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ARIA WHO 2008Literature reading

Faculty of Medicine Padjadjaran University

Dr. Hasan Sadikin General Hospital

Bandung

Yanuar Iman Santosa

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Allergic Rhinitis

Definition• Allergic rhinitis is clinically defined as symptomatic disorder of

the nose induced after allergen exposure by an IgE-mediated inflammation

• Characterized by nasal symptom : Anterior or posterior rhinorrhoea Sneezing Nasal blockage Itching of the nose

Allergic Rhinitis (AR) • AR defined 1929

– Sneezing– Nasal obstruction – Mucous discharge

• Global health problems +/- 500 million people world wide

• Economic impact often underestimated

• AR – asthma often co-morbidities

Allergic Rhinitis (AR)

• History – Islamic text 9th century– European text 16th century– Western countries carefully described 19th century

• Cause : indoor and outdoor allergen

• Diagnosis : easy but often under diagnosed

• Management : well established

ARIA WORKSHOP

• 1999 – Statement of evidence guidelines

– New classification intermittent (IAR) and persistent (PER)

– Associated with quality of life mild and moderate/severe

– Co-morbidities • eyes • Paranasal sinuses • Asthma

– 80% asthma have Rhinitis – 10-40% Rhinitis have asthma – one airway one disease

The ARIA initiative was developed

• As a state-of-the-art for the specialist, the general practitioner and for health care workers:

• To update their knowledge of allergic rhinitis,

• To highlight the impact of allergic rhinitis on asthma,

• To provide an evidence-based documented revision on the diagnosis methods,

• To provide an evidence-based revision on the

treatments available

• To propose a stepwise approach to the management of the disease,

•To assess the magnitude of the problem in developing countries and to implement guidelines (with IUATLD)

• ARIA documents was not intended to be a standard of care document for individual countries

• To facilitate the development of relevant local standard of care documents for patients

Need for ARIA Update

• Large number of papers have been published • ARIA recommendation needed to be validated • New evidence based system available• Gaps in the first ARIA documents :

– Some aspect of treatment (complimentary and alternative medicine) were not appropriately discussed.

– Links between upper and lower airways not sufficiently developed

– Sport and rhinitis in athletes – Rhinitis and its links with asthma in preschool children

ARIA 2001

RECOMMENDATIONS1. Classification of allergic rhinitis as

a major chronic respiratory disease due to its:• prevalence• impact on quality of life• impact on work/school performance and productivity• economic burden• links with asthma• association with sinusitis and other co-morbidities such as conjunctivitis.

ARIA 2007RECOMMENDATIONS1. Allergic rhinitis is a major chronic

respiratory disease due to its:• prevalence• impact on quality of life• impact on work/school performance and productivity• economic burden• links with asthma

ARIA 2001

RECOMMENDATIONS 2. Along with other known risk

factors, allergic rhinitis should be considered as a risk factor for asthma.

3. A new subdivision of allergic rhinitis has been made:• intermittent• persistent

ARIA 2007RECOMMENDATIONS 2. In addition, allergic rhinitis is

associated with co-morbidities such as conjuntivitis

3. Allergic rhinitis should be considered as a risk factor for asthma along with other known risk factors

ARIA 2001

RECOMMENDATIONS4. The severity of allergic rhinitis is

classified as "mild" or "moderate/severe“ depending on the severity of symptoms and quality of life outcomes.

5. Depending on the subdivision and severity of allergic rhinitis, a stepwise therapeutic approach is outlined.

ARIA 2007RECOMMENDATIONS4. A new subdivision of allergic

rhinitis has been proposed : - intermittent (IAR) - persistent (PER)

5. The severity of allergic rhinitis is classified as "mild" or "moderate/severe“ depending on the severity of symptoms and quality of life outcomes.

ARIA 2001

RECOMMENDATIONS6. The treatment of allergic rhinitis

should combine:• allergen avoidance (when possible)• pharmacotherapy• immunotherapy

7. Environmental and social factors should be optimized to allow the patient to lead a normal life.

ARIA 2007RECOMMENDATIONS6. Depending on the subdivision and

severity of allergic rhinitis, a stepwise therapeutic approach is outlined.

7. The treatment of allergic rhinitis combines:• education • pharmacotherapy• immunotherapy

ARIA 2001

RECOMMENDATIONS 8. Patients with persistent allergic

rhinitis should be evaluated for asthma by history, by chest examination, and if possible, by the assessment of airflow obstruction before and after a bronchodilator.

9. Patients with asthma should be appropriately evaluated (history and physical examination) for rhinitis.

ARIA 2007RECOMMENDATIONS 8. Patients with persistent allergic

rhinitis should be evaluated for asthma by history, by chest examination, and if possible, by the assessment of airflow obstruction before and after a bronchodilator.

9. Patients with asthma should be appropriately evaluated (history and physical examination) for rhinitis.

ARIA 2001

RECOMMENDATIONS10. A combined strategy should

ideally be used to treat coexistent upper and lower airway diseases in terms of efficacy and safety.

11. In developing countries, a specific strategy may be needed depending on available treatments and interventions, and their cost.

ARIA 2007RECOMMENDATIONS10. Ideally , a combined strategy

should ideally be used to treat coexistent upper and lower airway diseases in terms of efficacy and safety.

1. Recognize AR

1. Recognize AR

2. Differential Diagnosis of AR

3. Make the diagnosis of ARSymptoms suggestive of allergic rhinitis

Anterior rhinorrhea Sneezing

Nasal obstruction (and possibly other nasal or ocular symptoms )

Primary care

Multi-allergen test

Negative Positive

Rhinitis is unlikely to be allergic

Rhinitis is likely to be allergic, if more information needed or

immunotherapy to be proposed

Refer the patient to specialist

Specialist

Skin Prick Test

NegativePositive + correlated with

symptoms

Allergic rhinitis

If strong suggestion of allergy, perform serum

allergen specific IgE

Negative

Non allergic rhinitis

Positive + correlated with symptoms

Allergic rhinitis

4. Classify AR

5. Treat AR

Treatment goals • Unimpaired sleep• Ability to undertake normal daily activities • No troublesome symptoms • No or minimal side effects of rhinitis treatment

Diagnosis of allergic rhinitis Check for asthma espescially in patients with moderate-severe

and/or persistent rhinitis

Persistent symptomsIntermittent symptoms

Mild MildModerate-severe Moderate-severe

If + Conjunctivitis add:• Oral H-1-blocker or Intraocular H1-blocker or Intraocular Chromone (or saline)

Not in preferred order• Oral H-1 antihistamine• Intranasal- H-1 antihistamine• and/or decongestant or •LTRA

In persistent rhinitis review the patient after 2-4 weeks

Not in preferred order• Oral H-1 antihistamine• Intranasal- H-1 antihistamine• and/or decongestant or• Intranasal CS • LTRA or • (Chromone)

If failure: step-up If improved: continue for 1 month

In preferred order•Intranasal CS •Oral H-1 antihistamine or LTRA review the patient after 2-4 weeks

Increase intranasalCS dose

FailureImproved

Review diagnosisReview compliance

Query infections or other causes

Step-down andcontinue treatment

for 1 month

Itch sneeze:add H-1

antihistamine

Rhinorrhea:add ipratropium

Blockage: add decongestant, or oral

CS (short term)

Failure:Surgical refferal

Consider Specific Immunotherapy

Allergen and irritant avoidance may be appropriate

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SurgeryIndication for surgical intervention :

• Drug-resistant inferior turbinate hypertrophy

• Anatomical variation of the septum with functional relevance

• Anatomical variation of bony pyramid with functional/aesthetic relevance

• Secondary or independently developing chronic sinusitis

• Different forms of nasal unilateral polyposis

• Fungal sinus diseases

5. Treat ARSource of guideline ARIA 2001 ARIA 2007

Type of statement Expert panel evidence based

Expert panel evidence based

Diagnostic testing for IgE antibody (skin test or serum specific IgE)

Indicated to confirm allergy test

Indicated if symptoms persist and / or are moderate / severe, or QOL affected or SIT considered

Allergen avoidance Indicated (evidence D) Usually not indicated as public health measures. Maybe helpful in some highly selected patients

First generation oral H1-blocker

Not recommended because of unfavourable efficacy / safety ratio

Not recommended because of unfavourable efficacy / safety ratio

Second generation oral H1-blocker

First line therapy except for moderate-severe persistent rhinitis, not effective alone for nasal congestion

First line therapy except for moderate-severe persistent rhinitis (or added to INCS)

Source of guideline ARIA 2001 ARIA 2007

Topical H1 blocker (intranasal or topical conjuntival)

Same as oral, rapidly effective

Same as oral, rapidly effective

INCS First line therapy for moderate-severe disease, particularly in persistent rhinitis, despite slow onset of action (12hrs), effective for nasal congestion

First line therapy for moderate-severe disease, particularly in persistent rhinitis, despite slow onset of action (12hrs), effective for nasal congestion

antileukotriene One study only. Indication difficult to delineate

In rhinitis, efficacy similar to oral H1 blocker. Effective on asthma and rhinitis

Cromone (intranasal or topical conjunctival)

Safe and effective but less effective than other medications

Safe and modestly effective and less effective than other medications

Decongestant (oral) Indicated in combination with oral H1 antihistamine to reduce congestion. Safety issues

Indicated in combination with oral H1 antihistamine to reduce congestion. Safety issues

Source of guideline ARIA 2001 ARIA 2007

Depot corticosteroid Not recommended because of side effects

Not recommended because of side effects and lack of evidence in efficacy

Intranasal anticholinergic Indicated to reduce rhinorrhoea not controlled by other medication

Indicated to reduce rhinorrhoea not controlled by other medication

Subcutaneous immunotherapy

Indicated if only 1 or 2 relevant allergens and pharmacotherapy and avoidance therapy are insufficient. Risk of systemic effects

Indicated if only 1 or 2 relevant allergens and pharmacotherapy and avoidance therapy are insufficient. Risk of systemic effects

Sublingual immunotherapy Same as subcutaneous immunotherapy, with some reservation, is safer than subcutaneous immunotherapy

Same as subcutaneous immunotherapy, is safer than subcutaneous immunotherapy

Referral to allergy or other specialist

Indicated if symptoms persist > 3 months

Indicated if response to drugs is poor or if symptoms persist > 3 months

5. Treat AR

6. Assess possibility of asthma

Need for ARIA Update

• Large number of papers have been published • ARIA recommendation needed to be validated • New evidence based system available• Gaps in the first ARIA documents :

– Some aspect of treatment (complimentary and alternative medicine) were not appropriately discussed.

– Links between upper and lower airways not sufficiently developed

– Sport and rhinitis in athletes – Rhinitis and its links with asthma in preschool children

Complimentary and alternative medicine• Many patients who use complementary and alternative

medicine appear to be satisfied

• Evidence-based recommendations are difficult to propose for most complementary and alternative medicine interventions because of methodological problems

• There is no evidence for the efficacy of most complementary and alternative medicine on allergic rhinitis and asthma

• The safety of phytotherapy raises concerns

Links between upper and lower airways

• Vast majority of asthmatic have rhinitis

• Many patients with rhinitis have asthma

• Asthma prevalence is increased in rhinitis

• Allergy is associated with rhinitis and asthma

• Occupational agent can cause rhinitis and asthma

• Allergic and nonallergic rhinitis are risk factors for asthma

Links between upper and lower airways

• Nonallergic rhinitis is associated with asthma

• Rhinitis may be associated with non specific bronchial hyperreactivity

• The coexistence of rhinitis with asthma appears to impair asthma control

• Most asthmatic exacerbations are associated with a nasal viral infection

Links between rhinitis and asthma severity

Sport and rhinitis in athletes

• Treatment adapting criteria set by International Olympic Committee (IOC) and World Anti-Doping Agency(WADA).

Rhinitis and its links with asthma in preschool children

• AR most prevalent chronic allergic disease in children but often difficult to differentiate with non allergic rhinitis

• Significant effect on QOL

• The atopic march – Atopic dermatitis – Asthma – Allergic rhinitis

• AR in preschool children – Difficult to diagnose, DD/ infectious rhinitis – Persist longer than 2 weeks search for other cause than

infection

• Sign : – Sneezing, nasal itching, discharge and congestion – Allergic shiners, nasal crease– Noisy breathing, repeated throat clearing, snoring and loss

of olfaction and taste. – Facial manifestation of obstructed breathing

• Gaping mouth, chapped lips, hypertrophied ginggival mucosa, dental malocclusions

• Co-morbidities : asthma, atopic dermatitis/eczema, allergic conjuctivitis, chronic sinusitis, OME

• SPT if possible

• Differential diagnosis : – Infectious rhinitis (viral) – Foreign body– Anatomical variations – Benign tumor – Nasal obstruction due to Adenoid hypertrophy

• Differential diagnosis in older children : – Trauma CSF rhinorrhoea– Nasal glioma– Rhinitis medicamentosa (topical decongestant)

• Treatment – Pharmacologic :

• AR-Asthma medication often associated, asses side effects

• Consider cognitive function in relation to general malaise

• Many lack of pediatric approval • Oral glucocorticosteroids should be avoided

• Intranasal glucocorticosteroids most effective – Betamethasone should not be used in children – Mometasone furoate 2 yo and older – Fluticasone propionate 4 yo and older – Other over 5 yo

• Anti histamine : Children prefer Oral > intranasal medication

– First generation : sedation, fatigue, hyperactivity, insomnia, irritability

– Second generation : cetirizine, levocetirizine and loratadine have been studied for long term efficacy and safety in children

– Intranasal : levocabastine, azelastine effective for children with symptoms limited to nose and eyes

• Montelukast approved in some countries • Disodium cromoglycate 4-6x/day, low compliance • Avoid polypharmacy • Immunotherapy nor recommended before age 5 yo • Education of family, avoid allergen and irritant

Pregnancy

• Defined as nasal congestion present during pregnancy without other signs of respiratory tract infection and with no known allergic cause, disappearing completely within 2 weeks after delivery

• 1 of 5 pregnant women • Nasal glucocorticosteroids are not very effective in nonallergic

women• Nasal decongestants provide good temporary relief overuse

ARIA 2007

Ageing

ARIA 2001• With ageing, various

physiological changes occur in the connective tissue and vasculature of the nose which may predispose or contribute to chronic rhinitis

ARIA 2007• With ageing, various

physiological changes occur in the connective tissue and vasculature of the nose which may predispose or contribute to chronic rhinitis

Ageing

ARIA 2001• Allergy is a less common cause of

persistent rhinitis in subject over 65 yo– Atrophic rhinitis is common

and difficult to control– Rhinorrhea can be controlled

with anticholinergic – Some drugs (reserpine,

guanethidine, phentolamine, methyldopa, prazosin, chlorpromazine or ACE inhibitors) can cause rhinitis

ARIA 2007• Unpredicted

pharmacokinetic changes • Intranasal

glucocorticosteroids at recommended dose have not been associated with an increased risk of fractures

Ageing

ARIA 2001• Some drugs may induce

specific side effects in elderly patients– Decongestants and drugs

with anticholinergic activity may cause urinary retention in patient with prostat hypertrophy

– Sedative drugs may have greater side effects

ARIA 2007• Cardiovascular and urinary

risk of nasal or oral decongestan should be considered

Co-morbidities

1. Conjunctivitis 2. Rhinosinusitis 3. Nasal polyps 4. Adenoid hypertrophy 5. Tubal dysfunction 6. OME 7. Chronic cough 8. Laryngitis 9. Gastroesophageal reflux (GER)

Conjunctivitis

• Allergic conjunctivitis is a common co-morbidity of allergic rhinitis

• The other forms of conjunctivitis are not associated with an IgE-mediated allergic reaction

Rhinosinusitis

• Role of allergy in sinus disease is still unclear • Loratadine modestly improve symptoms • Surgery alone is not sufficient to completely resolve recurrent

sinus infection, add immunotherapy • Limited evidence on effectiveness of antiallergic therapy in

patient with chronic sinus disease, but logical.

Nasal polyps

• Role of allergy in generation of nasal polyps in unclear • Historically result of allergic reaction to unknown stimulus

giving rise to mucosal swelling and protrusion. • Until now, no clear epidemiologic data support a role of

allergy in nasal polyps

Adenoid hypertrophy

• Simptoms : nasal obstruction, rhinolalia clausa, open mouth breathing, snoring.

• In children AR and adenoid hypertrophy may give similar symptoms

• Role of allergy is unclear• No correlation is observed between the atopic state and the

degree of adenoid hypertrophy • Intranasal glucocorticosteroids capable of reducing adenoid

related symptoms • Short treatment with oral H1-antihistamine and intranasal

glucocorticosteroids spray reduce adenoid volume and associated symptoms

Tubal dysfunction

• Eustachian tube lined with respiratory epithelium allergic inflammation concomitant mucosal swelling impair function ET OME

• AR patient > risk eustachian tube dysfunction, assessed by tympanometry

OME

• Role of allergy in OME is still subject to controversy • Significant problem in pediatric population • All cells and mediators of allergic inflammation in AR are

present in the middle ear fluid of OME patients (eosinophil, IL-4 and IL-5 number in atopic > non atopic patients)

OME

• Question remains : – Whether rhinitis predisposes development of otitis ? – Whether nasal dysfunction causes otitis to worsen? – Whether OME can be cured by treating underlying nasal /

sinus infection ? – Whether the middle ear mucosa can be targeted directly

by allergens ?

Chronic cough

• Acute cough : viral, pneumonia, respiratory infections, left ventricular failure, asthma, foreign body

• Chronic cough (> 8 weeks) : infection, AR, rhinosinusitis, asthma, COPD, GERD, irritant, bronchiectasis, others,

• Nasal treatment for AR with steroid spray and oral H1 antihistamine relieve cough symptoms in AR patients

• Nonprescription treatment for cough in children under 6 yo is prohibited

Laryngitis

• In dysphonia inhalant allergy is a hidden but common cause of vocal cord dysfunction

• No prove of vocal edema allergic inflammation • No prove of allergen provocation on voice quality in atopic

patients • No prove of benefit anti allergic therapy on laryngeal edema

or voice quality • Inhaled steroids in allergic asthma may cause a reversible

vocal cord dysfunction

Gastroesophageal reflux (GER)

• May masquerade as CRS

• Associations have been reported between GER and variety of upper and lower respiratory tract conditions but not with allergic rhinitis

ARIA 2001

ARIA 2007

Authors

Conflict of interest• Jean Bousquet • Torsten Zuberbier• Christiaan van Weel’s• Michael S Blaiss• Sergio Bonini • Luis-Philippe Boulet • Kai-Hakon Carlsen• Adnan Custovic• others

No conflict of interest • De-Yun Wang• Philippe-J. Bousquet • Nikolai Khaltaev • Jing Li• Ken Otha • Paulo Camargos • Claus Bachert• Heather Zar • others

THANK YOU

“ The Allergic March “

Fig.8 History of antihistamines (AH)

First generation AHterfenadine fexofenadineStaub

Bovetphenbenzamine

Anti-histaminic effect

Anti-cholinergic effect

Sedative effect

chlorphenyramine astemizole

cetirizineloratadine

19961937 1942 1979 1988 2001

Xyzal®

desloratadine

Second generation AH

Prof(Emr) Dr.H. Iwin Sumarman. dr., SpTHT, KAI, KRA. Allergic Rhinitis: Update ARIA Consensus of AR Management. Presented at Scientific Sesion on Reuni of Graduated ENT&HNS Specialist of ENT-HNS Dept Faculty of Medicine Unpad / RSHS Bandung October 17-18th 2009

Glossary

Glossary

Glossary

Glossary

Glossary

Glossary

Pediatric aspect

ARIA 2001• AR is part of the “allergic

march” during childhood. Intermittent AR is unusual before two years of age. AR is most prevalent during school age years.

• Allergy test can be done at any age and may yield important information

ARIA 2007• AR is part of the “allergic

march” during childhood but intermittent AR is unusual before two years of age.

Pediatric aspect

ARIA 2001• The principles of treatment for

children are the same as for adults, but special care has to be taken to avoid the side effects typical in this age of group

• Doses of medication have to be adjusted and special considerations followed. Few medications have been tested in children under age of two years.

ARIA 2007• Allergic rhinitis is most

prevalent during school age years.

Pediatric aspect

ARIA 2001• In children, symptoms of AR

can impair cognitive functioning and school performance, which can be further impaired by the use of sedating oral H1 – AH

ARIA 2007• In preschool children, the

diagnosis of AR is difficult.

Pediatric aspect

ARIA 2001• Intranasal glucocorticoids are an

effective treatment for AR. However, their possible side effect on growth for some, but not all, intranasal glucocorticoids is of concern. It has been shown that the recommended doses of intranasal mometasone and fluticasone did not affect growth in children with AR

• Disodium cromoglycate is commonly used to treat allergic rhinoconjuctivitis in children because of the safety of the drugs

ARIA 2007• In school children and

adolescents, the principles of treatments are the same as for adults, but doses may be adapted, and special care should be taken to avoid the side effects of treatment typical in this age group.

Pregnancy

ARIA 2001• Rhinitis is often a problem

during pregnancy since nasal obstruction may be aggravated by the pregnancy itself

ARIA 2007• Rhinitis is often a problem

during pregnancy since nasal obstruction may be aggravated by the pregnancy itself

Pregnancy

ARIA 2001• Caution must be taken

when administering any medication during pregnancy, as most medication cross the placenta

ARIA 2007• Caution must be taken

when administering any medication during pregnancy, as most medication cross the placenta

Pregnancy

ARIA 2001• For most drugs, limited

studies have been completed, and only small groups with no long-term analysis

ARIA 2007• For most drugs, limited

studies have been completed, and only small groups with no long-term analysis

immunotherapy

allergen and irritant avoidance

intra-nasal decongestant (<10 days) or oral decongestant

local cromone

oral or local non-sedative H1-blocker

intra-nasal steroidmild

intermittent

moderatesevere

intermittent

mildpersistent

moderatesevere

persistent

Treatment of Allergic Rhinitis Allergic Rhinitis and its Impact on Asthma

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Stepwise treatment proposed Mild intermitten AR : oral H1-antihistamines

Moderate severe Intermittent AR :intra nasal topical steroid (high dose) + if needed: oral H-1 antihistamine and/or oral

steroid (short term course)

Mild persistent AR :oral H-1 Antihistamine, orlow dose intra nasal topical steroid

Moderate-severe persistent AR :High dose intra nasal topical steroid If symptoms are severe : add oral H-1 Antihistamine, and or short course of oral corticosteroid at beginning of the treatment

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mildintermittent

moderatesevere

intermittent

mildpersistent

moderatesevere

persistent

Oral H1- AH NasalBeclomethasone

high dose(300-400 μg

/daily)

Oral H1-AH

Oral CS

Oral H1-AH

NasalBeclomethasone

low dose(100-200 μg

/daily)add

and / or

or

NasalBeclomethasone

high dose(300-400 μg /daily)

add

Oral H1-AH

Oral CSand / or

If needed after 1 week treat

Severe symptoms

Stepwise treatment proposed

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ANTIHISTAMIN

Kompetisi dlm berikatan dng reseptor H1 di organ sasaran. Digolongkan menjadi:1. Generasi pertama ( classic ): promethazine, brompheramine2. Generasi kedua ( non – classic ): Terfenadine Astemizole Cetirizine Loratadine

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DEKONGESTAN

• Termasuk adrenergik (topikal/sistemik) Vasokontriktor• Mengatasi sumbatan hidung sementara• Lebih efektif digunakan bersama antihistamin • Pemakaian obat topikal jangka lama rhinitis medikamentosa

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ANTIKOLINERGIK 5,9

• Antikolinergik topical (Ipatropium Bromida) menghambat pelepasan asetilkolin, stimulasi parasimpatis mengurangi gejala rinore.

• Ipatropium Bromida nasal spray• hanya simptom saja, tidak sebagai anti histamin yang dapat

menghentikan akumulasi mastosit dan eosinofil

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ANTI LEUKOTRIEN5

• Antileukotrien gejala hidung tersumbat • Mediator leukotrien menginduksi gejala hidung tersumbat. • Obat antileuklotrien dapat dikombinasikan dengan

antihistamin.

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KROMOLIN SODIUM 5,7

• Mekanisme kerja kromolin belum jelas.• Invivo disodium kromoglikat << jumlah akumulasi sel-sel

eosinofil pada bopsi mukosa penderita rhinitis alergi seasonal serta dapat menekan fungsi sel-sel pro-Inflamatory.

• Pemakaiannya harus berulang tiap 6 jam karena lama obat pendek hingga pemberian obat ini kurang praktis

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KORTIKOSTEROID 5,9

• Pemberian steroid topikal penghambatan Eosinofil (EG2+) dalam memproduksi IL-5 oleh T cell CD3+.

• Penurunan menghambat dilepaskannya TCD3+ di submukosa serta menghambat produksi sekresi IL-5 dari T cells.

• Pengobatan dengan kortikosteroid sistemik memiliki efek anti inflamasi yg sangat kuat sangat cocok untuk intervensi system imun

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Terapi Imuno Alergen Spesifik (TIAS)6

• TIAS penyuntikan dengan allergen spesifik yang dilakukan secara berulang dan teratur kepada pasien yang menunjukan kondisi IgE mediated

• Tujuan memberikan perlindungan thd gejala-gejala alergi dan reaksi inflamasi yang berhubungan dengan paparan allergen alami.

antihistamine• Second-generation• Systemic:• Acrivastine Benadryl • Astemizole Hismanal• Cetirizine • Loratadine claritin, lorfast, • Mizolastine Mizollen• Terfenadine Seldane• Topical:• Azelastine Astelin • Levocabastine Livostin• Olopatadine Pataday, Patanol S, Opatanol• Third-generation• Systemic:• Levocetirizine[8] Xyzal, UVNIL• Desloratadine[9] NeoClarityn, Claramax, Clarinex, Aerius and Delot • Fexofenadine[10] Allegra, Telfast, Fastofen, Tilfur)

• Aerius • Alegi • Alernitis • Alpenaso • Anhissen • Anlos • Apeton • Avil

• Benadryl• Bestalin • Biolergy

• Celestamine • Cetirizine • Cetrixal • Cetryn • Cetymin • Chlorphenon • Cirrus • Clarihis • Clarinase