodic

Who get’s

Allergic Rhinitis?

• Worldwide epidemic - 500mil & rising

• 25% of Europeans

• 30% of Americans

• 1 in 7 Australians in 2007-08

Allergic Rhinitis ('hay Fever') in Australia. Canberra, ACT: Australian Institute of health and Welfare, 2011. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420519.

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2

Allergic Disease

over ages

Allergy 4th Ed, Holgate et al (Eds), Chapter 13 (Werfel & Kapp) p269

Age Distribution

Allergic Rhinitis

Sibbald B & Rink E 1991. Epidemiology of seasonal and perennial rhinitis: clinical presentation and medical history. Thorax 46:895-901.

Australian Institute of Health & Welfare 2011

Focus on Dust Mites• Usually Persistent (but can fluctuate) during the

year.

• Chronicity —> Unrecognised/accepted by patients

• Association with persistent allergic asthma

Asthma &

Allergic Rhinitis are linked• Up to 80% asthmatic patients have co-existent allergic rhinitis

• Up to 40% of allergic rhinitis patients have asthma

• United airways hypothesis

• Same disease, different place?

• Contiguous organ

• Same cells / mediators

• Same medications

Pawankar 2002

Allergic Rhinitis as

Risk Factor for Asthma (1)

0

2

4

6

8

10

12

% of patients

who developed

asthma

no allergic rhinitis

at baseline

(n=528)

Allergic rhinitis

at baseline

(n=168)

p < 0.002

23-year follow-up of College freshman (n=738, average age 40)

Settipane, R J, G W Hagy, and G A Settipane. "Long-term Risk Factors for Developing Asthma and Allergic Rhinitis: A 23-year Follow-up Study of College Students." Allergy

proceedings : the official journal of regional and state allergy societies 15, no. 1 (1994): 21-5.

Allergic Rhinitis as

Risk Factor for Asthma (2)

Su

bje

cts

Incidence of asthma over an 8 year period

1. Linneberg A, et al. Allergy 2002;57:1048-52.

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3

Impact of

Allergic Rhinitis

Tanner LA et al. Am J Managed Care 1999;5(Suppl):S235

Allergic Rhinitis impairs patients’ QoL

What does

Allergic Rhinitis look like?

• Rhinorrhea/runny nose

• Sneezing

• Nasal congestion

• typically alternating with nasal cycle

• (if not, ?anatomical issue, polyp, etc)

Classical Symptoms

Unrecognised

Symptoms• Snoring/disturbed sleep

• Mental clouding (inflammatory mediators)

• Tiredness (due to above) —>

Classification (ARIA)

Intermittent

< 4 days/week

or < 4 weeks

Persistent

> 4 days/week

and > 4 weeks

vs

MildNormal sleep and

• no impairment of daily

activities, sports, leisure

• normal school and work

• no troublesome symptoms

Moderate/severeOne or more of:

• abnormal sleep

• impairment of daily

activities, sports, leisure

• abnormal school and work

• troublesome symptoms

vs

Based on: Bousquet, J, N Khaltaev, A A Cruz, J Denburg, W J Fokkens, A Togias, T Zuberbier, C E Baena-Cagnani, G W Canonica, and C

Van Weel. "Allergic Rhinitis and Its Impact on Asthma (ARIA) 2008*." Allergy 63, no. s86 (2008): 8-160.

Managment of

allergic rhinitis Stepwise and additive approach:

Mild

Intermittent

Moderate

Severe

Intermittent

Mild

Persistent

Moderate

Severe

Persistent

Allergen Avoidance

Antihistamine

Intranasal Corticosteroid (INCS)

Specific Allergen Immunotherapy

Symptoms

Therapy{simplified and adapted from:

Bousquet, J, N Khaltaev, A A Cruz, J Denburg, W J Fokkens, A Togias, T Zuberbier, C E Baena-Cagnani, G W Canonica, and C Van Weel. "Allergic Rhinitis and Its Impact on Asthma (ARIA) 2008*." Allergy 63, no.

s86 (2008): 8-160.

Adkinson, N Franklin, Jr, and Elliott, Jr Middleton. "Chapter 42 - Allergic and Nonallergic Rhinitis ." In Middleton's Allergy : Principles and Practice. Philadelphia, PA: Elsevier/Saunders, 2014.

Allergen

Avoidance

• “Ideal”

• Underused

• Complicated for ambient allergens

Mild

Intermittent

Moderate

Severe

Intermittent

Mild

Persistent

Moderate

Severe

Persistent

Allergen Avoidance

Antihistamine

Intranasal Corticosteroid (INCS)

Specific Allergen Immunotherapy

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4

Removing

Carpets and Soft Furnishings

• Reducing/removing carpets and other soft

furnishings IS EFFECTIVE

• But can be expensive and/or impractical

• Not often feasible for many people

• May not be enough/temporising measure for

some

Arlian, L G, and T A Platts-Mills. "The Biology of Dust Mites and the Remediation of Mite Allergens in Allergic Disease." The Journal of

allergy and clinical immunology 107, no. 3 Suppl (2001): S406-13.

Nurmatov, U, C P van Schayck, B Hurwitz, and A Sheikh. "House Dust Mite Avoidance Measures for Perennial Allergic Rhinitis: An Updated Cochrane Systematic Review." Allergy 67, no. 2 (2012): doi:10.1111/j.1398-9995.2011.02752.x.

HEPA air purifiers

• HEPA air purifiers —> will remove dust mite from

the air, but NOT effective in significantly changing

symptoms

• much of dust is “settled”, not airborne - so not

extracted.

• not useful in isolation, and costly

Arlian, L G, and T A Platts-Mills. "The Biology of Dust Mites and the Remediation of Mite Allergens in Allergic Disease." The Journal of

allergy and clinical immunology 107, no. 3 Suppl (2001): S406-13.

Nurmatov, U, C P van Schayck, B Hurwitz, and A Sheikh. "House Dust Mite Avoidance Measures for Perennial Allergic Rhinitis: An Updated Cochrane Systematic Review." Allergy 67, no. 2 (2012): doi:10.1111/j.1398-9995.2011.02752.x.

Misconception:

Environmental Changes Don’t Work

(or do they?)

• Special Dust Mite Covers - possibly effective (in

children)

• do reduce measurable dust (as do normal covers)

• no significant change in symptoms*

• comfort complaints, and costly

Arlian, L G, and T A Platts-Mills. "The Biology of Dust Mites and the Remediation of Mite Allergens in Allergic Disease." The Journal of

allergy and clinical immunology 107, no. 3 Suppl (2001): S406-13.

Nurmatov, U, C P van Schayck, B Hurwitz, and A Sheikh. "House Dust Mite Avoidance Measures for Perennial Allergic Rhinitis: An Updated Cochrane Systematic Review." Allergy 67, no. 2 (2012): doi:10.1111/j.1398-9995.2011.02752.x.

Halken, Susanne, Arne Høst, Ulla Niklassen, Lars G Hansen, Frank Nielsen, Søren Pedersen, Ole Osterballe, Chris Veggerby, and Lars K

Poulsen. "Effect of Mattress and Pillow Encasings on Children with Asthma and House Dust Mite Allergy." The Journal of allergy and

clinical immunology 111, no. 1 (2003): 169-76.

* one study showed a 1 year, 50% (active) reduction in steroid use in asthmatic children

Mountain Air

• IS EFFECTIVE

• Much lower Dust mite levels

• Temperature (low) & Humidity (Low)

• Much improved Asthma and Rhinitis Symptoms

• (Hence Alpine sanatoriums)

Spieksma, F Th M, Pw Zuidema, and M J Leupen. "High Altitude and House-dust Mites." Br Med J 1, no. 5740 (1971): 82-84.

Rijssenbeek-Nouwens, L H, and E H Bel. "High-altitude Treatment: A Therapeutic Option for Patients with Severe, Refractory Asthma?" Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology 41, no. 6 (2011): doi:10.1111/j.1365-2222.2011.03733.x.

Efficacy vs Cost

From: Colloff, Matthew J. "Dust Mites." In Dust Mites. Collingwood, VIC, Australia: CSIRO Publishing, 2009.

Antihistamines

• Very effective for mild symptoms

• Particularly good for intermittent

• Prophylactic on demand

• Non-drowsy* “modern” 2nd gen antihistamines

preferred

Mild

Intermittent

Moderate

Severe

Intermittent

Mild

Persistent

Moderate

Severe

Persistent

Allergen Avoidance

Antihistamine

Intranasal Corticosteroid (INCS)

Specific Allergen Immunotherapy

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INCS

Intranasal corticosteroids

• Mainstay of Treatment

• “Nose preventer”

• Under-utilised

• Effective for Allergic Rhinitis and Asthma

• Needs pep-talk and education from GP!• (takes > week)

• Technique

Mild

Intermittent

Moderate

Severe

Intermittent

Mild

Persistent

Moderate

Severe

Persistent

Allergen Avoidance

Antihistamine

Intranasal Corticosteroid (INCS)

Specific Allergen Immunotherapy

www.avidallergy.com

www.avidallergy.com

Immunotherapy

• Specific Allergen

• Immunotherapy/desensitisation

• Restores Tolerance —> induces durable

improvement in symptoms and reduction in

medication use

• Under-utilised

Mild

Intermittent

Moderate

Severe

Intermittent

Mild

Persistent

Moderate

Severe

Persistent

Allergen Avoidance

Antihistamine

Intranasal Corticosteroid (INCS)

Specific Allergen Immunotherapy

Long History

of Immunotherapy Use

• Over 100 years

• Both AR and AA

• Improving evidence base - especially as new

immunotherapy types come on to market

• Closest thing to a cure

Why is immunotherapy

under-utilised?

• Mainly lack of awareness

• Previously very specialised diagnostics

• Minimal allergy teaching and exposure in medical

school

• Not-reimbursed by PBS

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New options in

Dust Mite Immunotherapy • Injectable preparations

• Short and “0 Day” up-dosing schedules

• Monthly injections with GP

• Tablet preparations

• Sublingually dissolving tablets

• Daily dose under tongue at home

Time to benefit• in double blind placebo controlled trials

• statistically significant benefit after 3 months

Adapted from: Demoly, Pascal, Waltraud Emminger, Dorte Rehm, Vibeke Backer, Lene Tommerup, and Jörg Kleine-Tebbe. "Effective Treatment of House Dust Mite-induced Allergic Rhinitis with 2 Doses of

the SQ HDM SLIT-tablet: Results From a Randomized Double-blind, Placebo-controlled Phase III Trial." The Journal of allergy and clinical immunology (2015)doi:10.1016/j.jaci.2015.06.036.

Also demonstrable

Asthma controlRisk of a first moderate or severe asthma exacerbation

Adapted from:Virchow, J Christian, Vibeke Backer, Piotr Kuna, Luis Prieto, Hendrik Nolte, Hanne Hedegaard Villesen, Christian Ljørring, Bente Riis, and

Frederic de Blay. "Efficacy of a House Dust Mite Sublingual Allergen Immunotherapy Tablet in Adults with Allergic Asthma: A Randomized Clinical Trial."

JAMA 315, no. 16 (2016): doi:10.1001/jama.2016.3964.

Suspect

House dust mite allergy

• Persistent Allergic Rhinitis symptoms

• Persistent Asthma

• Persistent nasal congestion/loss of smell

Subdue

House dust mite allergy

• Educate and Encourage Allergen Avoidance

• Recommend - enthuse regular “Nose Preventers”

(and technique!)

• Help understand time course & effects of therapy

• May be all that is needed to effectively “fix” mild -

moderate cases and significantly improve asthma

Solve

House dust mite allergy

• Consider immunotherapy in all patients with

persistent symptoms

• Consider referral for specialist review - especially

for severe and in setting of incompletely controlled

asthma [NB: asthma must be controlled before

commencement]

• Co-manage ongoing immunotherapy treatment with

specialist and monitor improvements over time.

22-Sep-16

7

Take Home

Messages

• 1. Dust mite allergy is an important cause of

chronic allergic rhinitis and asthma - with persistent

unrecognised morbidity.

• 2. Allergen Avoidance, Nasal Steroids and

Immunotherapy are all under-utilised.

• 3. GP’s are key! Patients rely on you to consider the

diagnosis and assist by educating, managing and

referring appropriately. Suspect, Subdue, Solve.