allergic and non-allergic rhinitis. objectives who cares? why? what else could it be? gazoontite...
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Allergic and Non-Allergic RhinitisAllergic and Non-Allergic Rhinitis
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ObjectivesObjectives
• Who cares?
• Why?
• What else could it be?
• Gazoontite
• Can’t we just give them Allegra and Flonase?
• Do they really need an Allergy consult?
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Allergic Rhinitis: EpidemiologyAllergic Rhinitis: Epidemiology
• In US, affects 80 million people annually– 10-30% adults affected– Up to 40% children
• 80% cases develop before age 20
• In childhood, males > females
• In adulthood, males = females
• Prevalence is increasing
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Allergic Rhinitis: The ImpactAllergic Rhinitis: The Impact
• 28 million restricted activity days each year
• 2 million missed school days each year
• 3.4 million missed work days each year
• Decreased productivity in US labor force– $2.4 billion for men– $1.4 billion for women
• Estimated $3 billion per year on Rx meds
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Rhinitis: The DefinitionRhinitis: The Definition
• Inflammation of the membranes lining the nose characterized by:– Nasal congestion– Rhinorrhea – Sneezing– Pruritis– Postnasal drainage
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Rhinitis: ClassificationRhinitis: Classification
• Allergic– ~ 50% cases– IgE-mediated reaction due to exposure to
airborne allergens– Seasonal, perennial, episodic, occupational
• Non-allergic– Infectious– Non-infectious
• Vasomotor, atrophic, hormonal, exercise, drug, reflex-induced, occupational
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Allergic Rhinitis: Risk FactorsAllergic Rhinitis: Risk Factors
• Family history of atopy
• Serum IgE > 100 IU/ml before 6 yo
• Higher socioeconomic class
• Non-Caucasians
• First born children
• Exposure to cigarette smoking in infancy
• Exposure to indoor allergens
• Presence of positive allergy prick skin tests
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Re-exposureRe-exposure
SensitizationSensitization
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Allergic Rhinitis: PathophysiologyAllergic Rhinitis: Pathophysiology
• Early allergic response, within minutes– Mast cell degranulation
• Preformed: Histamine, tryptase, chymase• Newly formed: Prostaglandins, cysteinyl leukotrienes
– Vascular leakage – edema, watery rhinorrhea– Exocytosis of mucosal glands– Vasodilation – nasal obstruction– Stimulation of sensory nerves – nasal itch,
congestion– Systemic reflexes – sneezing paroxyms
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Allergic Rhinitis: PathophysiologyAllergic Rhinitis: Pathophysiology
• Late phase response– Within 4-8 hours – Inflammatory cells attracted - basophils,
eosinophils, neutrophils, mononuclear cells, T helper lymphocytes
– Nasal congestion predominates– Sneezing, rhinorrhea, pruritis
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Symptoms of Allergic RhinitisSymptoms of Allergic Rhinitis
Classic• Sneezing paroxysms• Nasal pruritis• Nasal congestion• Clear rhinorrhea• Palatal itching
Associated• 20% asthma sx• Post nasal drip• Itchy, watery eyes• Ear fullness, popping• Itchy throat• Sinus pressure• Mouth breathing,
snoring
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PrimingPriming
• Exposed to allergen for days to weeks
• Significant inflammation – Increase numbers of mast cells– Upregulation of IgE receptors and surface
bound IgE on mast cells– Nonspecific nasal hyperreactivity– Influx of eosinophils, other inflammatory cells
• As allergy season progresses, 10-100 fold less allergen needed to cause sx
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Progression of Symptoms During Progression of Symptoms During Allergy SeasonAllergy Season
• Symptoms related to infiltration of inflammatory cells– Mucus hypersecretion– Tissue edema– Goblet cell hyperplasia– Tissue damage
• Primed mast cells• Role of histamine diminishes• Antihistamines less effective
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Which plant is more allergenic?
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Seasonal Allergic Rhinitis (SAR)Seasonal Allergic Rhinitis (SAR)
• Trees - Spring
• Grasses - Summer
• Weeds - Fall
• Outdoor molds – Summer and Fall
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Perennial allergic rhinitis (PAR)Perennial allergic rhinitis (PAR)
• Usually indoor allergens– Dust mites– Cockroach– Perennial molds– Animal danders
• Nasal congestion and post nasal drip may predominate
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Associated ConditionsAssociated Conditions
• Asthma
• Sinusitis
• Otitis media
• Nasal polyposis
• Lower respiratory tract infections
• Dental occlusions
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Allergic Rhinitis and its Impact on Allergic Rhinitis and its Impact on Asthma (ARIA)Asthma (ARIA)
"One airway, one disease "
Bousquet J. et al. JACI 2001;108:S147-334.Bousquet J. et al. JACI 2001;108:S147-334.
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ARIA “One airway, one disease”ARIA “One airway, one disease”
• Rhinitis and asthma are co-morbidities – Linked by epidemiologic, pathologic, and physiologic
characteristics
• AR considered a risk factor for asthma• Patients with AR should be screened for asthma
and vice versa• Combined strategy to treat upper and lower
airway disease• New classification system for AR• Stepwise therapeutic approach
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Moderate-severe
one or more items. abnormal sleep. impairment of daily
activities, sport, leisure. abnormal work and
school. troublesome symptoms
Persistent . ≥ 4 days per week . and ≥ 4 weeks
Mild normal sleep& no impairment of daily
activities, sport, leisure
& normal work and school
& no troublesome symptoms
Intermittent
. < 4 days per week
. or < 4 weeks
ARIA ClassificationARIA Classification
in untreated patients
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Non-Allergic Rhinitis (NAR)Non-Allergic Rhinitis (NAR)
• Sporadic or persistent perennial rhinitis sx• Not IgE-mediated• Infectious• Hormonal• Vasomotor• Non-allergic rhinitis with eosinophilia (NARES)• Occupational• Gustatory• Drug-induced
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Non-Allergic RhinitisNon-Allergic Rhinitis
• Vasomotor rhinitis– Variable sx, nasal obstruction and rhinorrhea– Provoked by nonspecific irritant stimuli– Cold dry air, changes in relative humidity– Strong odors, tobacco smoke, dust, fumes– Alcohol, spicy foods, bright lights
• Food allergy rarely presents with rhinitis alone
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Non-Allergic RhinitisNon-Allergic Rhinitis
• Drug induced rhinitis– Nasal congestion and/or rhinorrhea– Antihypertensives, OCPs, NSAIDs, Viagra
• Hormonal rhinitis – Hormone induced intranasal vascular
engorgement– Nasal congestion and/or hypersecretion– Pregnancy, conjugated estrogens, OCPs,
hypothyroidism
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Non-Allergic RhinitisNon-Allergic Rhinitis
• Occupational rhinitis– Sneezing, nasal discharge and/or congestion– Exposure to airborne agent in workplace– Sx improve away from workplace– Non IgE mediated - irritant, cold air, chemical– IgE mediated – animals, grain, wood dusts– Frequently co-exists with occupational asthma
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Non-Allergic RhinitisNon-Allergic Rhinitis
• Rhinitis medicamentosa– > 5-10 days of topical nasal decongestant use– Rebound nasal congestion after d/c– Hypertrophy of nasal mucosa– Downregulation of nasal mucosal alpha-
adrenergic receptors
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Other Conditions to ConsiderOther Conditions to Consider
• Anatomic abnormalities• Benign and malignant tumors• CSF leak – refractory clear rhinorrhea• Atrophic rhinitis
– Elderly patient, nasal congestion, constant bad smell in nose (ozena), thick crusts
• Systemic diseases– Uremia, diabetes– Wegener’s, sarcoidosis, infections causing
granulomatous nasal lesions
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Rhinitis HistoryRhinitis History
• Frequency, duration, and severity of Sx
• Provoking or aggravating triggers
• Environment – home, job, school
• Current/past treatments
• PMH, incl trauma
• FH, incl atopic disease
• Review of systems
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Physical ExaminationPhysical Examination
• Allergic facies (shiners, nasal crease)
• Allergic salute
• Injected conjunctiva with tearing
• Nose wrinkling, grimacing, or other facial mannerisms
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Physical Exam cont.Physical Exam cont.
• Long and narrow facies, high cheek bones• Injected sclera, edematous eyelids• Nasal mucosa, turbinate size, polyps• Nasal discharge, post-nasal drainage• Posterior pharyngeal cobblestoning• TM mobility, retraction, effusion• Other organ systems: eczema, wheezing
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Testing for Specific IgETesting for Specific IgE
• Allergen-specific IgE • In vivo testing
– Prick skin tests– Trees, grasses,
weeds, molds, dust mite, cat, dog, cockroach
• In vitro testing– RAST
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ManagementManagement
• Allergen Avoidance
• Pharmacotherapy
• Immunotherapy
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AvoidanceAvoidance
• Minimize exposure to outdoor allergens– Decrease exposure during high pollen counts– Keep house and car windows closed, use A/C– Do not dry laundry outdoors– Make the bed daily– Do not lay on a bed in clothes worn outside– Hire lawn service– Keep the pets out of the bedroom
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Dust Mite AvoidanceDust Mite Avoidance
• Encase bedding in allergen-impermeable covers• Wash sheets in water >130° F every 7-10 days• Remove stuffed animals, down pillows, draperies,
upholstered furniture, rugs from bedrooms• Maintain humidity <50%• Replace curtains with blinds• Vacuum weekly
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Avoidance Measures cont.Avoidance Measures cont.
• Indoor animal allergens– Get rid of the pet– Keep animals away from bedrooms – Bathe pet weekly and brush frequently– Vacuum with HEPA filter– Room air cleaners
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Environmental Controls cont.Environmental Controls cont.
• Indoor molds and pests– Exterminate– Decrease dampness– Improve ventilation– Increase exposure to sunlight– Use weak bleach solution to wash
baseboards and walls
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AntihistaminesAntihistamines
• Competitively bind to H1 receptor
• Prevent histamine release
• Reduce sneezing, pruritis, and rhinorrhea
• Little effect on nasal congestion
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First generation antihistaminesFirst generation antihistamines
• Eg: diphenhydramine (Benadryl), hydroxyzine (Atarax), chlorpheniramine (Chlor-Trimetron)
• Highly lipophilic, cross blood-brain barrier• Sedation, somnolence, incoordination• Anticholinergic side effects• Legally considered “under the influence of
drugs” in many states• Evening doses impair performance and
cognition in morning without the appreciation of sedation
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Second generation Second generation antihistaminesantihistamines
• Eg., fexofenadine (Allegra), cetirizine (Zyrtec), loratadine (Claritin)
• May inhibit release of mast cell and basophil mediators
• Prolonged duration of action
• Lipophobic, poor penetration of CNS
• Minimal, if any sedative effects
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They’re not all the sameThey’re not all the same
• Loratadine – Metabolized through cytochrome P450 system– Half life prolonged in elderly pts, co-admin with macrolide abx or
imidazole antifungals
• Cetirizine– Metabolite of hydroxyzine– Excreted unchanged in urine and feces
• Fexofenadine– Metabolite of terfenadine– Only 5% metabolized– Co-admin with ketoconazole and erythromycin increase GI
absorption, increased plasma levels – No sedative effects seen at doses up to 480 mg/day
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Fexofenadine vs CetirizineFexofenadine vs Cetirizine
0
2
4
6
8
10
Fexofenadine Cetirizine
%%
PatientsPatients
p=0.018
17/42118/209
Howarth et al. JACI 1999.
Incidence of Drowsiness + FatigueIncidence of Drowsiness + Fatiguep= 0.018
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Intranasal AntihistamineIntranasal Antihistamine
• Azelastine hydrochloride (Astelin)– 0.1% aqueous solution– 2 sprays/nostril twice daily– Onset of action 3 hours– Efficacy equal to oral antihistamines– Improves rhinitis symptoms incl congestion– Bitter taste, somnolence
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Intranasal CorticosteroidsIntranasal Corticosteroids
• Most effective med at controlling rhinitis sx
• First line for moderate-severe SAR/PAR– Reduce inflammation– Mild vasoconstriction– Suppress late phase response
• Adverse effects– No evidence of atrophy– Local irritation, epistaxis, septal perforation
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Leukotriene AntagonistsLeukotriene Antagonists
• Decrease vascular permeability
• Level of efficacy comparable to antihistamines
• FDA approved for AR and asthma
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Oral and Nasal DecongestantsOral and Nasal Decongestants
• Stimulate α-adrenergic receptors
• Reduce nasal congestion
• Side effects: elevated BP, nervousness, insomnia, loss of appetite, palpitations, urinary retention
• Topical preparation < 3-5 days
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Intranasal AnticholinergicsIntranasal Anticholinergics
• Ipratropium Nasal (Atrovent)
• Effective at reducing rhinorrhea
• 0.03% and 0.06%– Allergic/nonallergic perennial rhinitis
• 0.06% – Common cold
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Nasal Saline LavageNasal Saline Lavage
• Lavage with nasal irrigator or bulb syringe
• Hydrates mucosa
• Removal of mucous and debris
• Improves sx of rhinitis
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Intranasal CromolynIntranasal Cromolyn
• Prevents mast cell degranulation
• Helpful for sneezing, rhinorrhea, pruritus
• Not helpful for congestion
• Protective effect lasts 4-8 hours
• Use as pre-treatment prior to exposure
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Treatment of allergic rhinitis (ARIA)AllergicAllergic Rhinitis and its Impact on Asthma
mildintermittent
mildpersistentmoderate
severeintermittent
moderatesevere
persistent
allergen and irritant avoidance
immunotherapy
intra-nasal decongestant (<10 days) or oral decongestant
local cromone intra-nasal steroid
oral or local non-sedative H1-blocker
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Aeroallergen Immunotherapy (AIT)Aeroallergen Immunotherapy (AIT)
• Immunomodulation
• Candidates– Continuous pharmacotherapy required– Continued moderate-severe symptoms
despite maximal medical therapy– Multi-season symptoms – Adverse effects of pharmacotherapy
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Evidence Based MedicineEvidence Based Medicine
• Trees (birch, mountain cedar)
• Grasses (timothy, orchard, rye, bermuda)
• Weeds (ragweed)
• Dust mites (D. pteronyssinus)
• Molds (Cladosporium, Alternaria)
• Animals (cat)
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Immunotherapy cont.Immunotherapy cont.
• Can take several months to work• Is specific against allergens used in AIT• Treatment for 3-5 years• Relative contraindications – uncontrolled
asthma, ß-blocker therapy, co-morbid conditions
• Risk for anaphylaxis
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Allergy ReferralsAllergy Referrals
• Clarification and identification of allergic/nonallergic triggers
• Unsatisfactory management of symptoms– Suboptimal control– Adverse effects
• Consideration for immunotherapy• Moderate/severe persistent symptoms • Complications of rhinitis symptoms• Patient request for further evaluation• Education/counseling
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Internet SitesInternet Sites
• National Allergy Bureau – daily pollen count– www.aaaai.org/nab
• American Academy of Allergy, Asthma, and Immunology– www.aaaai.org
• American College of Allergy, Asthma, and Immunology– www.acaai.org