ALLERGIC RHINITIS AND ITS IMPACT ALLERGIC RHINITIS AND ITS IMPACT

ON ASTHMA (ARIA) UPDATE 2008ON ASTHMA (ARIA) UPDATE 2008

Suprihati ENT Depart. Fac of Medicine Diponegoro Univ-Kariadi

Hospital, Semarang

INTRODUCTION

Allergic rhinitis : a symptomatic disorder of the nose induced after

allergen exposure by IgE-mediated inflammation of the membranes lining the nose

3 cardinal symptoms : Sneezing Nasal obstruction Mucous discharge

Important achievement of ARIA WHO workshop (1999) :

A new classification for Allergic rhinitis : * Intermittent allergic rhinitis (IAR) and * Persistent allergic rhinitis (PAR)

The severity of AR : classical symptoms + impairments in how patients function in day-to day life : * mild * moderate to severe

The ARIA WHO workshop

Allergic rhinitis ARIA-WHO classification

Intermittent

Symptom:• < 4 days/ week• or < 4 weeks

Persistent

Symptom

* > 4 days/ week

* and > 4 weeks

Moderate-severe• abnormal sleep • abnormal daily activities• work and school problems• disturbing symptoms

Mild• normal sleep • normal daily activity, sport, recreation • normal work & school • no disturbing symptom

Gloria 2001

Rational for updated of the ARIA recommendations

• some aspects of treatment (complementary & alternative medicines ) • links between upper & lower airways in developing

countries• sport & rhinitis in athletes • rhinitis & links with asthma in pre school children

1. Complementary & alternative medicines are extensively used in the treatment of AR difficult to propose ( not randomized, not controlled, no quantitative measurement)

2. Links between upper & lower airways in developing countries

• Rhinitis is an independent risk factor of asthma• In developing countries rhinitis may be independent • The prevalence generally low than in developed country may be because : under diagnosis lack of awareness limited access to helth care

3. Sport & rhinitis in athletes

Recommendation for athletes address the issue of adapting dx and management to criteria set by International Olympic Committee (IOC) and regulations by the World Anti- Doping Agency ( WADA)

Ex : Oral glucocorticosteroids - prohibited by IOC and WADA Oral B2-agonist prohibited Immunotherapy prohibited Topical steroid - need notification pseudoephedrine - prohibited in competition

4. Rhinitis & links with asthma in pre school children

• The nasal & bronchial mucosa : present similarities• Most important concepts : nose & lung interaction is functional complementarity• Most patients with asthma have rhinitis concept of “ one air one disease”

• In infant & very young children lower respiratory tract symptoms often developed before nasal symptoms

• Chief complain :1. Itching nose2. Sneezing : morning >>3. Serous nose secretion 4. Nasal obstruction at night

• History of other allergic manifestation of patients and other allergic familial manifestations

DIAGNOSIS OF ALLERGIC RHINITISBased on the combination of a typical history of AR symptoms and diagnostic tests

Physical examination

• Nasal passageways• Nasal mucosa• Turbinate• Secretions• Septum• Polyps ?• Sinusitis ?

Including :

IgE examination

Skin Prick Test (in vivo)• Simple• Rapid performance• Low cost• High sensitivity/ specificity

Total serum IgE (in vitro)• Neither very sensitive nor very specific • 35 – 50 % AR Normal IgE levels• Poor correlation with symptom & skin testing result

Watery anterior and sneezing

yes

Nasal obstruction

Symptoms occur at the same time every year

No

Post nasal drip

Colored discharge and/or

facial pain

The patient may be allergic

The patient is likely to be allergic

The patient is unlikely to be allergic

Suspect chronic rhinosinusitis

Confirm diagnosisfor allergic rhinitis

Confirm diagnosisfor rhinosinusitis

Algorithm DX

Symptoms suggestive of Allergic Rhinitis

skin prick test

(+)

eosinophil on nasal cytology

(+) (-)

non allergic rhinitis

NARES

(-)

Allergic rhinitis

Classify andassess severity

MANAGEMENT OF AR

Objectives : • relieving symptoms for improving QOL• to avoid trigger factors • to change the natural history • to avoid / to treat complication

Pharmacologic treatment should take the following factors into account:• Efficacy• Cost-effectiveness of medications• Patient’s preference• Objective of the treatment• Likely adherence to the treatment• Severity and control of the disease• The presence of co-morbidities

Relieving symptoms of AR

1. ANTIHISTAMINE

Consider new antihistamine since : - long acting more practical - no sedating normal daily activity - no / less cardiac effect - broad spectrum effects

except : - patient doesn’t mind sedation effect - is not available - can not be afforded

classic antihistamine can be considered

The first line of pharmacological treatment

2. NASAL DECONGESTANT

• Indicated in patient with prominent nasal

obstruction complaint • As addition / combination with antihistamineLong-term treatment • Systemic nasal decongestant, be careful in hypertension cases & glaucoma.• Topical : rebound effect

3. INTRANASAL CORTICOSTEROID

• long-term treatment safer than systemic • effective to control AR symptomsnotes : * patients should be well informed how to use * symptom relieve is not directly achieved * in some places it is unavailable

EDUCATION

• Explain what is AR / allergic reaction • Explain the meaning of pos. SPT • Confirm whether there is correlation between allergen contact & rhinitis attack• Explain how to do allergen avoidance• Encourage to avoid the allergens

To avoid trigger factors

SPECIFIC IMMUNOTHERAPY ( SIT )

SIT: effective for treating AR

Recommended in patients with :• severe symptoms• fail by pharmacological treatment• positive correlation SPT& history• agree & well informed about duration, schedule of injection & expected results

To change the natural history

Updated ARIA recommendation

(Allergy Supl 86: 63 2008)

Intermittent symptoms Persistent symptoms

MildNot in preferred orderOral H1 blocker

or intranasaland/or

decongestant

Moderate - Mild severe

Not in preferred orderOral/ intranasal H1

blockerAnd/ or decongestant

or intranasal CS In persistent ARReview after 2-4 weeks

If failure, step upIf improved: continue for

1 mo

Moderate- severe

In preferred order Intra nasal CS, H1 blocker Review after 2-4 weeks

improved failure

Step-down& continue

> 1mo Review : Dx, complianceInfection or other causes

Increase intranasal CS doses

Rhhinorrheaadd

ipratropium

Blockade, add

decongestant or Oral CS

Failure: referred

Consider specific immunotherapy

Diagnosis of Allergic rhinitis Check for asthma

Intermittent symptoms

MildNot in preferred order

Oral H1 blockeror intranasal

and/or decongestant

Diagnosis of Allergic rhinitis

Intermittent symptoms Persistent symptoms

Moderate-severe Mild Not in preferred order

Oral/ intranasal H1 blockerand/ or decongestant

or intranasal CS In persistent AR

Review after 2-4 weeks

If failure, step upIf improved: continue for 1 mo

Diagnosis of Allergic rhinitis

Persistent symptoms

Moderate- severe

improved failure

Step-down & continue > 1mo Review : Dx, complianceInfection or other causes

Increase intranasal CS doses

Rhinorrheaadd ipratropium

Blockade, add decongestant/ Oral CS

Failure: referred to specialist

Consider specific immunotherapy

Diagnosis of Allergic rhinitis

In preferred orderIntranasal CS, H1 blocker

Review after 2-4 weeks

Shekelle guide for level of evidence ( BMJ 1999;318: 593-96)

Level of evidence • Ia : Meta-analysis of RCT• Ib : at least one RCT• IIa : at least one controlled study without randomization• IIb : at least one other type of study• III : Nonexperimental descriptive study• IV : Expert committee reports / opinions

Strength of recommendation

A : category I evidence

B : Category II evidence or extrapolated from

category I

C : Category III evidence

D : category IV evidence