ALLERGIC RHINITIS :

The most prevalent of type I allergic dis. The symptoms and signs caused by mediators : vessels, glands and nerves. Classified as inflammatory disease.

ALLERGIC RHINITIS :

Sign & symptoms :

Itching nose Sneezing Rhinorrhea Nasal obstruction

Allergic salute

EPIDEMIOLOGY
Prevalence in ISAAC (Asher 1995) :
0.8 14.95 % in 6-7 years old 1.4 39.7 % in 13 14 years old

Low pervalence : Indonesia, Georgia, Greece Semarang (2002) ISAAC phase 3, RA : 18,6% High pervalence : Australia, UK and Latin America In adults : no equivalent to ISAAC study National survey : 5.9 % France and 29 % UK

WHO Classification of Allergic rhinitis

1. INTERMITTENT

2.

Less than 4 days a week, or Less than 4 weeks

PERSISTENT

More than 4 days a week, and More than 4 weeks

SEVERITY OF THE DISEASE

1. MILD means no one of the following items are present
Sleep disturbance

Impairment of daily activities / sport

Impairment of school / work Troublesome symptoms

2. MODERATE SEVERE, when one or more of the symptoms are present

PATOFISIOLOGI
(II) EARLY PHASE
A C U T E S Y M T O M S

LATE P H A S E
Mastosit

Rhinorea Sneezing Congestion (I)

IgE

IgE antibody

Histamine Triptase PGD2 LTs Cytokines

IgE

IgE-bearing B-cells
Th2 MHC -

CHRONIC
INFLAMMATION

Fragment

Basic proteins Lts Cytokines

HISTAMINE

(LATE PHASE)

Rhinorea Sneezing Congestion

Lts Cytokines

( Adapted from Creticos, 1998 )

MECHANISMS OF Allergic RHINITIS

Mast cell IgE allergen Immediate rhinitis symptoms Histamine Leukotrienes Itch, sneezing Prostaglandin's Watery discharge Bradykinin,PAF Nasal congestion

B cell
IL4 Chronic ongoing rhinitis

Th2 cell
IL 3, 5, GMCSF

eosinophils

Nasal blockade Loss of smell Nasal hyperreactivity

MAST CELL DEGRANULATION allergen Y Y Newly formed mediators

PLA2 AA + PAF
C.O 5 L.O

PGD2

LTC4 LTD4 LTE4

LTB

Preformed mediators Histamine, Heparin, Tryptase, TNF , TGF , IL 3, 4, 5, 13

HISTAMINE EFFECTS
HISTAMINE DEGRADATION
( histamine methyl transferase)

H1-R Nociceptive Nerves Vascular wall

CNS
Itch. Systemic Reflexes Sneeze Allergic Salute Parasympathic Reflexes Glandular Exocytosis

Endothelium
(Vascular Permeability)

Vasodilatation
Serous/Mucous Secretion

Diagram of DIAGNOSTIC PROCEDURES (1)

patients with AR symptoms

skin prick test

( history of illness + physical exam.)

(+) AR with AR without complications / complication concomitant dis

(-) eosinophil on nasal cytology

(+)
NARES

(-)

allergic Rhinitis ?

non allergic rhinitis

Diagnostic Procedures (2)

1. Anamnesis
Chief complain :

1. 2. 3.

Itching nose Sneezing : morning >> Serous nasal secretion

4.

Nasal obstruction at night

Diagnostic Procedures (3)

1. Anamnesis
The symptoms was environment related History of other allergic manifestation of patients and other allergic familial manifestations Duration of illness, severity of the disease and the respond of the previous treatment

Diagnostic Procedures
2. Physical examination
Should be performed with appropriate lighting and use of nasal speculum

normal

oedema

Diagnostic Procedures (5)

2. Physical examination

Including :
1. Nasal passage ways
2. Nasal mucosa 3. Turbinates 4. Secretion 5. Septum 6. Polyps ? 7. Sinusitis ?

Diagnostic Procedures (6)

3. Nasal cytology
Large number of eosinophils may aid to differentiate AR & NARES from other Rhinitis
No consensus to routinely performed for evaluation of rhinitis

Diagnostic Procedures (7)

4. Total serum Ig E
Neither very sensitive nor very specific 35 50 % AR Normal Ig E levels

Poor correlation with symptom and skin testing result

Diagnostic Procedures (8)

5. Nasal provocation testing
Based on a history of AR symptoms provoked by allergen exposure and confirmed by skin testing

It may be required for confirmation of sensitivity to allergen in the work place

Diagnostic Procedures (9)

6. Special diagnostic techniques
Upper airway endoscopy / Rhinomanometry Standard radiographs CT MRI

Diagnostic Procedures (10)

7. Testing for specific Ig E, important for :
Determining whether patient has allergic rhinitis

Identifying specific allergen for avoidance measurement and allergen immunotherapy

Diagnostic Procedures (11)

8. Skin testing to allergen :
Simple Ease Rapid performance Low cost High sensitivity / spesificity ( Prick test )

Allergy skin prick testing

Skin prick test :

positive result
wheal > 3mm diameter

A R and other diseases

OME
U R T infection

Allergic Rhinitis Bronkhial asthma Sinusitis

Nasal polyp

Comorbidity AR and Sinusitis

US : sinusitis 30 Mill / year (1989 )
sinusitis : 25 30 % AR non sinusitis : 14 17 % AR

Sinusitis ( dx CT ) Newman at all 1994 :

AR Asthma : 78 % : 71 %

Differential diagnosis of RA
Non allergic rhinitis :
Infectious : bacterial, viral, fungal Drug induced : aspirin & other medications Occupational rhinitis (allergy & non allergy) Hormonal : puberty, pregnancy, menstruation and hormonal disorders Other causes : foods, irritants, emotions, NARES Atrophic Rhinitis Idiopatic

Management of AR
Objectives :
relieving symptoms for improving QOL to avoid triggering factor to avoid / to treat complication to change the natural history

Allergen elimination
EDUCATION
Explain what is allergic rhinitis / reaction
Explain the meaning of pos. allergic skin test

Confirm whether there is correlation between allergen contact & rhinitis attack
Explain how to do allergen avoidance Encourage to avoid the allergens

Globally important allergens

mites

mites sources

pets : dogs cockroaches

pollen

weed

 Pharmacological treatment
1. ANTIHISTAMINE

First line Consider new antihistamine since :

Long acting more practical No sedating normal daily activity No / less cardiac effect Broad spectrum effects

Except :
Patient doesnt mind sedation effect It is not available Can not be afforded Classic antihistamine can be considered

2. NASAL DECONGESTANT Indicated in patient with prominent nasal obstruction complaint

As addition / combination with A H

Long term treatment Systemic nasal decongestant, be careful in hypertension cases and glaucoma. Topical : rebound effect

3. INTRANASAL CORTICOSTEROID
Long term treatment safer than systemic application Effective to control AR symptoms

Note :

Patients should be well informed how to use Symptoms relieve is not directly achieved In some places it is unavailable

 Allergen Specific Immunotherapy ( ASIT )

ASIT : effective for treating allergic rhinitis

Recommended in patients with :

severe symptoms failed by pharmacological treatment positive correlation skin test & history agree & well informed about duration, schedule of injection & expected results

Diagnosis of Allergic rhinitis Intermittent symptoms Persistent symptoms

Check for asthma

Mild Not in preferred order Oral H1 blocker or intranasal and/or decongestant

Moderate-severe
Not in preferred order

Mild

Moderate- severe
In preferred order

Intra nasal CS, H1 blocker Review after 2-4 weeks improved

Step-down & continue > 1mo

Oral/ intranasal H1 blocker And/ or decongestant or intranasal CS In persistent AR Review after 2-4 weeks If failure, step up If improved: continue for 1 mo

failure
Review : Dx, compliance Infection or other causes

Rhhinorrhea Increase Blockade, add intranasal CS add ipratropium decongestant or doses Oral CS

Failure: referred

Updated ARIA recommendation (Allergy Supl 86: 63 2008)

Consider specific immunotherapy

Intermittent AR : Adults & children

Is therapy needed ? If yes

Non-pharmacological therapy Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Oral/nasal AH or cromon Moderate disease Nasal corticosteroids Severe disease

Nasal CS & oral/ nasal AH

If inadequate control

Add further symptomatic treatment Or Short course oral CS Or Consider IT

Persistent AR : Adults Is therapy needed ? If yes

Non-pharmacological therapy Allergen avoidance measure Environment control

Is pharmacotherapy needed ? If yes

Mild disease Oral/ nasal antihistamine Moderate disease Nasal corticosteroids Severe disease

Nasal CS & Oral antihistamine

If inadequate control

If resistent

If resistent
Nasal blockage

Antihistamine and Oral / nasal decongestant Or Short course oral steroid

Rhinorrhea Nasal ipratropium bromide

If persistent
Consider Immunotherapy

If inadequate control
Further examination & consider immunotherapy Or Surgical turbinate reduction