Allergic Rhinitis Dr. Shishir Modak Past President – IAP Pune Master trainer in ATM , RTI – GEM, PSPID RAP , Nutrition , TB Modules

Allergic Rhinitis Case 1 Varshini 11 yr old girl H/o Recurrent cold since 6 months. Paroxysmal sneezing , Sneezing more than 50 times in few minutes. Symptoms worsen in August/ September ? Seasonal Allergic Rhinitis , ? Viral

Allergic Rhinitis Case 2 Shourya 5 yr old boy H/ o Cough , cold off & on for last 3 months. H/ o Fever & Earache 2 months back . Subsided with a course of antibiotic. However Cold & Cough Don’t go away. It is always there. No Breathlessness. Could it be Allergic ?

Allergic Rhinitis Salil, 5 yr old boy Cough, Cold , Sneezing - 15 days Case 3 Salil, 5 yr old boy Cough, Cold , Sneezing - 15 days No Fever , No chest signs Recurrent since 4 months. GP gave Antibiotic , Nebulization & Cough Syrup but cough, cold persists. Now he has started Aerocort inhaler since 5 days & patient has come for a second opinion.

Allergic Rhinitis Patients come to us with common symptoms of Recurrent Cough & Cold with few additional points which are different in each patient. These confusing symptoms should be dissected out & Analyzed. Careful History & Examination is a must.

Allergic Rhinitis Need to differentiate between Allergic Rhinitis & Infectious Rhinitis (Cold) Sinusitis – Allergic/ Viral/ Bacterial Adenoid Hyperplasia & Otitis Media – ? Infectious with ? Underlying allergy Allergic Rhinitis alone Or As a Co morbid with Asthma Tratment Plan changes accordingly.

Allergic Rhinitis Symptoms suggestive of AR 2 or more of the following symptoms for >1 hr on most days Watery Rhinorrhea Sneezing, esp. paroxysmal Nasal Itching Nasal Obstruction

Allergic Rhinitis Symptoms usually NOT associated with AR Unilateral symptoms ++++ Only Nasal obstruction Mucopurulent Rhinorrhea-Posterior Rhinorrhea (post nasal drip)-With thick mucus-& no anterior Rhinorrhea- Pain, Recurrent Epistaxis & Anosmia Refer patient to an ENT

Allergic Rhinitis Common Cold Allergic Rhinitis Cold lasts for a week Cold lasts > 10 days Usually Fever + Fever absent Constitutional sympt. Allergic Signs Nasal mucosa Red Nasal mucosa pale ?Response to Antihist Good response to Antihist Family members affected Not affected at a time

Allergic Rhinitis Symptom Clues beyond nose Ocular Allergy – Watering , Itching & Redness of eyes ( Allergic Conjunctivitis ) Eczemas – Atopic Dermatitis Ear Fullnss Palatal Pruritus

Allergic Rhinitis Symptomps of Co morbidities & Complications Sinusitis – Headache , Bad Breath, Cough in Lying down posn. OSA – Snoring , Mouth Breathing, Hyper Nasality of Voice Otitis Media with Effusion ( OME ) Asthma – Uncontrolled Asthma

Allergic Rhinitis 4 major cardinal symptoms of AR are –Sneezing –Itching (Nasal) –Rhinorrhoea –Congestion Allergic Rhinitis (AR) is a chronic inflammatory disease of the nose induced by an IgE mediated inflammation, after allergen exposure of mucus membrane of nose Children affected with AR – 5 – 25 %

Allergic Rhinitis History Ask for Running Nose – Clear Watery Discharge Paroxysmal Sneezing Nasal itching Associated Nasal Block Watering of Eyes, Itching, redness Atopic Eczemas, Asthma like Symptoms Family H/o Allergy

Allergic Rhinitis Examination Allergic Signs – Allergic Shiners – Dark Circles below eyes Allergic Salute – Rubbing nose in upward direction Darrier Line – Horizontal crease above tip of the nose Allergic Gape – Mouth Breathing , Snoring

Allergic Rhinitis Itching of Nose with Rhinorrhea

Allergic Rhinitis Allergic Shiners

Allergic Rhinitis Transverse Crease

Allergic Rhinitis Allergic Salute

Allergic Rhinitis Grouping of Nasal Symptoms Sneezers & Runners Paroxysmal Sneezing, Watery Ant. Rhinorrhea, Nasal itching , conjunctivitis, Worse during day , Improves at night Blockers – Little Sneezing, Thick mucus, Severe congestion, worse at night

Management of Allergic Rhinitis Drugs Stepwise Approach Mild Intermittant Second Generation H1 Antihistaminics Or LTRA

Management of Allergic Rhinitis Mild Persistent Second Generation H1 Antihistamines + LTRA + INS Allergen Avoidance Severe Persistent SGH1A + LTRA + INS Allergen Specific Immunotherapy

Allergic Rhinitis Oral H1 Antihistamines First Generation – CPM , Diphenhydramine, Promethazine, Triprolidine Drying of Secretions , Drowsiness , Anti Cholinergic Side Effects Cognitive impairment Should not be used

Allergic Rhinitis Second Generation Antihistaminics – Preferred Drugs No or little drowsiness, Minimal side effects, Safe for long term use. Cetrizine , Levocetrizine Fexofenadine Loratadine

Allergic Rhinitis Topical Antihistaminics Delivered by Nasal Spray Quick action in minutes. Side Effects – Bitter taste, some irritation, Drowsiness. Can be used above 5 yrs. Azelastine spray – 1 – 2 sprays o.d.

Allergic Rhinitis Montelukast LTRA Recommended for all severities of AR. Useful for AR with Asthma Safe for long term use Dose 4mg upto – 5 yrs 5 mg – 5 to 10 yrs 10 mg – above 10 yrs Fixed dose combi with H1 Antihist.= avoid

Allergic Rhinitis Intra Nasal Steroids First line therapy for moderate-severe AR Effective against all symptoms of AR incl. Congestion, Sneezing, Itching (nasal), Rhinorrhea, & Eye symptoms Most efficacious medication available for Allergic Rhinitis

Allergic Rhinitis Intra Nasal Steroids Onset of action - 5-7 hours of dosing Up to 2 weeks required for optimum effect Very useful for nasal blockers Quality of life score improvement with INSs better than oral & topical H1 antihistamines

Allergic Rhinitis Intra Nasal Steroids Choose INS with low systemic bio availability Mometasone Furoate, Fluticasone Furoate Fluticasone Propionate Avoid – Beclomethasone, Triamcinolone Negligible side effects even after long term use Compliance & Technique should be checked

Allergic Rhinitis Intra Nasal Steroids Technique – Clear the nose of the secretions Insert the nozzle into the nostril Direct the spray laterally away from the septum - towards the ear Use right hand to spray left nostril & left hand to spray right nostril

Allergic Rhinitis Intra Nasal Decongestants Xylometazoline, Oxymetazoline Effective in nasal obstruction. To be used only for short term = 5 – 7 days Do not improve nasal itching, rhinorrhea & sneezing Prolonged use results in Tachyphylaxis & rebound congestion Oral Decongestants – Not Recommended Phenylephrine, Pseudoephedrine,

Allergic Rhinitis Environmental Control Triggers – Outdoor – Allergens -Pollens – Tree, Grass, Weeds Indoor – House Dust Mite, Fungal Molds, Pets, Cockroaches Irritants – Cigarette Smoke, Mosquito Coil, Cooking fuels, Air Pollution Avoidance of Environmental Triggers important

Allergic Rhinitis ImmunoTherapy Indications Moderate / Severe Persistent AR Inadequate response to Pharmacotherapy Unsatisfactory Compliance Inadequate response to Environmental Control Specific 2- 3 Allergens

Allergic Rhinitis ImmunoTherapy - Called as ‘Allergy Vaccines’ Modifies underlying cause of Allergy Short term & long term benefits Sustained effect even after treatment withdrawal Useful in Allergic Rhinitis & Asthma Allergy Skin Test a Prerequizite

Allergic Rhinitis Subcutaneous Immunotherapy Very Effective , Side effects – Urticarias, Severe Systemic Reactions , Clinic visits reqd. Sublingual Immunotherapy - Effective, Less side effects, Systemic reactions rare, Can be given at home.

Allergic Rhinitis AR & its impact on Asthma 30% of AR patients have Asthma, 80% asthmatics have AR AR is a risk factor for Asthma AR & Asthma share common allergens Proper treatment of AR improves Asthma Control & PFT

Allergic Rhinitis Take Home Messages Look for Cardinal Symptoms – Rhinorrhea, Itching, Sneezing,Nasal Block Watch for CoMorbids – Asthma, Occular Allergy, Adenoid Hypertrophy Rule out or treat Infections SGH1A, LTRA, INS depending on severity Treatment of AR improves Asthma control. Specific Immunothrapy in rare cases

Allergic Rhinitis THANK YOU !