ALLERGIC RHINITIS

An inflammatory disorder of the nose

induced by an IgE-mediated inflammation
following allergen exposure of the mucous
membrane lining the nose; characterized by
sneezing, and nasal obstruction
WHO Classification of allergic rhinitis
Intermittent
symptoms
< 4 days/ week
or < 4 weeks
Persistent
Symptoms
* > 4 days/ week
* and > 4 weeks
Moderate-severe
one or more items
Abnormal sleep
Impairment of daily activities,
sport, leisure
Problems at work or school
Troublesome symptoms
Mild
normal sleep
normal daily activities,
Sport, leisure
normal work or school
no troublesome symptoms

Epidemiology of allergic rhinitis :
Children
Prevalence of rhinitis symptoms in the
ISAAC in Childhood, (Asher et al, 1995)
0.8% - 14,95% ( 6-7 year old)
1.4% - 39.7% ( 13-14 years old)
Low prevalence : Indonesia, Georgia, Greece
High prevalence : Australia, UK and Latin America
Semarang (ISAAC 2002) : rhinitis symptoms in
13-14 years old students 18.6%
Diagnosis of allergic rhinitis : 1
Essential
Detail personal and family history and
physical examination
Nasal examination
History of eye symptoms
Allergy skin tests and/or measurement of
allergen specific IgE antibody
Allergy skin prick testing
Skin prick test :
positive result
wheal > 3mm diameter
Flare reaction
Globally important allergens
mites
pollen
mites sources
weed cockroaches
pets : dogs
Diagnosis of allergic rhinitis :
Additional diagnostic tests which may be
performed if required :
Total IgE
Fibreoptic rhinoscopy
Nasal secretions/scraping for cytology
Nasal challenge with allergen, including
rhinomanometry
CT scan
Differential diagnosis
Infectious : viral, bacterial, fungal
Drug induced : aspirin, other medications
Occupational (allergic and non-allergic)
Hormonal : puberty, pregnancy, menstruation,
endocrine disorders
Other causes : foods, irritants, emotions,
NARES, gastroesophageal reflux, atropic
Idiopathic
Non Allergic Rhinitis
Treatment of allergic disease :
Allergen avoidance is the first
step in the management of
allergic disease
Allergen avoidance
Allergen avoidance
House dust mite
Wash bedding weekly at 60
0
C
Encase pillow, mattress and quilt in
allergen impermeable covers
Dispose of feather bedding
Use vacuum cleaner with HEPA filter
Replace carpets with wooden floors
Remove curtain, pets and soft toys from
bedroom
Provide adequate ventilation to decrease
humidity

Treatment of allergic rhinitis :
Azelastine & levocobastine
Rapid onset of action
Recommended for organ limited disese
May be used in demand in addition to a
continuous medication
Good safety profile
Topical antihistamines
Treatment of allergic rhinitis :
Chlorpheniramine, diphenhydramine,
promethazine, tripolidine
Limited by sedative and anticholinergic
effects
First generation oral antihistamines
Treatment of allergic rhinitis :
Acrivastine, astemizole *, azelastine,
cetirizine, ebastine, epinastine, terfenadine*,
ketotifen, levocetirizine, loratadine,
mizolastine
Greatly reduced unwanted effect
First line treatment for intermittent or mild
persistent AR
Second generation oral antihistamines
Treatment of allergic rhinitis :
Decongestants
Topical sprays
Very effective treating
nasal obstruction
Limit treatment to 10
days
Application > 10 days
may lead to unwanted
effect
Oral tablets
Less effective than sprays ;
no rhinitis medicamentosa
Effective when combined
with antihistamines
Avoid in : < 1year,
pregnancy, hypertension,
cardiopathy, glaucoma,
prostatism
Treatment of allergic disease :
Potent-anti-inflammatory
Effective in treatment of all nasal symptoms
Superior to antihistamine for all nasal
symptoms
Firstline pharmacotherapy for moderate
severe persistent AR
Topical-corticosteroids -1
Treatment of allergic disease :
Occasional unwanted effects
Rarely affect HPA axis
Anecdotally, perforation of the nasal
septum has been reported
One study reports decrease in growth in
children ( Beclomethasone)
Topical-corticosteroids-2
Treatment of allergic disease :
Short-course of oral corticosteroids
(< 3weeks) can be prescribe for severe
refractory symptoms
Can be repeated every 3 months
May be used with caution in children and in
pregnancy, if no alternative available
Intramuscular injection of corticosteroid
suspensions should be avoided
Systemic-corticosteroids
Treatment of allergic disease :
Recommended for clinically relevant Ig E
mediated disease. May involve multiple
allergens; usually restricted to two allergens
in Europe.
Risk : benefit ratio must be considered in all
cases
Highly effective in carefully selected patients
Injection allergen immunotherapy
Evidence-based step-wise guidelines
for the management of allergic
rhinitis
The stepwise guidelines do offer a rational
basis
The guidelines are based on the assumption
that all treatments are readily available and
affordable to the patient
Intermittent AR : Adults & children
Is therapy needed ? If yes
Non-pharmacological therapy:
Allergen 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
Or
Short course oral CS
Or
Consider IT
If inadequate
control
Persistent AR : Adults
Is therapy needed ? If yes
Non-pharmacological therapy
Alergen 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 inadequate
control
If resistent
I f resistent
Nasal blockage
Rhinorrhea
Antihistamine and
Oral / nasal
decongestant
Or
Short course oral
steroid
Nasal ipratropium
bromide
I f persistent
Consider
Immunotherapy
I f inadequate control
Further examination &
consider immunotherapy
Or
Surgical turbinate reduction
Persistent AR : children
Is therapy needed ? If yes
Non-pharmacological therapy
Allergen avoidance measure
Environment control
Is pharmacotherapy needed ? If yes
If inadequate control
Oral/ nasal antihistmaines or
nasal cromon
Nasal corticosteroids in adequate dosis
If inadequate control
Review diagnosis
Consider immunotherapy