35
• 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 :
• 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 :
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 – Less than 4 days a week, or– Less than 4 weeks
2. 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
( Adapted from Creticos, 1998 )
-
MHC
Fragment
Th2
PATOFISIOLOGI
CHRONIC
INFLAMMATION
(LATE PHASE)
RhinoreaSneezing
Congestion
ACUT
E
SYMTOMS
Rhinorea
Sneezing
Congestion
Basic proteins
LtsCytokines
HISTAMINELts
Cytokines
HistamineTriptasePGD2LTsCytokines
E A R L Y P H A S E
IgE-bearing B-cellsIgE-bearing B-cells
IgE antibody IgE antibody IgE IgE
IgE IgE
Mastosit
3
LATE P H A S E
(I)
(II)
MECHANISMS OF Allergic RHINITIS
Mast cell
HistamineLeukotrienesProstaglandin'sBradykinin,PAF
Itch, sneezingWatery dischargeNasal congestion
allergen
Th2 cell
B cell
eosinophils Nasal blockadeLoss of smellNasal hyperreactivity
IL4
IgE
IL 3, 5, GMCSF
Immediate rhinitis symptoms
Chronic ongoing rhinitis
MAST CELL DEGRANULATION
Histamine, Heparin, Tryptase, TNF , TGF , IL 3, 4, 5, 13
Newly formed mediators
PLA2 AA + PAF
C.O 5 L.O
PGD2 LTC4 LTB
LTD4
LTE4
Y
Yallergen
Preformed mediators
Y Y
Y
HISTAMINE
HH11-R-R
DEGRADATION( histamine methyl transferase)
CNS Endothelium(Vascular Permeability)
Nociceptive Nerves
• Itch.• Systemic Reflexes Sneeze Allergic Salute
Serous/Mucous Secretion• Parasympathic Reflexes Glandular Exocytosis
HISTAMINE EFFECTS
Vascular wall
Vasodilatation
Diagram of DIAGNOSTIC PROCEDURES (1)
patients with AR symptoms ( history of illness + physical exam.)
skin prick test
(+)
AR with complications / concomitant dis
AR without complication
eosinophil on nasal cytology
(+)
allergic Rhinitis ?
(-)
non allergic rhinitis
NARES
(-)
Diagnostic Procedures (2)
1. Anamnesis– Chief complain :
1. Itching nose
2. Sneezing : morning >>
3. 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
Allergic Rhinitis
O M E
Nasal polyp
Sinusitis
U R T infection
Bronkhial
asthma
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 : 78 %
– Asthma : 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
pollen
mites sources
weed cockroaches
pets : dogs
• 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 doesn’t 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
Updated ARIA recommendation
(Allergy Supl 86: 63 2008)
Intermittent symptoms Persistent symptoms
MildNot in preferred
orderOral H1 blocker
or intranasaland/or
decongestant
Moderate-severe Mild
Not in preferred orderOral/ intranasal H1 blocker
And/ or decongestantor intranasal CS
In persistent ARReview after 2-4 weeks
If failure, step upIf improved: continue for
1 mo
Moderate- severe
In preferred orderIntra nasal CS, H1 blocker
Review after 2-4 weeks
improved failure
Step-down& continue >
1mo Review : Dx, complianceInfection or other causes
Increase intranasal CS
doses
Rhhinorrheaadd ipratropium
Blockade, add decongestant or
Oral CS
Failure: referred
Consider specific immunotherapy
Diagnosis of Allergic rhinitis Check for asthma
Intermittent AR : Adults & children
Is therapy needed ? If yes
Non-pharmacological therapyAllergen avoidance measure
Is pharmacotherapy needed ? If yes
Mild disease Moderate disease Severe disease
Oral/nasal AH or cromon
Nasal corticosteroids
Nasal CS & oral/ nasal AH
Add further symptomatic treatment
OrShort course oral CS
Or Consider IT
If inadequatecontrol
Persistent AR : Adults Is therapy needed ? If yes
Non-pharmacological therapyAllergen avoidance measure
Environment control
Is pharmacotherapy needed ? If yes
Mild disease Moderate disease Severe disease
Oral/ nasal antihistamine
Nasal corticosteroids
Nasal CS & Oral antihistamine
If inadequatecontrol If resistent
If resistent
Nasal blockage
RhinorrheaAntihistamine and
Oral / nasal decongestant
OrShort course oral
steroid
Nasal ipratropium bromide
If persistent
ConsiderImmunotherapy
If inadequate control
Further examination & consider immunotherapy
Or Surgical turbinate reduction
