ALLERGIC RHINITIS

Allergic Rhinits: Definition

Allergic rhinitis is clinically defined as

a symptomatic disorder of the nose
induced by an IgE-mediated
inflammation after allergen exposure
of the membranes lining the nose

ARIA Report 2001

Natural History of AR
 Onset is common in childhood,
adolescence and early adulthood
 Symptoms often wane in older adults, but
may develop or persist at any age
 No apparent gender selectivity or
predisposition for developing allergic
rhinitis
 May contribute to other conditions such as
– Sleep disorders
– Fatigue
– Learning problems
Causes of AR
The Allergic
Reaction
 How are the symptoms
caused?
 Irritation of free
nerve endings---- Itching and sneezing

 Increased
mucus production ------ Rhinorrhoea

 Vasodilation -------- Congestion

 Increased
vascular permeability---- Oedema
 Clinical Manifestations

Others
 Repetitive sneezing
 Eye symptoms
 Watery rhinorrhea  Ear symptoms
 Nasal pruritus  Postnasal drainage

 Nasal congestion
 ARIA Classification
Intermittent
• < 4 days per week
• or < 4 weeks
Mild
normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and school
& no troublesome symptoms
Persistent
• ≥ 4 days per week
• and ≥ 4 weeks
Moderate-severe
one or more items
 abnormal sleep
 impairment of daily activities,
sport, leisure
 abnormal work and school
 troublesome symptoms
ARIA Report 2001
 Minimal Persistent
Inflammation
An underlying cause of
chronicity
An inflammatory process
which is actually present even
in asymptomatic subjects who
are exposed to allergens
 Concept of "minimal persistent
inflammation"
100
mite allergen (µg/g of dust)

10

Threshold level
1
for symptoms

0,1
0 2 4 6 8 10 12 Months

Symptoms Minimal persistent

inflammation

inflammation

Ciprandi et al, J Allergy Clin Immunol 1996

 Diagnosis of AR
 History
 Physical / Nasal Examination
 Laboratory Testing
- Skin Prick Test
- Peak Nasal Inspiratory Flow Rate
- Rhinomanometry
 PHYSICAL EXAMINATION
 Allergic shiner
 Dennie Morgan line
 Allergic crease
 Allergic salute
 Nasal mucosa may appear normal or pale bluish, swollen
with watery secretions but only if patient is symptomatic
 Exclude structural problems (polyps, deflected nasal
septum)

Others:
nasal voice, constant mouth breathing, frequent
snoring, coughing, repetitive sneezing, chronic open
gape of the mouth, weakness, malaise, irritability
 Management of AR
 Allergen Avoidance
 Pharmacotherapy
 Immunotherapy
 Pharmacotherapy
Medications used to treat allergic rhinits:

 Antihistamines
 Decongestants
 AH-D combinations
 Corticosteroids
 Mast Cell stabilizers
 Anticholinergics
 Antileukotrienes
 Actions of Various Nasal
Preparations in the Treatment
Nasal
of Rhinitis
Sneezing Itching Rhinorrhoea Congestion
Preparation
Antihistamine +++++ ++++ +++ 0
s
Anticholinergi 0 0 +++++ 0
cs
Corticosteroid +++++ +++++ +++ +++
s
Decongestant 0 0 + +++++
s
Mast cell +++++ +++ + 0
stabiliser

Antileukotri +++ ++ 0 ++++

enes
Anti-Histamines
 Act by preventing histamine from binding to
the H1-receptors
 Primarily helpful in controlling Sneezing,
itching & rhinorrhoea; ineffective in releiving
nasal blockage
 1st generation anti-histamines
- chlorpheniramine
- diphenylhydramine
 2nd generation anti-histamines
- cetrizine
- azelastine
- fexofenadine
- loratadine
 Intranasal corticosteroid
therapy
 Potent topical activity
 Administration of low doses directly at site
of action
 Considerable efficacy at low doses
 High topical: systemic activity ratios
 Rapid first-pass hepatic metabolism of any
systemically absorbed drug, to compounds
with negligible activity
 Markedly greater inhibition of EAR than
with oral steroids
The “Ideal” Drug For Allergic
Rhinitis Should Have The
Following Features:
 Inhibit both early and late phases
 Be an H1 blocker
 Counter effects of other mediators
 Fast-acting, to control the early phase
 Dosing-od or bd for compliance
 No side effects
 Manage all symptoms
 Intranasal administration
JACI 1999; 103:S388
The “Ideal” Drugs Are……

“Corticosteroids are undoubtedly

the pharmacotherapeutic agents
with the broadest application for
the treatment of many types of
rhinitis”
Otolaryngol Head Neck Surg 1992, 107, 855-60
 Management of Allergic Rhinitis
Allergen Avoidance

Intermittent Symptoms Persistent Symptoms

Mild Moderate-severe Mild Moderate-severe

Oral H1 blocker Oral H1 blocker Intranasal CS
Oral H1 blocker and/or LTRA
ntranasal H1blocker and/or LTRA If nose very blocked
and/or decongestant Intranasal H1 Intranasal H1 blocker and/or
add oral CS or decongestant
decongestant or LTRA
No Improvement : blocker and/or
switch or add decongestant Intranasal CS
LTRA Intranasal CS Review patient
after 2-4 weeks
Improved Not improved
No improvement
step up Step-down and continue
treatment for Review diagnosis, compliance, or other causes

Improved: continue for > 3 month

1 month
If intranasal CS
reduced by1/2

Itch/sneeze/rhinorrhea Rhinorrhea: Blockage: add LTRA or decongestant or oral CS

add H1 blocker add ipratropium (short term) or increase INCS

No improvement: refer to specialist