Diagnostic approach Diagnostic approach to the allergic patientto the allergic patient

Total

population

(n)

Asthma

(%)

Allergic

rhinitis

(%)

Skin

allergy

(%)

Insect

bite/sting

(%)

Food

allergy

(%)

Drug

allergy

(%)

Total 1637 14 14 8 3 6 8

Allergic conditions in Israel

AllergyAllergy

1906 1906

von Pirquet von Pirquet

immunity (a immunity (a beneficial effect) beneficial effect)

or allergic disease or allergic disease (a harmful effect). (a harmful effect).

AtopyAtopy

(from the Greek (from the Greek atopos,atopos, meaning out meaning out of place) is often used to describe of place) is often used to describe IgE-mediated diseases. IgE-mediated diseases.

Kay, A.B. N Engl J Med 2001;344:30-37

The Role of Cytokines Produced by Th2 Cells in Chronic Allergic Inflammation

Kay, A.B. N Engl J Med 2001;344:30-37

Pathways Leading to Acute and Chronic Allergic Reactions

Taking a history

Patient's account of symptoms

How long has the condition been present?

Impact on lifestyle: how frequent and severe is it?

Does it affect work, school, leisure time, sleep?

Seasonal or perennial?

Trigger factors: allergic or non-allergic?

Exposure to allergens through occupation or hobbies?

Allergens in the home

Does patient have history of asthma, eczema, rhinitis?

Drug or food induced?

Family history

Treatment: compliance, efficacy, side effects

What is the main symptom?

Chronic RhinitisChronic Rhinitis

Non- AllergicNon- Allergic Idiopathic rhinitisIdiopathic rhinitis NARESNARES Hormonal RhinitisHormonal Rhinitis Drug induced Drug induced

RhinitisRhinitis Food induced Food induced

RhinitisRhinitis Infective RhinitisInfective Rhinitis

AllergicAllergic Seasonal Seasonal

RhinitisRhinitis

Perennial Perennial RhinitisRhinitis

Occupational Occupational RhinitisRhinitis

גישה טיפולית מניעת חשיפה•

טיפול תרופתי •• corticosteroids• Antileukotrienes • Antihistamines

חיסונים •

Itchingsneezing

Rhinorrhea Nasalobstruction

Oralantihistamines +++ ++ +

Topicalcorticosteroids +++ +++ ++

Decongestant - - +++Ipatropium - +++ -Cromoglycate + + -

Effect of drug treatment

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

0 40 80 120 160 200 240 280 300

PLACEBO 60 mg 120 mg

Rapidity of Symptom ReliefM

ean

Sym

ptom

Sco

re(c

hang

e fr

om b

asel

ine)

Time (minutes)

Antiallergic and Anti-inflammatory Effects of Antihistamines

• Blocking anti H1 receptors

• Decreased released of some chemical mediators of inflammation from mast cells

• Decreased migration, accumulation and activation of cells

• Decreased production and activation of inflammatory products

First generation of First generation of AntihistaminesAntihistamines

Onset ofaction (h)

SedativeEffects

PossibleCardiaceffect

ChlorpheniramineMaleate (Ahiston)

2-3 Yes No

Hydroxizine(Otarex)

1-2 Yes No

Dimethidinemaleate (Fenistil)

2-3 Yes No

Second generation of Second generation of AntihistaminesAntihistamines

Onset ofaction (h)

SedativeEffects

PossibleCardiaceffect

Cetrizine(Zytrec)

1-2 NO NO

Loratidine(Lorastine)

1-2 NO NO

Fexofenadine(Telfast)

1-2 NO NO

Astemizole(Hismanal)

1-2 NO YES

Terfenadine(Ternalin)

1-2 NO YES

Effects of Fexofenadine, Diphenhydramine, and Alcoholon Driving PerformanceA Randomized, Placebo-Controlled Trial in the IowaDriving Simulator

John M. Weiler, MD; John R. Bloomfield, PhD; George G.Woodworth, PhD; Angela R. Grant, BS; Teresa A. Layton, BSN;Timothy L. Brown, MS; David R. McKenzie, MS; Thomas W. Baker,MS; and Ginger S. Watson, PhD

Annals of Internal Medicine. 2000; 132: 354-363

Durham S et al. N Engl J Med 1999;341:468-475

Median Weekly Pollen Counts and Symptom, Rescue-Medication, and Visual-Analogue Scores for the Initial Placebo Trial (1989) and for the Current Trial (1993 through 1995)

FUTURE THERAPIESFUTURE THERAPIES

Recombinant Recombinant allergensallergens

immunotherapyimmunotherapy

Anti-IgE therapyAnti-IgE therapy

AnticytokineAnticytokine

treatmenttreatment