• The most prevalent of type I allergic dis.• The symptoms and signs caused by mediators : vessels, glands and nerves.• Classified as inflammatory disease.

ALLERGIC RHINITIS :

Sign & symptoms :Sign & symptoms : Itching noseItching nose SneezingSneezing RhinorrheaRhinorrhea Nasal obstructionNasal obstruction

Allergic salute

ALLERGIC RHINITIS :

EPIDEMIOLOGYEPIDEMIOLOGY

Prevalence in ISAAC (Asher 1995) :Prevalence in ISAAC (Asher 1995) : 0.8 – 14.95 % in 6-7 years old0.8 – 14.95 % in 6-7 years old 1.4 – 39.7 % in 13 – 14 years old 1.4 – 39.7 % in 13 – 14 years old

Low pervalenceLow pervalence : Indonesia, Georgia, Greece : Indonesia, Georgia, Greece Semarang (2002) ISAAC phase 3, RA : 18,6% Semarang (2002) ISAAC phase 3, RA : 18,6% High pervalence : Australia, UK and Latin High pervalence : Australia, UK and Latin

AmericaAmerica In adults : no equivalent to ISAAC study In adults : no equivalent to ISAAC study National survey : 5.9 % France and 29 % UKNational survey : 5.9 % France and 29 % UK

WHO Classification ofWHO Classification of Allergic rhinitis Allergic rhinitis

1.1. INTERMITTENT INTERMITTENT Less than 4 days a week, Less than 4 days a week, oror Less than 4 weeksLess than 4 weeks

2.2. PERSISTENTPERSISTENT More than 4 days a week, More than 4 days a week, andand More than 4 weeks More than 4 weeks

SEVERITY OF THE SEVERITY OF THE DISEASEDISEASE

1.1. MILDMILD – means – means no oneno one of the following of the following items are presentitems are present

Sleep disturbanceSleep disturbance Impairment of daily activities / sportImpairment of daily activities / sport Impairment of school / workImpairment of school / work Troublesome symptomsTroublesome symptoms

2.2. MODERATE – SEVEREMODERATE – SEVERE, when , when one or one or moremore of the symptoms are present of the symptoms are present

MECHANISMS OF Allergic RHINITIS

Mast cell

HistamineLeukotrienesProstaglandin'sBradykinin,PAF

Itch, sneezingWatery dischargeNasal congestion

allergen

Th2 cell

B cell

eosinophils Nasal blockadeLoss of smellNasal hyperreactivity

IL4

IgE

IL 3, 5, GMCSF

Immediate rhinitis symptoms

Chronic ongoing rhinitis

MAST CELL DEGRANULATION

Histamine, Heparin, Tryptase, TNF , TGF , IL 3, 4, 5, 13

Newly formed mediators

PLA2 AA + PAF

C.O 5 L.O

PGD2 LTC4 LTB

LTD4

LTE4

Y Yallergen

Preformed mediators

Y Y

Y

HISTAMINE

HH11-R-R

DEGRADATION( histamine methyl transferase)

CNS Endothelium(Vascular Permeability)

Nociceptive Nerves

• Itch.• Systemic Reflexes Sneeze Allergic Salute

Serous/Mucous Secretion• Parasympathic Reflexes Glandular Exocytosis

HISTAMINE EFFECTS

Vascular wall

Vasodilatation

Diagram of DIAGNOSTIC PROCEDURES (1)

patients with AR symptoms ( history of illness + physical exam.)

skin prick test

(+)

AR with complications / concomitant dis

AR without complication

eosinophil on nasal cytology

(+)

allergic Rhinitis ?

(-)

non allergic rhinitis

NARES

(-)

Diagnostic Procedures (2)Diagnostic Procedures (2)

1.1. AnamnesisAnamnesis Chief complain :Chief complain :

1.1. Itching noseItching nose2.2. Sneezing : morning >>Sneezing : morning >>3.3. Serous nasal secretion Serous nasal secretion 4.4. Nasal obstruction at night Nasal obstruction at night

Diagnostic Procedures (3)Diagnostic Procedures (3)1.1. AnamnesisAnamnesis

The symptoms was environment relatedThe symptoms was environment related History of other allergic manifestation of History of other allergic manifestation of

patients and other allergic familial patients and other allergic familial manifestationsmanifestations

Duration of illness, severity of the Duration of illness, severity of the disease and the respond of the previous disease and the respond of the previous treatmenttreatment

Diagnostic Procedures (4)Diagnostic Procedures (4)

2. Physical examination2. Physical examination Should be performed with Should be performed with

appropriate lighting and use of appropriate lighting and use of nasal speculumnasal speculum

normal oedema

Diagnostic Procedures (5)Diagnostic Procedures (5)2. Physical examination2. Physical examination

Including : Including : 1.1. Nasal passage waysNasal passage ways2.2. Nasal mucosaNasal mucosa3.3. TurbinatesTurbinates4.4. SecretionSecretion5.5. SeptumSeptum6.6. Polyps ?Polyps ?7.7. Sinusitis ?Sinusitis ?

Diagnostic Procedures (6)Diagnostic Procedures (6)

3. Nasal cytology3. Nasal cytology Large number of eosinophils may aid to Large number of eosinophils may aid to

differentiate AR & NARES from other differentiate AR & NARES from other RhinitisRhinitis

No consensus to routinely performed for No consensus to routinely performed for evaluation of rhinitis evaluation of rhinitis

Diagnostic Procedures (7)Diagnostic Procedures (7)

4. Total serum Ig E4. Total serum Ig E Neither very sensitive nor very Neither very sensitive nor very

specificspecific 35 – 50 % AR 35 – 50 % AR Normal Ig E Normal Ig E

levelslevels Poor correlation with symptom Poor correlation with symptom

and skin testing result and skin testing result

Diagnostic Procedures (8)Diagnostic Procedures (8)

5. Nasal provocation testing5. Nasal provocation testing Based on a history of AR symptoms Based on a history of AR symptoms

provoked by allergen exposure and provoked by allergen exposure and confirmed by skin testingconfirmed by skin testing

It may be required for confirmation It may be required for confirmation of sensitivity to allergen in the work of sensitivity to allergen in the work placeplace

Diagnostic Procedures (9)Diagnostic Procedures (9)

6. Special diagnostic techniques6. Special diagnostic techniques Upper airway endoscopy / Upper airway endoscopy /

Rhinomanometry Rhinomanometry Standard radiographs Standard radiographs CT CT MRIMRI

Diagnostic Procedures (10)Diagnostic Procedures (10)

7. Testing for specific Ig E,7. Testing for specific Ig E, important for :important for :

Determining whether patient Determining whether patient has allergic rhinitishas allergic rhinitis

Identifying specific allergen for Identifying specific allergen for avoidance measurement and avoidance measurement and allergen immunotherapyallergen immunotherapy

Diagnostic Procedures (11)Diagnostic Procedures (11)

8. Skin testing to allergen :8. Skin testing to allergen : SimpleSimple EaseEase Rapid performanceRapid performance Low costLow cost High sensitivity / spesificityHigh sensitivity / spesificity ( Prick test )( Prick test )

Allergy skin prick testingAllergy skin prick testing

Skin prick test :

positive result

wheal > 3mm diameter

A R and other diseases A R and other diseases

Allergic Rhinitis

O M E

Nasal polyp

Sinusitis

U R T infection

Bronkhial

asthma

Comorbidity AR and Comorbidity AR and SinusitisSinusitis

US : sinusitis 30 Mill / year (1989 )US : sinusitis 30 Mill / year (1989 ) sinusitis sinusitis : 25 – 30 % AR: 25 – 30 % AR non sinusitisnon sinusitis : 14 – 17 % AR: 14 – 17 % AR

SinusitisSinusitis ( dx CT ) Newman at all 1994 : ( dx CT ) Newman at all 1994 : AR AR : 78 %: 78 % AsthmaAsthma : 71 %: 71 %

Differential diagnosis of RA Differential diagnosis of RA

Non – allergic rhinitis :Non – allergic rhinitis : Infectious :Infectious : bacterial, viral, fungal bacterial, viral, fungal Drug induced :Drug induced : aspirin & other medications aspirin & other medications Occupational rhinitisOccupational rhinitis (allergy & non allergy) (allergy & non allergy) Hormonal :Hormonal : puberty, pregnancy, menstruation puberty, pregnancy, menstruation and hormonal disordersand hormonal disorders Other causesOther causes : foods, irritants, emotions, : foods, irritants, emotions, NARES NARES Atrophic RhinitisAtrophic Rhinitis IdiopaticIdiopatic

Management of AR Management of AR

Objectives : Objectives : relieving symptoms for relieving symptoms for

improving QOLimproving QOL to avoid triggering factor to avoid triggering factor to avoid / to treat complication to avoid / to treat complication to change the natural history to change the natural history

Allergen elimination Allergen elimination

EDUCATIONEDUCATION Explain what is allergic rhinitis / reaction Explain what is allergic rhinitis / reaction Explain the meaning of pos. allergic skin Explain the meaning of pos. allergic skin

testtest Confirm whether there is correlation Confirm whether there is correlation

between allergen contact & rhinitis attackbetween allergen contact & rhinitis attack Explain how to do allergen avoidanceExplain how to do allergen avoidance Encourage to avoid the allergensEncourage to avoid the allergens

Globally important allergens

mites

pollen

mites sources

weed cockroaches

pets : dogs

• Pharmacological treatmentPharmacological treatment1.1. ANTIHISTAMINEANTIHISTAMINE

First lineFirst line Consider new antihistamine since :Consider new antihistamine since :

Long acting Long acting more practical more practical No sedating No sedating normal daily activity normal daily activity No / less cardiac effectNo / less cardiac effect Broad spectrum effectsBroad spectrum effects

Except :Except : Patient doesn’t mind sedation effectPatient doesn’t mind sedation effect It is not availableIt is not available Can not be affordedCan not be afforded Classic antihistamine can be consideredClassic antihistamine can be considered

2. NASAL DECONGESTANT2. NASAL DECONGESTANT Indicated in patient with prominent Indicated in patient with prominent

nasal obstruction complaintnasal obstruction complaint As addition / combination with As addition / combination with

A HA H

Long term treatmentLong term treatment Systemic nasal decongestant, Systemic nasal decongestant,

be careful in hypertension cases be careful in hypertension cases and glaucoma.and glaucoma.

Topical : rebound effectTopical : rebound effect

3. INTRANASAL CORTICOSTEROID3. INTRANASAL CORTICOSTEROID

Long term treatment safer than Long term treatment safer than systemic application systemic application

Effective to control AR symptomsEffective to control AR symptoms Note :Note :

Patients should be well informed how Patients should be well informed how to use to use

Symptoms relieve is not directly achieved Symptoms relieve is not directly achieved In some places it is unavailableIn some places it is unavailable

• Allergen Specific Immunotherapy Allergen Specific Immunotherapy ( ASIT ) ( ASIT )

ASIT : effective for treating allergic rhinitisASIT : effective for treating allergic rhinitisRecommended in patients with :Recommended in patients with :

severe symptomssevere symptoms failed by pharmacological treatmentfailed by pharmacological treatment positive correlation skin test & historypositive correlation skin test & history agree & well informed about duration, agree & well informed about duration,

schedule of injection & expected schedule of injection & expected resultsresults

Intermittent AR : Adults & childrenIs therapy needed ? If yes

Non-pharmacological therapyAllergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/nasal AH or cromon

Nasal corticosteroids

Nasal CS & oral/ nasal AH

Add further symptomatic treatment

OrShort course oral CS

Or Consider IT

If inadequatecontrol

Persistent AR : Adults Is therapy needed ? If yes

Non-pharmacological therapyAllergen avoidance measure

Environment control

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/ nasal antihistamine

Nasal corticosteroids

Nasal CS & Oral antihistamine

If inadequatecontrol If resistent

If resistent

Nasal blockageRhinorrhea

Antihistamine andOral / nasal

decongestantOr

Short course oral steroid

Nasal ipratropium bromide

If persistent

ConsiderImmunotherapy

If inadequate control

Further examination & consider immunotherapy

Or Surgical turbinate reduction

Persistent AR : children

Is therapy needed ? If yesNon-pharmacological therapyAllergen avoidance measure

Environment controlIs pharmacotherapy needed ? If yes

If inadequate control

Oral/ nasal antihistmaines or nasal cromon

Nasal corticosteroids in adequate dosis

If inadequate control

Review diagnosis

Consider immunotherapy