Management of Allergic Rhinitis Dr Rubaiyat Haque Consultant Allergist.
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Transcript of Management of Allergic Rhinitis Dr Rubaiyat Haque Consultant Allergist.
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Management of Allergic Rhinitis
Dr Rubaiyat Haque
Consultant Allergist
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An introduction to allergy services in the UK
• Allergy traditionally dealt with by several specialties– Respiratory physicians– Dermatologists– ENT surgeons– Gastroenterologists– Clinical immunologists– Paediatricians
• Very little allergy training in medical school, general medical training and GP training
• An allergy ‘epidemic’
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• Rates of allergy are climbing rapidly
• 1 in 3 people suffer from some form of allergy during their lifetimes
• 3.3 million people in the UK have allergic rhinitis
• 5-7% of infants and 1-2% of adults have a food allergy
• 2% of adults have an allergy to wasp or bee stings
An increasingly common problem
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• Decision made to introduce specialist training in allergy in late 1990s– To provide an multisystem and comprehensive approach in dealing with
the rising burden of allergic disease
• Specialist allergy curriculum established in 2001– 5 year training programme– Based at one of 7 training centres in the UK (adult allergy)– Includes extended rotations in all the associated specialties– At least one year of research during training programme
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Adult allergy training centres in the UK
• Guy’s Hospital, London• The Royal Brompton Hospital, London• Southampton General Hospital• Addenbrooke’s Hospital, Cambridge• Glenfield Hospital, Leicester• Manchester Royal Infirmiary• Royal Liverpool University Hospital
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Rhinitis
Non-Allergic Allergic
Seasonal Perennial
• Pollens• Moulds
• Dust Mite• Moulds• Animals
• Vasomotor• Infective• Structural• Drugs• Hormonal• Polyps
Classification of rhinitis
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The allergist’s approach to allergic rhinitis
• History– Symptoms– Timing– Triggers
• Examination– Anterior rhinoscopy
• Investigations– Skin prick tests– Specific IgE tests
• Treatment– Allergen avoidance– Standard medical therapy– Immunotherapy
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History
• Nature of symptoms can give a clue to allergic or non-allergic origin– Nasal itching– Throat itching– Eye symptoms– Sneezing– Rhinorrhoea– Nasal Congestion– Anosmia– Sinus Pain
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Timing of symptoms – allergen identification
• Perennial– Dust mite– Animals– Fungal spores– Non-allergic
• Seasonal– Pollens– Fungal spores
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Triggers – allergen identification
• Pet exposure• Bed time• Dusting / vacuum cleaning• Building work• Gardening• Non-allergic triggers
– Smoke– Inorganic dust– Alcohol– Temperature changes
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Examination - Anterior Rhinoscopy
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Investigations – Skin Prick Testing
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Investigations – Specific IgE blood testing (RAST)
• Result given as an absolute value between 0 and >100 or as a class (0 to 6)
• Always interpret in context of clinical symptoms
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Treatment
• Allergen avoidance– It can work if you can avoid the allergen– House dust mite
• Mattress and pillow covers• Washing sheets at high temperature• Removing carpets• Vacuum cleaning with HEPA filtration
– Animals• Getting rid of pets
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Standard medical therapy
• Non-sedating antihistamines– Cetirizine– Loratadine– Fexofenadine (completely non-drowsy)
• Topical nasal steroids– By far the best single treatment– Good technique is important
• Topical eye treatment– Cromones– Antihistamines
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Standard medical therapy
• Montelukast• Avoid sympathomimetic decongestants
– Rhinitis medicamentosa
• Ideally start treatments before expected onset of symptoms• Continue treatment daily throughout hay fever season
• If allergen avoidance and optimised standard medical therapy fails: consider referring for immunotherapy
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Immunotherapy / Desensitisation
• Controversial history in UK• 3 year course of controlled allergen exposure• Produces long term reduction in symptom severity of about 30%• Long term reduction in requirement of standard treatment of about 40%• Administered as subcutaneous injections or sublingual tablets / drops• Perennial or seasonal courses• Risk of anaphylaxis with injections• Sublingual route is safer and probably as effective• Patients must be chosen carefully• Contra-indicated in poorly controlled asthmatics
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Questions?
www.consultantallergist.co.uk