presentation of allergic rhinitis by puja

this slide contain introduction, sign and symptom, etiology, pathophysiology and pharmacotherapy of allergic rhinitis

1. ALLERGIC RHINITIS Puja Patel Mpharm Second semester PUSHS

2. RHINITIS Rhinitis is- two or more nasal symptoms of: Nasal congestion Rhinorrhea Sneezing/Itching Impairment of Smell for more than 1 hour a day

3. RHINITIS Occurs most commonly as allergic rhinitis Non-infectious rhinitis has been classified as either allergic or non-allergic. Non-allergic rhinitis is defined as rhinitis symptoms in the absence of identifiable allergy, structure abnormality or sinus disease.

4. EPIDEMIOLOGY Global health problem Prevalence :10-20%  Higher in pediatric age group - 42% Affecting every 6th person Peak age - 13 to 14. Approx. 80% - develop symptoms < 20

5. INTRODUCTION Nasal function includes Temperature regulation Olfaction Humidification Filtration and Protection

6. INTRODUCTION (Cont.) Nasal lining contains secretion of IgA, proteins and enzymes Nasal Cilia propel the matter toward the natural ostia at frequency of 10-15 beats per minute Mucous move at a rate of 2.5-7.5 ml per minute

7. ALLERGIC RHINITIS 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. an inflammation of the nasal mucosa, caused by an allergen Most common atopic allergic reaction Affects 10 to 25% of population 50% of rhinitis in ENT is AR Most commonly seen in young children and adolscents .

8. ETIOLOGY Classified as Precipitating factors Pre-disposing factors

9. PRECIPI ATING FACTORS Aerobiological flora Allergens present in the environment House dust and dust mites Feathers Tobacco smoke Industrial chemicals Animal dander Nasal physiology Disturbances in normal nasal cycle

10. PREDISPOSING FACTORS Genetic Multiple gene interactions are responsible for allergic phenotype Chromosomes 5, 6, 11, 12 & 14 control inflammatory process in atopy 50% of allergic rhinitis patients have a positive family history of allergic rhinitis Endocrine Puberty Pregnant states and post partum stages menopausal

11. PREDISPOSING FACTORS Psychological Focal sensitivity states Infections: fungal infections Physical Degree of pollution of air Humidity and temperature differences Temperature changes Age & sex IgA deficiency

12. COMMON ALLERGENS Pollen Spring tree pollens(maple) Summer: grass pollens Autums : weed pollens Molds Penicillium , cladosporium etc. Insects Cockroaches, house flies, fleas, bed bugs Animals Cats, Dogs, Horse, monkeys, rats, rabbits etc Dust mites Dermatophagoides Ingestants Nuts, fish, eggs, milk etc

13. PATHOPHYSIOLOGY Immunoglobulin IgE mediated type1 hypersensitivity response to an antigen (allergen) in a genetically susceptible person Type 1 Hypersensitivity causes local vasodilation and increased capillary permeability

14. PATHOPHYSIOLOGY (Contd.) Sensitization: Development of specific IgE Allergens reach Anti-Presenting Cells (APCs) APCs promote Th2 polarization Th2 promotes production of allergens-specific IgE Subsequent response: Development of symptoms Nasal symptoms: Early and Late phase response Specific and non-specific hyperresponsiveness Lower airways symptoms

15. CLASSIFICATON-FORMER Seasonal Also known as Hay Fever Neither caused by hay or fever Summer Cold Caused by virus causing URTI Rose Fever Perennial Allergens present throughout the year

16. CLASSIFICATION-CURRENT Intermittent Symptoms present less than 4 days per week and less than 4 weeks per year Persistent Symptoms present more than 4 days per week and more than 4 weeks per year

17. SEVERITY Mild No interference with daily activity or troublesome symptoms Moderate Presence of at least one Impaired sleep, daily work, activity. Troublesome symptoms

18. ARIA CLASSIFICATION: ALLERGIC RHINITIS AND ITS IMPACT ON ASHMA

19. COMPLICATIONS Allergic asthma Chronic otitis media Hearing loss Chronic nasal obstruction Sinusitis Orthodontic malocclusion in children

20. SIGNS AND SYMPTOMS Sneezing Itchy nose, ears, eyes and palate Rhinorrhea Post nasal drip Congestion Anosmia Headache Earache Tearing of eyes Red eyes Swollen eyes Fatigue Drowsiness Malaise

21. PHYSICAL EXAMINATION Nasal crease Horizontal crease across the lower half of the bridge of the nose Rhinorrhea Thin watery secretions Deviated or perforated nasal septum

22. EXTRA NASAL MANIFESTATIONS Retracted and abnormal flexibility of tympanic membrane Swelling of palpebral conjunctivae with excess tearing Cobble stoning on oropharynx

23. CLASSICAL SIGNS OF ALLERGIC RHINITIS High arched palate Allergic shiners Allergic salute Transverse crease over tip of nose and lower e ye lid Conjunctival congestion Periorbital oedema

24. INVESTIGATIONS FBC (Full blood count) Histamine test A nasal smear for eosinophil Intranasal provocation test Skin tests Sub- cuticular test More accurate with lower incidence of false positive results Contraindicated in case of anti histaminic, anti-inflammatory or decongestant treatment

25. INVESTIGATIONS (Contd.) Intradermal tests Be prepared for anaphylaxis Skin end point titration test Quantitative intradermal test for specific allergen Nasal challenge (Nasal Provocation) Nasal cytology Take a sample of nasal cavity without anaesthesia and send for identification of cell types in the nasal cavity. Increased number of eosinophil suggests allergic disease.

26. OTHER INVESTIGATIONS RAST (radio allergo sorbant test) detect allergen-specific  IgE  antibodies Stablized allergen is incubated with patient’s serum Any specific IgE binds to allergen Identfied by a second incubation with labelled anti- IgE . PRIST (paper radio immuno sorbant test) X-ray PNS ( Paranasal sinuses) CT PNS (for complicated cases with polyposis) Nasal endoscopy ( under local or GA) Evaluate for asthma

27. MANAGEMENT Avoidance Outdoor exposure Stay indoors as much as possible when pollen counts are at their peak. Avoid using window fans that can draw pollens and molds into the house. Wear glasses or sunglasses when outdoors to minimize the amount of pollen getting into your eyes. Wear a pollen mask (such as a NIOSH-rated 95 filter mask) Try not to rub your eyes; doing so will irritate them and could make your symptoms worse.

28. MANAGEMENT Avoidance Indoor exposure Reduce exposure to dust mites, especially in the bedroom. Use “mite-proof” covers for pillows, comforters and duvets, and mattresses and box springs. Wash your bedding frequently, Clean floors with a damp rag or mop, rather than dry-dusting or sweeping. Exposure to pets Wash your hands immediately after petting any animals; wash your clothes after visiting friends with pets. If you are allergic to a household pet, keep the animal out of your home as much as possible

29. MEDICATION Class Agents Mechanism Symptoms Treated Antihistamines Cetirizine Stabilizes H1 receptor in inactive conformation Itching, sneezing, rhinorrhea; not as effective as nasal congestion Fexofenadine Levocetirizine Loratadine Desloratadine Intranasal antihistamine Azelastine Stabilizes H1 receptor in inactive conformation Itching, sneezing, rhinorrhea, and nasal congestion Olopatadine Leukotriene receptor antagonist Montelukast Leukotriene receptor antagonist Reduce inflammation, edema and mucous secretions of allergic rhinitis Anticholinergic agent Ipratropium Nasal spray Anticholinergic Rhinorrhea only Intranasal Corticosteroid Fluticasone Propionate Multiple Anti-inflammatory effect Itching, sneezing, rhinorrhea; not as effective as nasal congestion, Reduce inflammation of mucosa, Prevent mediator release . Fluticasone Furoate Momotasone Budesonide Flunisolide

30. OTHERS Decongestants Shrink nasal mucous membrane by vasoconstriction Available OTC and in combination with antihistamines, analgesics and anti cholinergics Relieve the stuffiness and pressure caused by swollen nasal tissue. Eg : Oxymetazoline , Phenylephrine, Pseudoephedrine Intranasal cromolyn sodium Mast cell stabiliser Prevents release of chemical mediators Oral mast cell stabilizer Prevent the release of histamine and other powerful chemical mediators from mast cells Eg : Olopatadine , Rupatadine Opthalmic solution cromolyn

31. IMMUNOTHERAPY Allergy shots: A treatment program, which can take three to five years, consists of injections of a diluted allergy extract, administered frequently in increasing doses until a maintenance dose is reached. Immunotherapy helps the body build resistance to the effects of the allergens. Sublingual tablets: Placing a tablet containing a mixture of several allergens under your tongue. It works similarly to allergy shots but without an injection.

32. SURGICAL THERAPY It is limited to Submucosal turbinectomy - reduces size of boggy turbinates Septoplasty - correction of deviation of septum Sinus surgery - clearance of sinuses if sinusitis is present

33. Implement appropriate environmental controls. If not totally effective, select single-drug treatment based on symptoms: Antihistamines—sneezing, itching, rhinorrhea, and ocular symptoms Decongestants (systemic)—nasal congestion Intranasal steroids—sneezing, itching, rhinorrhea, and nasal congestion Cromolyn —sneezing, itching, and rhinorrhea Intranasal antihistamine—rhinorrhea and itching Intranasal anticholinergic—rhinorrhea Assess efficacy. If symptoms controlled but adverse effects are bothersome or intolerable, adjust dosage or switch to another agent within the same therapeutic category. If non-adherent, discuss reasons with patient. If patient is adherent, adjust dosage or if necessary, switch to another agent in a different therapeutic category or add a second agent from a different therapeutic category. If symptoms are not controlled, assess adherence. Symptoms controlled.

34. Symptoms controlled. For perennial disease, once symptoms are adequately controlled with minimal adverse effects, continue therapy and reassess patient in 6 to12 months. For seasonal disease, once symptoms are adequately controlled with minimal adverse effects, continue therapy until end of patient’s allergy season. Discuss when therapy should be reinitiated. If symptoms still not controlled, consider montelukast . Additional consideration: Assess patient for appropriateness of immunotherapy initially and again if pharmacotherapy options are not sufficiently effective. Fig: Treatment algorithm for allergic rhinitis.

35. TREATMENTS THAT ARE NOT RECOMMENDED FOR ALLERGIC RHINITIS Antibiotics Effective for the treatment of bacterial infections, antibiotics do not affect the course of uncomplicated common colds (a viral infection) and are of no benefit for noninfectious rhinitis, including allergic rhinitis. Nasal surgery Surgery is not a treatment for allergic rhinitis, but it may help if patients have nasal polyps or chronic sinusitis that is not responsive to antibiotics or nasal steroid sprays.