Download allergic rhinitis Gawronska

Allergic rhinitis
Ewa Gawrońska- Ukleja
Allergic rhinitis
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Tradicional classification of allergic rhinitis include :
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Seasonal allergic rhinitis (hay fever)
Perennial allergic rhinitis
This classification is very practical, and very good for Polish
climatic zone.
However in other countries hay season is present all year
round, so the symptoms appear also during the whole year.
Similary allergy to dust also can be seasonal.
This is the reason why the new classification contains
seasonal (intermittent) and persistent (chronic) allergic
rhinitis. Both can have mild, moderate and severe form.
New classification
Allergic rhinitis
Seasonal
Persistant
Symptoms < 4 days In the week
or
< 4 weeks
Symptoms ≥ 4 days In the week
And
≥4 weeks
Mild
Moderete
And
Severe
Mild
Moderete
And
Severe
Without sleep
disorders, normal
daily activity
With sleeping
disorders, influence
of daily activity,
concentration
Without sleep
disorders, normal
daily activity
With sleeping
disorders, influence
of daily activity,
concentration
Hay fever (seasonal allergic rhinitis)
Definition (ARIA)
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Seasonal allergic rhinitis is a symptomatic
disorder of the nose induced after allergen
exposure by an immunoglobulin E (IgE)mediated inflammation of the membranes lining
the nose. The three cardinal symptoms in nasal
reactions occurring in allergy are sneezing, nasal
obstruction and mucous discharge’.
History

Although asthma and other forms of allergic disease
have been described in antiquity, ‘hay fever’ is
surprisingly modern. Very rare descriptions can be
traced back to Islamic texts of the 9th century and
European texts of the 16th century. It was only in the
early 19th century that the disease was carefully
described, and at that time it was regarded as most
unusual . In the 19th century, the disease followed the
industrialization of westernized countries. By the end of
the 19th century it had become commonplace in both
Europe and North America.
Epidemiology

Depends of climatic zone, between 1–40% of
people are affected by seasonal allergic rhinitis.
The biggest morbidity is in Great Britain, RSA,
Peru, Paraguay, Philippines. In Europe the
average frequency is between 10 – 20%, in
Poland about 4,1-12,2%, and in 5-13,3% of
children. However the new research of ECAP
(Polish Epidemiology of allergic diseases) shows
that morbidity is increasing very fast and now is
about 21-25%
Symptoms
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The characteristic symptoms of allergic rhinitis
are: rhinorrhea (excess nasal secretion), itching,
and nasal congestion and obstruction. First
symptoms can appear in a new born, but disease
usually starts between 5-15.
Seasonal allergic rhinitis is more common in
cities then in villages.
Allergic rhinitis is a multifactor disease with
genetic as well as environmental factors
influencing disease development. Main gens of
pollenossis are located on many chromosomes.
Etiology
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Risk factors for allergic rhinitis are well identified.
Indoor and outdoor allergens as well as occupational
agents cause rhinitis and other allergic diseases.
The role of indoor and outdoor pollution is probably
very important, but has yet to be fully understood both
for the occurrence of the disease and its manifestations.
In Poland the most common allergy in patients with
AR is allergy to grass (above 82%), the second are trees
and third weeds.
Etiology

The scientist consider the allergens of moulds
(Cladosporium, Alternaria) as a risk factor of
seasonal rhinitis symptoms.
Pathomechanism
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In susceptible individuals, exposure to certain foreign
proteins leads to allergic sensitization, which is
characterized by the production of specific IgE directed
against these proteins.
This specific IgE coats the surface of mast cells, which
are present in the nasal mucosa.
When the specific protein (eg, a specific pollen grain) is
inhaled into the nose, it can bind to the IgE on the
mast cells, leading to immediate and delayed release of a
number of mediators
Pathomechanism

TYPE I HYPERSENSITIVITY is the most
characteristic reaction in AR. It contains two phase
First one – early phase :
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The mediators that are immediately released include
histamine, tryptase, chymase, kinins, and heparin.
The mast cells quickly synthesize other mediators, including
leukotrienes and prostaglandin D2.
These mediators, via various interactions, ultimately lead to
the symptoms of rhinorrhea (nasal congestion, sneezing,
itching, redness, tearing, swelling, ear pressure, postnasal
drip).
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Mucous glands are stimulated, leading to
increased secretions.
Vascular permeability is increased, leading to
plasma exudation.
Vasodilation occurs, leading to congestion and
pressure.
Sensory nerves are stimulated, leading to
sneezing and itching.
All of these events can occur in minutes; so this
reaction is called the early, or immediate, phase
of the reaction.

Second phase – late phase
Over 4-8 hours, these mediators, through a complex
interplay of events, lead to the recruitment of other
inflammatory cells to the mucosa, such as
neutrophils, eosinophils, lymphocytes, and
macrophages.
 This results in continued inflammation, termed the
late-phase response.
 The symptoms of the late-phase response are similar
to those of the early phase, but less sneezing and
itching and more congestion and mucus production
tend to occur.
 The late phase may persist for hours or days.

Clinical presentation
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The characteristic symptoms of allergic rhinitis
contain:
Nose:
Sneezing
Itching
Watery rhinorrhea
Loss of the sense of smell
Nasal congestion and obstruction
Clinical presentation
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
-
Eyes
Tearing eyes
Itchy eyes
Redness
Conjunctivitis
Ears
Itchy ears
Swollen Eustachian Tube
Clinical presentation
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-
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Other organs
Atopic dermatitis
Symptoms of asthma
Fever
Headache
Sleeping disorders
Physical examination
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The physical examination should focus on the
nose, but examination of facial features, eyes,
ears, oropharynx, neck, lungs, and skin is also
important.
Look for physical findings that may be
consistent with a systemic disease that is
associated with rhinitis!
Typical appearance
Allergic salute
Physical examination
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The mucosa of the nose may be swollen and
have a pale, bluish-gray color.
Some patients may have predominant erythema
of the mucosa, which can also be observed with
rhinitis medicamentosa, infection, or vasomotor
rhinitis.
Physical examination
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Perform otoscopy to look for tympanic
membrane retraction, air-fluid levels, or bubbles.
Performing pneumatic otoscopy can be
considered to look for abnormal tympanic
membrane mobility.
These findings can be associated with allergic
rhinitis, particularly if eustachian tube
dysfunction or secondary otitis media is present.
Physical examination
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Ocular examination may reveal findings of injection
and swelling of the palpebral conjunctivae, with excess
tear production.
The term "cobblestoning" is used to describe streaks of
lymphoid tissue on the posterior pharynx, which is
commonly observed with allergic rhinitis.
Tonsillar hypertrophy can also be observed.
Malocclusion (overbite) and a high-arched palate can be
observed in patients who breathe from their mouths
excessively.
Diagnostics
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Skin prick test – gold standard
Prick by Prick tests with native allergens to confirm
food allergy
Total IgE level – low meaning
Specific IgE – good senstivity and specificity
Phadiatop test
Provocation test with cytological estimation of nose
mucose membrane
Spirometry in the case of asthma symptoms
Treatment
The management of allergic rhinitis consists of 3
major categories of treatment
1. Environmental control measures and allergen
avoidance
2. Pharmacological management
3. Immunotherapy

Treatment
1. Environmental control measures and allergen
avoidance involve both the avoidance of known
allergens (substances to which the patient has
IgE-mediated hypersensitivity) and avoidance of
nonspecific, or irritant, triggers. Consider
environmental control measures, when practical,
in all cases of allergic rhinitis. However, global
environmental control without identification of
specific triggers is inappropriate.
Treatment
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Pollens and outdoor molds
Because of their widespread presence in the
outdoor air, pollens can be difficult to avoid.
Reduction of outdoor exposure during the season
in which a particular type of pollen is present can
be somewhat helpful.
In general, tree pollens are present in the spring,
grass pollens from the late spring through summer,
and weed pollens from late summer through fall,
but exceptions to these seasonal patterns exist
Treatment
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Indoor allergens
Depending on the allergen, environmental control measures
for indoor allergens can be quite helpful.
For dust mites, covering the mattress and pillows with
impermeable covers helps reduce exposure.
Bed linens should be washed every 2 weeks in hot water to
kill any mites present. Thorough and efficient vacuum
cleaning of carpets and rugs can help, but, ultimately,
carpeting should be removed. The carpet can be treated with
one of a number of chemical agents that kill the mites or
denature the protein, but the efficacy of these agents does
not appear to be dramatic.
Dust mites thrive when indoor humidity is above 50%, so
dehumidification, air conditioning, or both is helpful.
Treatment of symptoms
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1.
2.
3.
4.
5.
The goal of rhinitis treatment is to prevent or
reduce the symptoms caused by the
inflammation of affected tissues. Treatments
for allergic rhinitis include :
ANTIHISTAMINES
CORTICOSTERIDES
DECONGESTANTS
LEUKOTRIENE INHIBITOR
Anty IgE theraphy
ANTIHISTAMINES DRUGS
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Good for treating allergy symptoms, especially when
symptoms occure not very often or do not last for a
long time.
Available in both oral and nasal spray forms
Antihistamines suppress the histamineinduced wheel (swelling) and vasodilatation (flare)
response by blocking the binding of histamine to its
receptors on nerves, vascular smooth muscle, glandular
cells, endothelium, and mast cells. They effectively exert
competitive antagonism of histamine for H1-receptors.
Itching and sneezing are suppressed by antihistamine
blockade of H1-receptors on nasal sensory nerves.
ANTIHISTAMINES
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Sedation is a common side effect, and some
H1 antagonists, such
as diphenhydramine and doxylamine, are also
used to treat insomnia. However, second
generation antihistamines do not cross the blood
brain barrier, and as such do not cause
drowsiness.
ANTIHISTAMINES
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ANTIHISTAMINES available in Poland
(second generation)
Cetirizine
Zyrtec, Alertec
Loratadine
Clarytyna, Loratydyna
Levocetirizine
Xyzal
Fexofenadine
Telfast
Desloratadine
Aerius
Ebastine
Kestine
ANTIHISTAMINES
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Azelastine is a antihistamine nasal spray that is
used to treat allergic rhinitis
Nasal corticosteroids
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These prescription sprays reduce inflammation
of the nose and help relieve sneezing, itching,
and runny nose. It may take a few days to a
week to see improvement in symptoms.
Beclomethasone
Fluticasone
Mometasone
Triacinolone
Decongestants
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They are often used with antihistamines.
Oral and nasal decongestants -- Include
oksymethazolin, ksylomethazolin, naphazolin. Some
decongestants may contain pseudoephedrine, which can
raise blood pressure. People with high blood pressure
or enlarged prostate should not take drugs containing
pseudoephedrine. Using nasal decongestant sprays for
more than 3 days can cause "rebound congestion,"
which makes congestion worse.
Anti IgE therapy
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Omalizumab is a monoclonal antibody targeted
against the high-affinity receptor binding site on
human immunoglobulin (IgE). Bound IgE is not
available for basophile binding, degranulation is
attenuated, and allergic symptoms are reduced.
Leukotriene modifiers
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These prescription drugs block the production
of leukotrienes, which are inflammatory
chemicals produced by the body. They are taken
once a day and do not cause sleepiness, and are
also used to treat allergic asthma. Leukotriene
modifiers include montelukast (Singulair) and
zafirlukast.
Other drugs
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Cromolyn sodium (NasalCrom)
This nasal spray prevents the release of histamine and helps relieve
swelling and runny nose. It works best when taken before
symptoms start and may needed to be used several times a day.
Nasal atropine
Ipratropium bromide (Atrovent) is a prescription nasal spray that
can help relieve a very runny nose.
Eye drops
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Antihistamine eye drops - relieve both nasal and eye symptoms.
Examples include azelastine, olopatadine, ketotifen, and
levocabastine
Decongestant eye drops -- such as phenylephrine and naphazoline
Immunotherapy
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Is recommended if the allergen cannot be
avoided and if symptoms are hard to control.
This includes regular injections of the allergen,
given in increasing doses (each dose is slightly
larger than the previous dose) that may help the
body adjust to the antigen.
Persistent allergic rhinitis

It is a chronic IgE – depend, mucose membrane
inflammatory process with clinical symptoms. It
occur in every season or all year. The symptoms
are almost the same like in seasonal allergic
rhinitis, but without conjunctivitis.
Epidemiology
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Depends of country, between 10-20% of people
suffer from persistent allergic rhinitis. In Poland
morbidity is now about 3% in adults and 2,1 % in
children. Disease usually starts before 30.
Causes
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The most common cause of persistent rhinitis is
an allergy to house dust mite. However, allergy
to pets, other animals, indoor moulds is also
common. Occasionally it can be food allergy.
Patomechanism
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The same like in seasonal allergic rhinitis
Clinical presentation
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The symptoms are almost the same like in
seasonal allergic rhinitis, but without
conjunctivitis. Nasal congestion and obstruction
are main symptoms
Differention of clinical symptoms
Symptom
Seasonal
Persistent
Nose obstruction
+/-
Always
Excretion
Watery, often
Mucus or serum
Sneezing
Always
Sometimes
Lack of smell
+/-
Often
Eye symptoms
Often
Rare
Asthma
Occasionally
Often
Chronic sinusitis
Rare
Often
Diagnostics
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Interview
Skin prick test – gold standard
Total IgE level – low meaning
Specific IgE – good sensitivity and specificity
Provocation test with cytological estimation of
nose mucose membrane
Spirometry
Treatment
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There is a lack of good quality evidence in
clinical trials and studies for the effectiveness of
reducing the numbers of house dust mites in
terms of reducing rhinitis symptoms
Avoiding the cause of allergy by :
reduce the number of mites in your home
regular cleaning and vacuuming with particular
attention to your bedroom and bedclothes
give up the pet
washing pets regularly can also help
Allergic rhinitis therapy by ARIA
Immunotherapy
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Can be also helpful to decrease symptoms and
improve quality of life.
AR & Asthma
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Allergic rhinitis is one of the multiple risk
factors identified for asthma development.
Patients with persistent allergic rhinitis should
be diagnose for asthma. About 20% of children
treated because of allergic rhinitis for more then
10 years develop asthma.
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Thank you for your attention !!!