ALLERGIC RHINITIS
Allergic Rhinits: 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
ARIA Report 2001
Natural History of AR
Onset is common in childhood,
adolescence and early adulthood
Symptoms often wane in older adults, but
may develop or persist at any age
No apparent gender selectivity or
predisposition for developing allergic
rhinitis
May contribute to other conditions such as
– Sleep disorders
– Fatigue
– Learning problems
Causes of AR
The Allergic
Reaction
How are the symptoms
caused?
Irritation of free
nerve endings---- Itching and sneezing
Increased
mucus production ------ Rhinorrhoea
Vasodilation -------- Congestion
Increased
vascular permeability---- Oedema
Clinical Manifestations
Others
Repetitive sneezing
Eye symptoms
Watery rhinorrhea Ear symptoms
Nasal pruritus Postnasal drainage
Nasal congestion
ARIA Classification
Intermittent Persistent
• < 4 days per week • ≥ 4 days per week
• or < 4 weeks • and ≥ 4 weeks
Moderate-severe
Mild one or more items
abnormal sleep
normal sleep impairment of daily activities,
& no impairment of daily sport, leisure
abnormal work and school
activities, sport, leisure troublesome symptoms
& normal work and school
& no troublesome symptoms
ARIA Report 2001
Minimal Persistent
Inflammation
An underlying cause of
chronicity
An inflammatory process
which is actually present even
in asymptomatic subjects who
are exposed to allergens
Concept of "minimal persistent
inflammation"
100
mite allergen (µg/g of dust)
10
Threshold level
1
for symptoms
0,1
0 2 4 6 8 10 12 Months
Symptoms Minimal persistent
inflammation
inflammation
Ciprandi et al, J Allergy Clin Immunol 1996
Diagnosis of AR
History
Physical / Nasal Examination
Laboratory Testing
- Skin Prick Test
- Peak Nasal Inspiratory Flow Rate
- Rhinomanometry
PHYSICAL EXAMINATION
Allergic shiner
Dennie Morgan line
Allergic crease
Allergic salute
Nasal mucosa may appear normal or pale bluish, swollen
with watery secretions but only if patient is symptomatic
Exclude structural problems (polyps, deflected nasal
septum)
Others:
nasal voice, constant mouth breathing, frequent
snoring, coughing, repetitive sneezing, chronic open
gape of the mouth, weakness, malaise, irritability
Management of AR
Allergen Avoidance
Pharmacotherapy
Immunotherapy
Pharmacotherapy
Medications used to treat allergic rhinits:
Antihistamines
Decongestants
AH-D combinations
Corticosteroids
Mast Cell stabilizers
Anticholinergics
Antileukotrienes
Actions of Various Nasal
Preparations in the Treatment
Nasal
of Rhinitis
Sneezing Itching Rhinorrhoea Congestion
Preparation
Antihistamine +++++ ++++ +++ 0
s
Anticholinergi 0 0 +++++ 0
cs
Corticosteroid +++++ +++++ +++ +++
s
Decongestant 0 0 + +++++
s
Mast cell +++++ +++ + 0
stabiliser
Antileukotri +++ ++ 0 ++++
enes
Anti-Histamines
Act by preventing histamine from binding to
the H1-receptors
Primarily helpful in controlling Sneezing,
itching & rhinorrhoea; ineffective in releiving
nasal blockage
1st generation anti-histamines
- chlorpheniramine
- diphenylhydramine
2nd generation anti-histamines
- cetrizine
- azelastine
- fexofenadine
- loratadine
Intranasal corticosteroid
therapy
Potent topical activity
Administration of low doses directly at site
of action
Considerable efficacy at low doses
High topical: systemic activity ratios
Rapid first-pass hepatic metabolism of any
systemically absorbed drug, to compounds
with negligible activity
Markedly greater inhibition of EAR than
with oral steroids
The “Ideal” Drug For Allergic
Rhinitis Should Have The
Following Features:
Inhibit both early and late phases
Be an H1 blocker
Counter effects of other mediators
Fast-acting, to control the early phase
Dosing-od or bd for compliance
No side effects
Manage all symptoms
Intranasal administration
JACI 1999; 103:S388
The “Ideal” Drugs Are……
“Corticosteroids are undoubtedly
the pharmacotherapeutic agents
with the broadest application for
the treatment of many types of
rhinitis”
Otolaryngol Head Neck Surg 1992, 107, 855-60
Management of Allergic Rhinitis
Allergen Avoidance
Intermittent Symptoms Persistent Symptoms
Mild Moderate-severe Mild Moderate-severe
Oral H1 blocker Oral H1 blocker Intranasal CS
Oral H1 blocker and/or LTRA
ntranasal H1blocker and/or LTRA If nose very blocked
and/or decongestant Intranasal H1 Intranasal H1 blocker and/or
add oral CS or decongestant
decongestant or LTRA
No Improvement : blocker and/or
switch or add decongestant Intranasal CS
LTRA Intranasal CS Review patient
after 2-4 weeks
Improved Not improved
No improvement
step up Step-down and continue
treatment for Review diagnosis, compliance, or other causes
Improved: continue for > 3 month
1 month
If intranasal CS
reduced by1/2
Itch/sneeze/rhinorrhea Rhinorrhea: Blockage: add LTRA or decongestant or oral CS
add H1 blocker add ipratropium (short term) or increase INCS
No improvement: refer to specialist
