Allergic rhinitis Ewa Gawrońska- Ukleja

Allergic rhinitis Tradicional classification of allergic rhinitis include : Tradicional classification of allergic rhinitis include : Seasonal allergic rhinitis (hay fever) Seasonal allergic rhinitis (hay fever) Perennial allergic rhinitis Perennial allergic rhinitis This classification is very practical, and very good for Polish climatic zone. However in other countries hay season is present all year round, so the symptoms appear also during the whole year. Similary allergy to dust also can be seasonal. This is the reason why the new classification contains seasonal (intermittent) and persistent (chronic) allergic rhinitis. Both can have mild, moderate and severe form.

New classification Allergic rhinitis SeasonalPersistant Symptoms < 4 days In the week or < 4 weeks Symptoms ≥ 4 days In the week And ≥4 weeks MildModerete And Severe MildModerete And Severe Without sleep disorders, normal daily activity With sleeping disorders, influence of daily activity, concentration Without sleep disorders, normal daily activity With sleeping disorders, influence of daily activity, concentration

Hay fever (seasonal allergic rhinitis)

Definition (ARIA) Seasonal allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an immunoglobulin E (IgE)- mediated inflammation of the membranes lining the nose. The three cardinal symptoms in nasal reactions occurring in allergy are sneezing, nasal obstruction and mucous discharge’. Seasonal allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an immunoglobulin E (IgE)- mediated inflammation of the membranes lining the nose. The three cardinal symptoms in nasal reactions occurring in allergy are sneezing, nasal obstruction and mucous discharge’.

History Although asthma and other forms of allergic disease have been described in antiquity, ‘hay fever’ is surprisingly modern. Very rare descriptions can be traced back to Islamic texts of the 9th century and European texts of the 16th century. It was only in the early 19th century that the disease was carefully described, and at that time it was regarded as most unusual. In the 19th century, the disease followed the industrialization of westernized countries. By the end of the 19th century it had become commonplace in both Europe and North America. Although asthma and other forms of allergic disease have been described in antiquity, ‘hay fever’ is surprisingly modern. Very rare descriptions can be traced back to Islamic texts of the 9th century and European texts of the 16th century. It was only in the early 19th century that the disease was carefully described, and at that time it was regarded as most unusual. In the 19th century, the disease followed the industrialization of westernized countries. By the end of the 19th century it had become commonplace in both Europe and North America.

Epidemiology Depends of climatic zone, between 1–40% of people are affected by seasonal allergic rhinitis. The biggest morbidity is in Great Britain, RSA, Peru, Paraguay, Philippines. In Europe the average frequency is between 10 – 20%, in Poland about 4,1-12,2%, and in 5-13,3% of children. However the new research of ECAP (Polish Epidemiology of allergic diseases) shows that morbidity is increasing very fast and now is about 21-25% Depends of climatic zone, between 1–40% of people are affected by seasonal allergic rhinitis. The biggest morbidity is in Great Britain, RSA, Peru, Paraguay, Philippines. In Europe the average frequency is between 10 – 20%, in Poland about 4,1-12,2%, and in 5-13,3% of children. However the new research of ECAP (Polish Epidemiology of allergic diseases) shows that morbidity is increasing very fast and now is about 21-25%

Symptoms The characteristic symptoms of allergic rhinitis are: rhinorrhea (excess nasal secretion), itching, and nasal congestion and obstruction. First symptoms can appear in a new born, but disease usually starts between The characteristic symptoms of allergic rhinitis are: rhinorrhea (excess nasal secretion), itching, and nasal congestion and obstruction. First symptoms can appear in a new born, but disease usually starts between Seasonal allergic rhinitis is more common in cities then in villages. Seasonal allergic rhinitis is more common in cities then in villages. Allergic rhinitis is a multifactor disease with genetic as well as environmental factors influencing disease development. Main gens of pollenossis are located on many chromosomes. Allergic rhinitis is a multifactor disease with genetic as well as environmental factors influencing disease development. Main gens of pollenossis are located on many chromosomes.

Etiology Risk factors for allergic rhinitis are well identified. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations. In Poland the most common allergy in patients with AR is allergy to grass (above 82%), the second are trees and third weeds. In Poland the most common allergy in patients with AR is allergy to grass (above 82%), the second are trees and third weeds.

Etiology The scientist consider the allergens of moulds (Cladosporium, Alternaria) as a risk factor of seasonal rhinitis symptoms. The scientist consider the allergens of moulds (Cladosporium, Alternaria) as a risk factor of seasonal rhinitis symptoms.

Pathomechanism In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins. In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins. This specific IgE coats the surface of mast cells, which are present in the nasal mucosa. This specific IgE coats the surface of mast cells, which are present in the nasal mucosa. When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators

Pathomechanism TYPE I HYPERSENSITIVITY is the most characteristic reaction in AR. It contains two phase First one – early phase : First one – early phase : The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin. The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin. The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2. The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2. These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip). These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip).

Mucous glands are stimulated, leading to increased secretions. Mucous glands are stimulated, leading to increased secretions. Vascular permeability is increased, leading to plasma exudation. Vascular permeability is increased, leading to plasma exudation. Vasodilation occurs, leading to congestion and pressure. Vasodilation occurs, leading to congestion and pressure. Sensory nerves are stimulated, leading to sneezing and itching. Sensory nerves are stimulated, leading to sneezing and itching. All of these events can occur in minutes; so this reaction is called the early, or immediate, phase of the reaction. All of these events can occur in minutes; so this reaction is called the early, or immediate, phase of the reaction.

Second phase – late phase Second phase – late phase Over 4-8 hours, these mediators, through a complex interplay of events, lead to the recruitment of other inflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, and macrophages. Over 4-8 hours, these mediators, through a complex interplay of events, lead to the recruitment of other inflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, and macrophages. This results in continued inflammation, termed the late-phase response. This results in continued inflammation, termed the late-phase response. The symptoms of the late-phase response are similar to those of the early phase, but less sneezing and itching and more congestion and mucus production tend to occur. The symptoms of the late-phase response are similar to those of the early phase, but less sneezing and itching and more congestion and mucus production tend to occur. The late phase may persist for hours or days. The late phase may persist for hours or days.

Clinical presentation The characteristic symptoms of allergic rhinitis contain: The characteristic symptoms of allergic rhinitis contain: Nose: Nose: - Sneezing - Itching - Watery rhinorrhea - Loss of the sense of smell - Nasal congestion and obstruction

Clinical presentation Eyes Eyes - Tearing eyes - Itchy eyes - Redness - Conjunctivitis  Ears - Itchy ears - Swollen Eustachian Tube

Clinical presentation Other organs Other organs - Atopic dermatitis - Symptoms of asthma - Fever - Headache - Sleeping disorders

Physical examination The physical examination should focus on the nose, but examination of facial features, eyes, ears, oropharynx, neck, lungs, and skin is also important. The physical examination should focus on the nose, but examination of facial features, eyes, ears, oropharynx, neck, lungs, and skin is also important. Look for physical findings that may be consistent with a systemic disease that is associated with rhinitis! Look for physical findings that may be consistent with a systemic disease that is associated with rhinitis! Typical appearance Typical appearance Allergic salute Allergic salute

Physical examination The mucosa of the nose may be swollen and have a pale, bluish-gray color. The mucosa of the nose may be swollen and have a pale, bluish-gray color. Some patients may have predominant erythema of the mucosa, which can also be observed with rhinitis medicamentosa, infection, or vasomotor rhinitis. Some patients may have predominant erythema of the mucosa, which can also be observed with rhinitis medicamentosa, infection, or vasomotor rhinitis.

Physical examination Perform otoscopy to look for tympanic membrane retraction, air-fluid levels, or bubbles. Performing pneumatic otoscopy can be considered to look for abnormal tympanic membrane mobility. Perform otoscopy to look for tympanic membrane retraction, air-fluid levels, or bubbles. Performing pneumatic otoscopy can be considered to look for abnormal tympanic membrane mobility. These findings can be associated with allergic rhinitis, particularly if eustachian tube dysfunction or secondary otitis media is present. These findings can be associated with allergic rhinitis, particularly if eustachian tube dysfunction or secondary otitis media is present.

Physical examination Ocular examination may reveal findings of injection and swelling of the palpebral conjunctivae, with excess tear production. Ocular examination may reveal findings of injection and swelling of the palpebral conjunctivae, with excess tear production. The term "cobblestoning" is used to describe streaks of lymphoid tissue on the posterior pharynx, which is commonly observed with allergic rhinitis. The term "cobblestoning" is used to describe streaks of lymphoid tissue on the posterior pharynx, which is commonly observed with allergic rhinitis. Tonsillar hypertrophy can also be observed. Malocclusion (overbite) and a high-arched palate can be observed in patients who breathe from their mouths excessively. Tonsillar hypertrophy can also be observed. Malocclusion (overbite) and a high-arched palate can be observed in patients who breathe from their mouths excessively.

Diagnostics Skin prick test – gold standard Skin prick test – gold standard Prick by Prick tests with native allergens to confirm food allergy Prick by Prick tests with native allergens to confirm food allergy Total IgE level – low meaning Total IgE level – low meaning Specific IgE – good senstivity and specificity Specific IgE – good senstivity and specificity Phadiatop test Phadiatop test Provocation test with cytological estimation of nose mucose membrane Provocation test with cytological estimation of nose mucose membrane Spirometry in the case of asthma symptoms Spirometry in the case of asthma symptoms

Treatment The management of allergic rhinitis consists of 3 major categories of treatment The management of allergic rhinitis consists of 3 major categories of treatment 1. Environmental control measures and allergen avoidance 2. Pharmacological management 3. Immunotherapy

Treatment 1. Environmental control measures and allergen avoidance involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis. However, global environmental control without identification of specific triggers is inappropriate.

Treatment Pollens and outdoor molds Pollens and outdoor molds Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist

Treatment Indoor allergens Indoor allergens Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure. Bed linens should be washed every 2 weeks in hot water to kill any mites present. Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful.

Treatment of symptoms The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Treatments for allergic rhinitis include : The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Treatments for allergic rhinitis include : 1. ANTIHISTAMINES 2. CORTICOSTERIDES 3. DECONGESTANTS 4. LEUKOTRIENE INHIBITOR 5. Anty IgE theraphy

ANTIHISTAMINES DRUGS Good for treating allergy symptoms, especially when symptoms occure not very often or do not last for a long time. Good for treating allergy symptoms, especially when symptoms occure not very often or do not last for a long time. Available in both oral and nasal spray forms Available in both oral and nasal spray forms Antihistamines suppress the histamine- induced wheel (swelling) and vasodilatation (flare) response by blocking the binding of histamine to its receptors on nerves, vascular smooth muscle, glandular cells, endothelium, and mast cells. They effectively exert competitive antagonism of histamine for H1-receptors. Itching and sneezing are suppressed by antihistamine blockade of H1-receptors on nasal sensory nerves. Antihistamines suppress the histamine- induced wheel (swelling) and vasodilatation (flare) response by blocking the binding of histamine to its receptors on nerves, vascular smooth muscle, glandular cells, endothelium, and mast cells. They effectively exert competitive antagonism of histamine for H1-receptors. Itching and sneezing are suppressed by antihistamine blockade of H1-receptors on nasal sensory nerves.

ANTIHISTAMINES Sedation is a common side effect, and some H1 antagonists, such as diphenhydramine and doxylamine, are also used to treat insomnia. However, second generation antihistamines do not cross the blood brain barrier, and as such do not cause drowsiness. Sedation is a common side effect, and some H1 antagonists, such as diphenhydramine and doxylamine, are also used to treat insomnia. However, second generation antihistamines do not cross the blood brain barrier, and as such do not cause drowsiness.

ANTIHISTAMINES ANTIHISTAMINES available in Poland (second generation) ANTIHISTAMINES available in Poland (second generation) Cetirizine Zyrtec, Alertec Loratadine Clarytyna, Loratydyna Levocetirizine Xyzal Fexofenadine Telfast Desloratadine Aerius Ebastine Kestine

ANTIHISTAMINES Azelastine is a antihistamine nasal spray that is used to treat allergic rhinitis Azelastine is a antihistamine nasal spray that is used to treat allergic rhinitis

Nasal corticosteroids These prescription sprays reduce inflammation of the nose and help relieve sneezing, itching, and runny nose. It may take a few days to a week to see improvement in symptoms. These prescription sprays reduce inflammation of the nose and help relieve sneezing, itching, and runny nose. It may take a few days to a week to see improvement in symptoms. Beclomethasone Beclomethasone Fluticasone Fluticasone Mometasone Mometasone Triacinolone Triacinolone

Decongestants They are often used with antihistamines. They are often used with antihistamines. Oral and nasal decongestants -- Include oksymethazolin, ksylomethazolin, naphazolin. Some decongestants may contain pseudoephedrine, which can raise blood pressure. People with high blood pressure or enlarged prostate should not take drugs containing pseudoephedrine. Using nasal decongestant sprays for more than 3 days can cause "rebound congestion," which makes congestion worse. Oral and nasal decongestants -- Include oksymethazolin, ksylomethazolin, naphazolin. Some decongestants may contain pseudoephedrine, which can raise blood pressure. People with high blood pressure or enlarged prostate should not take drugs containing pseudoephedrine. Using nasal decongestant sprays for more than 3 days can cause "rebound congestion," which makes congestion worse.

Anti IgE therapy Omalizumab is a monoclonal antibody targeted against the high-affinity receptor binding site on human immunoglobulin (IgE). Bound IgE is not available for basophile binding, degranulation is attenuated, and allergic symptoms are reduced. Omalizumab is a monoclonal antibody targeted against the high-affinity receptor binding site on human immunoglobulin (IgE). Bound IgE is not available for basophile binding, degranulation is attenuated, and allergic symptoms are reduced.

Leukotriene modifiers These prescription drugs block the production of leukotrienes, which are inflammatory chemicals produced by the body. They are taken once a day and do not cause sleepiness, and are also used to treat allergic asthma. Leukotriene modifiers include montelukast (Singulair) and zafirlukast. These prescription drugs block the production of leukotrienes, which are inflammatory chemicals produced by the body. They are taken once a day and do not cause sleepiness, and are also used to treat allergic asthma. Leukotriene modifiers include montelukast (Singulair) and zafirlukast.

Other drugs Cromolyn sodium (NasalCrom) Cromolyn sodium (NasalCrom) This nasal spray prevents the release of histamine and helps relieve swelling and runny nose. It works best when taken before symptoms start and may needed to be used several times a day. Nasal atropine Nasal atropine Ipratropium bromide (Atrovent) is a prescription nasal spray that can help relieve a very runny nose. Eye drops Antihistamine eye drops - relieve both nasal and eye symptoms. Examples include azelastine, olopatadine, ketotifen, and levocabastine Antihistamine eye drops - relieve both nasal and eye symptoms. Examples include azelastine, olopatadine, ketotifen, and levocabastine Decongestant eye drops -- such as phenylephrine and naphazoline Decongestant eye drops -- such as phenylephrine and naphazoline

Immunotherapy Is recommended if the allergen cannot be avoided and if symptoms are hard to control. Is recommended if the allergen cannot be avoided and if symptoms are hard to control. This includes regular injections of the allergen, given in increasing doses (each dose is slightly larger than the previous dose) that may help the body adjust to the antigen. This includes regular injections of the allergen, given in increasing doses (each dose is slightly larger than the previous dose) that may help the body adjust to the antigen.

Persistent allergic rhinitis It is a chronic IgE – depend, mucose membrane inflammatory process with clinical symptoms. It occur in every season or all year. The symptoms are almost the same like in seasonal allergic rhinitis, but without conjunctivitis. It is a chronic IgE – depend, mucose membrane inflammatory process with clinical symptoms. It occur in every season or all year. The symptoms are almost the same like in seasonal allergic rhinitis, but without conjunctivitis.

Epidemiology Depends of country, between 10-20% of people suffer from persistent allergic rhinitis. In Poland morbidity is now about 3% in adults and 2,1 % in children. Disease usually starts before 30. Depends of country, between 10-20% of people suffer from persistent allergic rhinitis. In Poland morbidity is now about 3% in adults and 2,1 % in children. Disease usually starts before 30.

Causes The most common cause of persistent rhinitis is an allergy to house dust mite. However, allergy to pets, other animals, indoor moulds is also common. Occasionally it can be food allergy. The most common cause of persistent rhinitis is an allergy to house dust mite. However, allergy to pets, other animals, indoor moulds is also common. Occasionally it can be food allergy.

Patomechanism The same like in seasonal allergic rhinitis The same like in seasonal allergic rhinitis

Clinical presentation The symptoms are almost the same like in seasonal allergic rhinitis, but without conjunctivitis. Nasal congestion and obstruction are main symptoms The symptoms are almost the same like in seasonal allergic rhinitis, but without conjunctivitis. Nasal congestion and obstruction are main symptoms

Differention of clinical symptoms SymptomSeasonalPersistent Nose obstruction+/-Always ExcretionWatery, oftenMucus or serum SneezingAlwaysSometimes Lack of smell+/-Often Eye symptomsOftenRare AsthmaOccasionallyOften Chronic sinusitisRareOften

Diagnostics Interview Interview Skin prick test – gold standard Skin prick test – gold standard Total IgE level – low meaning Total IgE level – low meaning Specific IgE – good sensitivity and specificity Specific IgE – good sensitivity and specificity Provocation test with cytological estimation of nose mucose membrane Provocation test with cytological estimation of nose mucose membrane Spirometry Spirometry

Treatment There is a lack of good quality evidence in clinical trials and studies for the effectiveness of reducing the numbers of house dust mites in terms of reducing rhinitis symptoms There is a lack of good quality evidence in clinical trials and studies for the effectiveness of reducing the numbers of house dust mites in terms of reducing rhinitis symptoms Avoiding the cause of allergy by : Avoiding the cause of allergy by : reduce the number of mites in your home reduce the number of mites in your home regular cleaning and vacuuming with particular attention to your bedroom and bedclothes regular cleaning and vacuuming with particular attention to your bedroom and bedclothes give up the pet give up the pet washing pets regularly can also help washing pets regularly can also help

Allergic rhinitis therapy by ARIA

Immunotherapy Can be also helpful to decrease symptoms and improve quality of life. Can be also helpful to decrease symptoms and improve quality of life.

AR & Asthma Allergic rhinitis is one of the multiple risk factors identified for asthma development. Patients with persistent allergic rhinitis should be diagnose for asthma. About 20% of children treated because of allergic rhinitis for more then 10 years develop asthma. Allergic rhinitis is one of the multiple risk factors identified for asthma development. Patients with persistent allergic rhinitis should be diagnose for asthma. About 20% of children treated because of allergic rhinitis for more then 10 years develop asthma.

Thank you for your attention !!! Thank you for your attention !!!