an update on allergic rhinitis - university of cape town · 2015-02-02 · allergic rhinitis...
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An Update on Allergic Rhinitis
Mike Levin
Division of Asthma and Allergy
Department of Paediatrics
University of Cape Town
Red Cross Hospital
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Allergic Rhinitis
Common condition with increasing prevalence
Affects 10-40% of the population
Significant reduction in quality of life
Decreased work & school attendance of 3 – 4%
Reduced work & school efficiency of 30 – 40 %
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Core symptoms
Running nose
Itchy nose
Sneezing
Postnasal drip
Mannerisms
Allergic salute
Rabbit face
Noises
Tongue thrusting
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Core symptoms
Running nose
Itchy nose
Sneezing
Nasal obstruction
Postnasal drip
Commonest problem
Nasal congestion
Affects sleep
Effects sleep 76.6%
Every night 37.2.%
Feel miserable 85.2%
Allergic Rhinitis Care
Programme in South Africa
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• Underestimated by patients and doctors
• Poor levels of satisfaction
• No single definition of disease control
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Core symptoms
Nasal obstruction
Running nose
Itchy nose
Sneezing
Postnasal drip
Mannerisms
Mouth breathing
Allergic salute
Rabbit face
Noises
Tongue thrusting
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Allergic Rhinitis
Intermittent
• 4 days per week
• or 4 weeks
Persistent
• > 4 days per week
• and > 4 weeks
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Allergic Rhinitis
Mild
• Normal sleep and
• No impairment of daily
activities, sport, leisure and
• Normal work and school and
• No troublesome symptoms
Moderate - Severe
One or more items:
• Abnormal sleep
• Impairment of daily activities,
sport, leisure
• Abnormal work and school
• Troublesome symptoms
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Allergic Rhinitis
Intermittent
• 4 days per week
• or 4 weeks
Mild
• Normal sleep and
• No impairment of daily
activities, sport, leisure and
• Normal work and school and
• No troublesome symptoms
Moderate - Severe
One or more items:
• Abnormal sleep
• Impairment of daily activities,
sport, leisure
• Abnormal work and school
• Troublesome symptoms
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Allergic Rhinitis
Persistent
• > 4 days per week
• and > 4 weeks
Mild
• Normal sleep and
• No impairment of daily
activities, sport, leisure and
• Normal work and school and
• No troublesome symptoms
Moderate - Severe
One or more items:
• Abnormal sleep
• Impairment of daily activities,
sport, leisure
• Abnormal work and school
• Troublesome symptoms
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Environmental
Control Measures Education
Pharmacotherapy Allergen
Immunotherapy
Management of allergic rhinitis
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Environmental control
• All patients should have sensitisations tested
• Avoidance alone will not be successful
• Avoidance is challenging!
• Select patients for avoidance on basis of
disease severity and sensitisation patterns
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Allergy testing
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Education
• Patient expectations important
– Effects symptom reporting
– Effects adherence to treatment
– … need to teach patients to recognise symptoms
• Pathophysiology important to foster adherence
• Technique
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Technique is critical
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Step-wise therapy of rhinitis
Step 1
Step 2
Step 3
Oral/nasal
antihistamines
or nasal
cromones
Nasal steroids in
recommended
dose
Consider
immunotherapy
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mild intermittent
mild persistent
moderate severe
intermittent
moderate severe
persistent
avoidance of allergens, irritant and pollutants
immunotherapy
intranasal decongestant (<10 days) or oral decongestant
intranasal steroid
oral or local nonsedative H1-blocker
Modified from Bousquet J et al. J Allergy Clin Immunol. 2001;108:S147.
leukotriene receptor antagonists
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Pharmacotherapy
• Intranasal corticosteroids
• Antihistamines
• Cromones
• Anticholinergics
• Decongestants
• Leukotriene antagonists
• Saline irrigation
• Do NOT use systemic esp depot steroids
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Blockage Running Sneezing Itching
Intranasal
Corticosteroids
+++ +++ ++ +
Antihistamines
+ +++ +++ +++
Intranasal
cromones
+ + + +
Intranasal
decongestants
++++
Anticholinergics
++
Leukotriene
antagonists
++ ++
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Intranasal corticosteroids
• Most effective therapy
• Effective against all symptoms
• Low adverse effects
• Impact on ocular symptoms
• Most cost effective
• First line therapy for moderate-severe or
persistent symptoms
• Regular “controller” therapy
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Antihistamines
• Antihistamines relieve sneezing,
itching and rhinorrhoea
• Older antihistamines have sedative and
anticholinergic side effects
• Treatment with older antihistamines worsens
educational outcomes!
• Most new antihistamines are equally effective
in practice
• Best for intermittent rhinitis / acute symptoms
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Others: Burst of therapy for a “flare”
• Nasal irrigation
– Simple and inexpensive
– Improves symptoms, QOL and reduces medication
• Intranasal decongestants
– Very effective for obstruction
– Use in older schoolgoing kids and adults
– Oral decongestants have additional side effects
• Other intranasal steroid formulations: drops
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Immunotherapy
• Reduces symptoms
• Reduces medication use
• Only disease modifying therapy
– Alters course of disease
– Prevents new sensitisations
– Reduces development of asthma
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Immunotherapy
• Indicated in subgroup of patients
– Moderate – severe persistent AR
– Proven IgE mediated allergy
– To single allergen
– Incompletely controlled with pharmacotherapy
– Do not wish long term therapy
– Side effects from pharmacotherapy
– Who are capable of adherence
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Rhinitis-asthma link
• Rhinitis can exacerbate asthma
• Rhinitis can cause bronchial hypersensitivity
• Histamine challenge +ve in rhinitis without
asthma
• Most asthma exacerbations start in the upper
respiratory tract
• Treatment of rhinitis can improve asthma
symptoms
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