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1. Allergic Rhinitis Dr. Dinesh Kumar, Assistant Professor, ENT, GMC Amritsar

2. 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

3. Natural History Onset is common in childhood, adolescence and early childhood . Symptoms often wane in older adults, but may develop or persist at any age

4. Natural History No apparent gender selectivity or predisposition to developing AR May contribute to a number of other conditions

5. Allergic rhinitis Inflammatory disorder of nasal mucosa, characterized by pruritus, sneezing, rhinorrhoea and nasal congestion. Adversely affects social life, school performance, and work productivity; especially in patients with severe disease Loss of productivity, missed school and work days, and direct costs associated with treatment create substantial costs to society. Lancet 2011; 378: 2112–22

6. An Allergic Reaction

7. The Allergic reaction

8. Inflammatory cascade in allergic rhinitis Adapted from Indian J Chest Dis Allied Sci. 2003 Jul-Sep;45(3):179-89

9. How are the symptoms caused

10. Classical Symptoms

11. Other Manifestations

12. AR

13. Intermittent

14. Persistent

15. Mild

16. Moderate to Severe

17. Risk Factors for Allergic Disease

18. Allergic Shiners

19. Allergic Salute and Crease

20. Allergic Conjuctivitis

21. AR & Co-morbidities

22. Allergic rhinitis and diseases of the upper airway

23. Key factors important to normal PNS function

24. AR and Asthma Approx. 80% of patients with asthma have accompanying symptoms of rhinitis, and up to 60% of the patients with asthma have sinusitis

25. Possible Mechanisms by which Rhinitis Could Provoke a Worsening of Asthma Possible mechanism AR could provoke worsening of Asthma

26. Management of Allergic Rhinitis

27. First Generation Antihistamines Rapid onset of action Short half life Significant relief from rhinorrhoea Easily cross blood brain barrier

28. Side Effects

29. Second Generation AH Improve selectivity Hepatic and Cardiovascular side effects of terfanadine and astemizole Non sedating Demonstrated efficacy for AR symptoms

30. Wide Therapeutic Window of Second Generation Antihistamines The second generation H1-antihistamines have a rapid onset of action with persistence of clinical effects for at least 24 hours, so these drugs can be administered once a day. They do not lead to the development of tachyphylaxis and show a wide therapeutic window (e.g. fexofenadine)

31. Significance of wide therapeutic window (fexofenadine) Low H 1 -antihistamine dose High Ineffective Therapeutic Window Not tested for adverse effects Maximum Studied dose (Fexo 1380 mg) Minimally effective dose (Fexo 60 mg) Howarth PH. Advanced Studies in Medicine. 2004;4(7A):S508-512

32. Third Generation AH Minimal side effects Increased duration of action Positive effect on nasal airflow Reduction in nasal congestion

33. Effects of leukotrienes on airways Increased levels in nasal fluid after allergen challenge Contribute to both early and late phase Nasal congestion Sneezing, rhinorrhea Chemoattractant for eosinophils Promote eosinophil adhesion Decrease eosinophil apoptosis

34. Leukotrine Inhibitors: Competitively block binding of leukotrines to end organs. Montelukast is only FDA approved Leukotrine inhibitor Montelukast reduces exhaled Nitric oxide, a marker for airway inflammation Montelukast works through LC C4 and D$ which are found in upper airway Because Montelukast acts throughout the airway this agent is a good choice for those with concurrent Asthma and AR

35. Rationale for antihistamine- montelukast combination in AR Histamine Responsible for rhinorrhea , nasal itching and sneezing Less evident effect on nasal congestion Leukotrienes Increase in nasal airway resistance and vascular permeability Blockage or inhibition of these two mediators may provide additional benefits compared to single mediator inhibition

36. Intra-nasal Steroids Work mostly locally, thus avoid unwanted side effects associated with their oral or I/V use • Newer formulations show even lower systemic absorption • Most effective against late-phase mediators with some effect on acute phase response.

37. Intra-nasal Steroids Should be used in a chronic manner Higher dose results in greater benefit Judicious use in children and pregnant women recommended Large paed studies have not shown significant adverse effects

38. Intra-nasal Steroids First line drug in seasonal AR However for perennial AR management with I/N steroids alone has not proved to be as beneficial Depending upon severity of disease short courses of oral steroids in addition to topical symptomatic relief more Fewer side effects (IOP)

39. Drug and Symptom Matrix

40. Algorithm for management of AR Allergic Rhinitis Intermittent Symptoms Persistent Symptoms Mild Moderate/Severe Mild Moderate/Severe Oral H1 Blocker Intranasal H1 Blocker Leukotrine modifie r Intranasal Steroid Oral H1 Blocker Intranasal H1 Blocker Nasal Cromone Leukotrine modifier In PAR Pt. FU after 2-4 wks . If failure step up, if improved continue for one month Intranasal Steroid Follow up after 2 wks . Improved Failed Step down Review Dx Compliance Intranasal Steroid Itch/sneeze add H1 Blocker Rhinorrhea add Ipratropium Blockage: add oral decongestant/steroid short term

41. Immunotherapy Involves the sequential administration of antigen to patients with symptomatic, atopic conditions to induce tolerance to offending antigens Effective in treatment of both AR & Asthma Generally safe and well tolerated

42. Immunotherapy Injectable: Popular in US Sublingual: Popular in Europe Intranasal: Under investigation

43. Selections of candidates for IT Symptoms induced by allergen exposure Patients with rhinitis and symptoms from lower airway during peak allergen exposure Insufficient control of symptoms with AH and/or topical steroids

44. Summary… Allergic rhinitis is associated with several co-morbidities and affects quality of life and productivity Second generation antihistamines are recommended for treatment of allergic rhinitis in adults and children; fexofenadine has proven efficacy, is devoid of sedation and has wide therapeutic window Leukotrienes play key role in allergic rhinitis; montelukast is most throroughly tested leukotriene antagonist

45. Summary Antihistamine- montelukast combination seems to be a more effective strategy than monotherapy in the treatment of allergic rhinitis in patients with moderate to severe symptoms Fexofenadine- montelukast combination yields significant reduction in nasal congestion and nasal resistance in allergic rhinitis vs. fexofenadine

46. Drug and Symptom Matrix

47. Place in therapy for antihistamine- montelukast combination Allergic rhinitis with nasal congestion Allergic rhinitis with moderate-to-severe symptoms

48. Blessings from the Holy City…….

49. A very cordial invitation to all of you to the 5th AOIPBCON being organized at M K Hotel Amritsar on 13th and 14th April 2013 .

50. Guest Faculty

51. Thankyou !!!!!!