ALLERGIC RHINITIS AND ITS IMPACT

ON ASTHMA (ARIA) UPDATE 2008

Suprihati
ENT Depart. Fac of Medicine Diponegoro Univ-Kariadi
Hospital, Semarang

INTRODUCTION
Allergic rhinitis :
a symptomatic disorder of the nose induced after
allergen exposure by IgE-mediated inflammation of
the membranes lining the nose
3 cardinal symptoms :
Sneezing
Nasal obstruction
Mucous discharge

The ARIA WHO workshop

Important achievement of ARIA WHO
workshop (1999) :

A new classification for Allergic rhinitis :

* Intermittent allergic rhinitis (IAR) and
* Persistent allergic rhinitis (PAR)
The severity of AR :
classical symptoms + impairments in how patients
function in day-to day life : * mild
* moderate to severe

Allergic rhinitis ARIA-WHO classification

Intermittent
Symptom:
< 4 days/ week
or < 4 weeks
Mild
normal sleep
normal daily activity,
sport, recreation
normal work & school
no disturbing symptom

Persistent
Symptom
* > 4 days/ week
* and > 4 weeks

Moderate-severe
abnormal sleep
abnormal daily activities
work and school problems
disturbing symptoms

Gloria 2001

Rational for updated of the ARIA

recommendations
some aspects of treatment (complementary &
alternative medicines )
links between upper & lower airways in developing
countries
sport & rhinitis in athletes
rhinitis & links with asthma in pre school children

1. Complementary & alternative medicines

are extensively used in the treatment of AR
difficult to propose ( not randomized, not
controlled, no quantitative measurement)
2. Links between upper & lower airways in
developing countries
Rhinitis is an independent risk factor of asthma
In developing countries rhinitis may be
independent
The prevalence generally low than in developed
country
may be because : under diagnosis
lack of awareness

3. Sport & rhinitis in athletes

Recommendation for athletes address the issue of
adapting dx and management to criteria set by
International Olympic Committee (IOC) and
regulations by the World Anti- Doping Agency ( WADA)
Ex : Oral glucocorticosteroids - prohibited by IOC and WADA
Oral B2-agonist
prohibited
Immunotherapy
prohibited
Topical steroid
- need notification
pseudoephedrine
- prohibited in competition

4. Rhinitis & links with asthma in pre school children

The nasal & bronchial mucosa : present similarities
Most important concepts : nose & lung interaction
is functional complementarity
Most patients with asthma have rhinitis concept
of one air one disease
In infant & very young children lower respiratory
tract symptoms often developed before nasal
symptoms

DIAGNOSIS OF ALLERGIC RHINITIS

Based on the combination of a typical history of AR
symptoms and diagnostic tests
Chief complain :
1. Itching nose
2. Sneezing : morning >>
3. Serous nose secretion
4. Nasal obstruction at night
History of other allergic manifestation of patients
and other allergic familial manifestations

Physical examination
Including :

Nasal passageways
Nasal mucosa
Turbinate
Secretions
Septum
Polyps ?
Sinusitis ?

IgE examination
Skin Prick Test (in vivo)
Simple
Rapid performance
Low cost
High sensitivity/ specificity
Total serum IgE (in vitro)
Neither very sensitive nor very specific
35 50 % AR Normal IgE levels
Poor correlation with symptom & skin
testing result

Algorithm DX

The patient
may be
allergic

Watery anterior and sneezing

yes
Nasal obstruction

The
patient is
likely to be
allergic

Symptoms occur at the

same time every year

Confirm diagnosis
for allergic rhinitis

No

The patient
is unlikely to
be allergic

Post nasal
drip
Colored discharge
and/or
facial pain

Confirm diagnosis
for rhinosinusitis

Suspect
chronic
rhinosinusitis

Symptoms suggestive of
Allergic Rhinitis
skin prick test
(-)

(+)

Allergic rhinitis

eosinophil on nasal
cytology
(+)

Classify and
assess severity

NARES

(-)
non allergic
rhinitis

MANAGEMENT OF AR
Objectives :
relieving symptoms for improving QOL
to avoid trigger factors
to change the natural history
to avoid / to treat complication

Relieving symptoms of AR
Pharmacologic treatment should take the following
factors into account:
Efficacy
Cost-effectiveness of medications
Patients preference
Objective of the treatment
Likely adherence to the treatment
Severity and control of the disease
The presence of co-morbidities

1. ANTIHISTAMINE
The first line of pharmacological treatment

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
- is not available
- can not be afforded
classic antihistamine can be considered

2. NASAL DECONGESTANT
Indicated in patient with prominent nasal
obstruction complaint
Long-term
As additiontreatment
/ combination with antihistamine
Systemic nasal decongestant, be careful in
hypertension cases & glaucoma.
Topical : rebound effect

3. INTRANASAL CORTICOSTEROID
long-term treatment safer than systemic
effective to control AR symptoms
notes :
* patients should be well informed how to use
* symptom relieve is not directly achieved
* in some places it is unavailable

To avoid trigger factors

EDUCATION
Explain what is AR / allergic reaction
Explain the meaning of pos. SPT
Confirm whether there is correlation
between allergen contact & rhinitis attack
Explain how to do allergen avoidance
Encourage to avoid the allergens

To change the natural history

SPECIFIC IMMUNOTHERAPY ( SIT )

SIT: effective for treating AR
Recommended in patients with :
severe symptoms
fail by pharmacological treatment
positive correlation SPT& history
agree & well informed about duration,
schedule of injection & expected results

Diagnosis of Allergic rhinitis

Intermittent symptoms
Mild
Not in preferred order

Oral H1 blocker
or intranasal
and/or
decongestant

Moderate severe

Persistent symptoms
Mild

Not in preferred order

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

Updated ARIA recommendation

(Allergy Supl 86: 63 2008)

Check
for
asthma

Moderate- severe
In preferred order

Intra nasal CS, H1 blocker

Review after 2-4 weeks
improved
Step-down
& continue
> 1mo
Increase
intranasal
CS doses

failure
Review : Dx, compliance
Infection or other causes

Rhhinorrhea
add
ipratropium

Blockade,
add
decongestant
or Oral CS

Failure: referred
Consider specific immunotherapy

Diagnosis of Allergic rhinitis

Intermittent symptoms

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

Diagnosis of Allergic rhinitis

Intermittent symptoms

Moderate-severe

Persistent symptoms

Mild

Not in preferred order

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

Diagnosis of Allergic rhinitis

Persistent symptoms

Moderate- severe
In preferred order

Intranasal CS, H1 blocker

Review after 2-4 weeks
improved

failure

Step-down & continue > 1mo Review : Dx, compliance

Infection or other causes
Blockade, add
Increase intranasal Rhinorrhea decongestant/
Oral CS
add ipratropium
CS doses

Failure: referred to specialist

Consider specific immunotherapy

Shekelle guide for level of evidence ( BMJ 1999;318: 593-96)

Level of evidence
Ia : Meta-analysis of RCT
Ib : at least one RCT
IIa : at least one controlled study without randomization
IIb : at least one other type of study
III : Nonexperimental descriptive study
IV : Expert committee reports / opinions

Strength of recommendation
A : category I evidence
B : Category II evidence or extrapolated from
category I
C : Category III evidence
D : category IV evidence