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Diagnostic approach to the allergic patient Allergic conditions in Israel Total Asthma Allergic Skin Insect Food Drug population (%) rhinitis allergy bite/sting allergy allergy (%) (%) (%) (%) (%) 14 8 3 6 8 (n) Total 1637 14 Allergy 1906 von Pirquet immunity (a beneficial effect) or allergic disease (a harmful effect). Atopy (from the Greek atopos, meaning out of place) is often used to describe IgEmediated diseases. 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 Kay, A.B. N Engl J Med 2001;344:30-37 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 Rhinitis Non- Allergic Idiopathic rhinitis NARES Hormonal Rhinitis Drug induced Rhinitis Food induced Rhinitis Allergic Seasonal Rhinitis Perennial Rhinitis Occupational Rhinitis גישה • מניעת חשיפה טיפולית • טיפול תרופתי corticosteroids• Antileukotrienes • Antihistamines • • חיסונים Effect of drug treatment Itching Rhinorrhea Nasal sneezing obstruction Oral antihistamines +++ ++ + +++ +++ ++ Decongestant - - +++ Ipatropium - +++ - Cromoglycate + + - Topical corticosteroids Rapidity of Symptom Relief Time (minutes) Mean Symptom Score (change from baseline) 0 40 80 120 160 200 240 280 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 PLACEBO 60 mg 120 mg 300 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 Antihistamines Onset of Sedative action (h) Effects Possible Cardiac effect Chlorpheniramine Maleate (Ahiston) 2-3 Yes No Hydroxizine (Otarex) 1-2 Yes No Dimethidine maleate (Fenistil) 2-3 Yes No Second generation of Antihistamines Onset of Sedative action (h) Effects Cetrizine (Zytrec) Loratidine (Lorastine) Fexofenadine (Telfast) Astemizole (Hismanal) Terfenadine (Ternalin) Possible Cardiac effect 1-2 NO NO 1-2 NO NO 1-2 NO NO 1-2 NO YES 1-2 NO YES Effects of Fexofenadine, Diphenhydramine, and Alcohol on Driving Performance A Randomized, Placebo-Controlled Trial in the Iowa Driving 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 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) Durham S et al. N Engl J Med 1999;341:468-475 FUTURE THERAPIES Recombinant allergens immunotherapy Anti-IgE therapy Anticytokine treatment