Allergic Rhinitis

Dr. Dinesh Kumar, Assistant Professor, ENT, GMC Amritsar

DefinitionAllergic rhinitis is clinically defined as a symptomaticdisorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose

Natural History

Onset is common in childhood, adolescence and early childhood .

Symptoms often wane in older adults, but may develop or persist at any age

Natural HistoryNo apparent gender selectivity or predisposition to developing AR

May contribute to a number of other conditions

Allergic rhinitis Inflammatory disorder of nasal mucosa,

characterized by pruritus, sneezing, rhinorrhoea and nasal congestion.

Adversely affects social life, school performance, and work productivity; especially in patients with severe disease

Loss of productivity, missed school and work days, and direct costs associated with treatment create substantial costs to society.

Lancet 2011; 378: 2112–22

An Allergic Reaction

Inflammatory Cells

Dendritic Cells

T- Cells

B-Lymphocyt

es

Mast Cells

Eosinophils

Moncytes &

Macrophages

Histamine Chemokines

Cytokines

Chemical Mediator

s

Leukotrines Prostaglandins

The Allergic reactionSensitization

Ig E Production

Arming of mast cells

Release of mediators

Clinical effects

Inflammatory cascade in allergic rhinitis

Adapted from Indian J Chest Dis Allied Sci. 2003 Jul-Sep;45(3):179-89

How are the symptoms causedItchingSneezing

Increased mucus production Rhinorrhea

Vasodilation CongestionIncreased vascular permeability Oedema

Irritation of free nerve endingsnerve endings

Classical Symptoms

Repetitive

Sneezing

Nasal Congesti

on

Watery Rhinorrh

eaNasal

Pruritus

Other ManifestationsEye Symptoms

Ear Symptoms

Post nasal drip

AR

Intermittent

Persistent

Mild

Moderate to Severe

Classification

Intermittent

< 4 days/week< 4 weeks

Persistent

> 4 days /week> 4 weeks

Mild

Normal sleep

No impairment of daily activit

No troublesome Symptoms in untreated patients

Moderate to Severe

Abnormal Sleep

Impairement of daily activity

Abnormal work

Troublesome Symptoms

Risk Factors for Allergic Disease

Family History

Season of Birth

Male Gender during

ChildhoodIncrease in pollution

Dietary Changes Obesity

Allergic Shiners

Allergic Salute and Crease

Allergic Conjuctivitis

AR & Co-morbiditiesOtitis Media

URTI

Sinusitis

Nasal Polyps

Asthma

Allergic rhinitis and diseases of the upper airway

Key factors important to normal PNS function

Patency of ostia

Function of ciliary apparatusQuality of secretions

AR and AsthmaApprox. 80% of patientswith asthma haveaccompanying symptomsof rhinitis, and up to 60%of the patients with asthmahave sinusitis

Possible Mechanisms by which RhinitisCould Provoke a Worsening of Asthma

Possible mechanism AR could provoke worsening of Asthma

Nasobronchial refex

Nasal Obstruction

PND

Management of Allergic Rhinitis•Allergen Avoidance

•Pharmacotherapy

•Surgery• Immunotherapy

First Generation AntihistaminesRapid onset of actionShort half lifeSignificant relief from rhinorrhoea

Easily cross blood brain barrier

Side Effects

Second Generation AHImprove selectivityHepatic and Cardiovascular side effects of terfanadine and astemizole

Non sedatingDemonstrated efficacy for AR symptoms

Wide Therapeutic Window of Second Generation AntihistaminesThe second generation H1-antihistamines have a rapid onset of action with persistence of clinical effects for at least 24 hours, so these drugs can be administered once a day.

They do not lead to the development of tachyphylaxis and show a wide therapeutic window (e.g. fexofenadine)

Significance of wide therapeutic window (fexofenadine)

Low H1-antihistamine dose High

Ineffective Therapeutic Window Not tested for adverse effects

Maximum Studied dose

(Fexo 1380 mg)

Minimallyeffective dose(Fexo 60 mg)

Howarth PH. Advanced Studies in Medicine. 2004;4(7A):S508-512

Third Generation AHMinimal side effectsIncreased duration of action

Positive effect on nasal airflow

Reduction in nasal congestion

Effects of leukotrienes on airways Increased levels in nasal fluid after

allergen challenge Contribute to both early and late

phase Nasal congestion Sneezing, rhinorrhea Chemoattractant for eosinophils Promote eosinophil adhesion Decrease eosinophil apoptosis

Leukotrine Inhibitors: Competitively block binding of leukotrines

to end organs. Montelukast is only FDA approved

Leukotrine inhibitor Montelukast reduces exhaled Nitric oxide,

a marker for airway inflammation Montelukast works through LC C4 and D$

which are found in upper airway Because Montelukast acts throughout the

airway this agent is a good choice for those with concurrent Asthma and AR

Rationale for antihistamine-montelukast combination in AR Histamine

Responsible for rhinorrhea, nasal itching and sneezing

Less evident effect on nasal congestion

Leukotrienes Increase in nasal airway resistance

and vascular permeabilityBlockage or inhibition of these two mediators may provide additional benefits compared to single mediator inhibition

Intra-nasal SteroidsWork mostly locally, thus avoid unwanted side effects associated with their oral or I/V use

• Newer formulations show even lower systemic absorption

• Most effective against late-phase mediators with some effect on acute phase response.

Intra-nasal SteroidsShould be used in a chronic manner

Higher dose results in greater benefit

Judicious use in children and pregnant women recommended

Large paed studies have not shown significant adverse effects

Intra-nasal Steroids First line drug in seasonal AR However for perennial AR

management with I/N steroids alone has not proved to be as beneficial

Depending upon severity of disease short courses of oral steroids in addition to topical symptomatic relief more

Fewer side effects (IOP)

Drug and Symptom MatrixDrugs and Symptoms Sneezing Itching Rhinorrhea CongestionAntihistamines ***** **** ***Anticholinergics (Ipratropium bromide) *****Corticosteroids ***** ***** *** ***Decongestants *****Mast Cell Stabilisers ***** *** *Antileukotrines *** ** ****

Algorithm for management of ARAllergic Rhinitis

Intermittent Symptoms Persistent Symptoms

Mild Moderate/Severe

MildModerate/Severe

• Oral H1 Blocker• Intranasal H1

Blocker• Leukotrine

modifier

• Intranasal Steroid• Oral H1 Blocker• Intranasal H1

Blocker• Nasal Cromone• Leukotrine modifier

In PAR Pt. FU after 2-4 wks.

If failure step up, if improved continue for one month

Intranasal Steroid

Follow up after 2 wks.

Improved

Failed

Step down

Review DxCompliance

Intranasal Steroid

Itch/sneeze add H1 Blocker

Rhinorrhea add Ipratropium Blockage: add oral

decongestant/steroid short term

ImmunotherapyInvolves the sequential administration of antigen to patients with symptomatic, atopic conditions to induce tolerance to offending antigens

Effective in treatment of both AR & Asthma

Generally safe and well tolerated

ImmunotherapyInjectable: Popular in US

Sublingual: Popular in Europe

Intranasal: Under investigation

Selections of candidates for ITSymptoms induced by allergen exposure

Patients with rhinitis and symptoms from lower airway during peak allergen exposure

Insufficient control of symptoms with AH and/or topical steroids

Summary… Allergic rhinitis is associated with several

co-morbidities and affects quality of life and productivity

Second generation antihistamines are recommended for treatment of allergic rhinitis in adults and children; fexofenadine has proven efficacy, is devoid of sedation and has wide therapeutic window

Leukotrienes play key role in allergic rhinitis; montelukast is most throroughly tested leukotriene antagonist

Summary

Antihistamine-montelukast combination seems to be a more effective strategy than monotherapy in the treatment of allergic rhinitis in patients with moderate to severe symptoms

Fexofenadine-montelukast combination yields significant reduction in nasal congestion and nasal resistance in allergic rhinitis vs. fexofenadine

Drug and Symptom MatrixDrugs and Symptoms Sneezing Itching Rhinorrhea CongestionAntihistamines ***** **** ***Anticholinergics (Ipratropium bromide) *****Corticosteroids ***** ***** *** ***Decongestants *****Mast Cell Stabilisers ***** *** *Antileukotrines *** ** ****

Place in therapy for antihistamine-montelukast combination

Allergic rhinitis with nasal congestion

Allergic rhinitis with moderate-to-severe symptoms

Blessings from the Holy City…….

A very cordial invitation to all of you to the 5th

AOIPBCON being organized

at M K Hotel Amritsar

on 13th and 14th April 2013.

Guest Faculty

Dr. Renuka Bradoo

Dr. Ashok Gupta

Dr. Vikas Kakkar

Dr. Anil Monga

Dr. K K Handa

Thankyou !!!!!!