1. September 21 to September 24 Charity Fox, MD Clinical Associate Professor of Rheumatology/ Immunology Division of Rheumatology/ Immunology The Ohio State University Medical Center Debora Ortega- Carr, MD Division of Rheumatology/ Immunology The Ohio State University Medical Center Midwest Allergy Associates, Inc. #1001 Recent Advances in the Treatment of Allergies

2. Debora Ortega- Carr, MD Division of Rheumatology/ Immunology The Ohio State University Medical Center Midwest Allergy Associates, Inc. 1

3. Profile Chad 8 year old young male S ymptoms - Nasal congestion - Sneezing - Cough - Skin itching Family history is significant - Several brothers and father with allergic rhinitis Chad 8 year old young male S ymptoms - Nasal congestion - Sneezing - Cough - Skin itching Family history is significant - Several brothers and father with allergic rhinitis 2

4. Profile Chad Evaluation showed sensitivities to: - Grass - Dogs - Dust mites Diagnosis: Allergic Rhinitis Chad Evaluation showed sensitivities to: - Grass - Dogs - Dust mites Diagnosis: Allergic Rhinitis 2A

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14. Sources Of Allergens Seasonal Pollens Trees Grasses Weeds Molds Seasonal Pollens Trees Grasses Weeds Molds Perennial Animals Pets Insects House dust mites Indoor molds Occupational Perennial Animals Pets Insects House dust mites Indoor molds Occupational 12

15. Appearance Of Seasonal Allergens Pollens Hardwood trees: Spring Mountain cedars: Late Fall/Winter Western red cedars: Late Winter Grasses: Spring/ Summer Ragweed: Summer/Fall Molds Outdoor: Spring/Summer/Fall Pollens Hardwood trees: Spring Mountain cedars: Late Fall/Winter Western red cedars: Late Winter Grasses: Spring/ Summer Ragweed: Summer/Fall Molds Outdoor: Spring/Summer/Fall 13

16. Treatment Strategies Avoidance/Environmental Control Medications Nonpharmacologic - Saline nasal sprays Pharmacologic - Antihistamines - Decongestants - Cromolyn sodium - Anticholinergic preparations - Corticosteroids Immunotherapy Avoidance/Environmental Control Medications Nonpharmacologic - Saline nasal sprays Pharmacologic - Antihistamines - Decongestants - Cromolyn sodium - Anticholinergic preparations - Corticosteroids Immunotherapy 14

17. Summary Chad Evaluation - Tested for several inhalant allergies - Found to be sensitive to dust mites, grass and dogs Treatment - Immunotherapy - Topical nasal anti-inflammatory therapy - Responded well to therapy with significant symptoms improvement Prognosis: Good Chad Evaluation - Tested for several inhalant allergies - Found to be sensitive to dust mites, grass and dogs Treatment - Immunotherapy - Topical nasal anti-inflammatory therapy - Responded well to therapy with significant symptoms improvement Prognosis: Good 15

18. Charity Fox, MD Clinical Associate Professor of Rheumatology/ Immunology Division of Rheumatology/ Immunology The Ohio State University Medical Center 16

19. Profile Margherita 42 year old woman Has had typical seasonal allergy symptoms for a number of years This year, more symptoms with increased difficulty breathing No changes in environment Positive family history of allergies Margherita 42 year old woman Has had typical seasonal allergy symptoms for a number of years This year, more symptoms with increased difficulty breathing No changes in environment Positive family history of allergies 17

20. Profile Margherita Physical Exam - Typical findings of seasonal allergic rhinitis - Pale, swollen nasal mucosa - Red eyes Skin Tests revealed: - Reactivity to grasses - PFT - borderline obstruction Diagnosis: Seasonal Allergic Rhinitis and Mild Allergic Asthma Margherita Physical Exam - Typical findings of seasonal allergic rhinitis - Pale, swollen nasal mucosa - Red eyes Skin Tests revealed: - Reactivity to grasses - PFT - borderline obstruction Diagnosis: Seasonal Allergic Rhinitis and Mild Allergic Asthma 17A

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22. Areas Of New Knowledge Identifying Risk Factors Pharmacologic Therapy Immune Modulation Identifying Risk Factors Pharmacologic Therapy Immune Modulation 19

23. Risk Factors Genetic Predisposition - Multigenic System Cytokine gene cluster on chromosome 5, Beta chain of IgE receptor on chromosome II, changes on chromosome 12, changes on chromosome 16 Environmental Factors - Allergen exposure - Indoor air quality - Outdoor air pollution Diet - Neonatal exposure Infectious Disease - Role of early childhood infections Genetic Predisposition - Multigenic System Cytokine gene cluster on chromosome 5, Beta chain of IgE receptor on chromosome II, changes on chromosome 12, changes on chromosome 16 Environmental Factors - Allergen exposure - Indoor air quality - Outdoor air pollution Diet - Neonatal exposure Infectious Disease - Role of early childhood infections 20

24. Environmental Risk Factors Allergen Exposure - High allergen count indoors, especially in bedroom - associated with great severity of allergic disease - Dust mite, cockroach, cat Rx - Early intervention with families and children with increase risk of atopy Requires - Identification of allergens - Education and support Allergen Exposure - High allergen count indoors, especially in bedroom - associated with great severity of allergic disease - Dust mite, cockroach, cat Rx - Early intervention with families and children with increase risk of atopy Requires - Identification of allergens - Education and support 21

25. Environmental Risk Factors Indoor air quality - Tobacco - Limited air exchange Indoor air quality - Tobacco - Limited air exchange 22

26. Environmental Risk Factors Outdoor Air Pollution - Fossil fuel combustion - Diesel exhaust particles - Ozone - Sulfur dioxide exposure - Respirable particulate matter - Drive immune response toward IgE production and allergic inflammation - Suggest - Monitor air quality - Refrain from exercising along roadways and on days with poor air quality - especially during pollen season Outdoor Air Pollution - Fossil fuel combustion - Diesel exhaust particles - Ozone - Sulfur dioxide exposure - Respirable particulate matter - Drive immune response toward IgE production and allergic inflammation - Suggest - Monitor air quality - Refrain from exercising along roadways and on days with poor air quality - especially during pollen season 23

27. Environmental Risk Factors Diet - Neonatal or fetal exposure - Variable data regarding effects of material diet - More consensus on the effect of early exposure to certain common food allergens (especially cow’s milk, peanuts, eggs) - Suggest - Delayed introduction of food allergens to the diet Diet - Neonatal or fetal exposure - Variable data regarding effects of material diet - More consensus on the effect of early exposure to certain common food allergens (especially cow’s milk, peanuts, eggs) - Suggest - Delayed introduction of food allergens to the diet 24

28. Risk Factors Infections - “Hygiene Hypothesis” - Decreased incidence of bacterial infection in developed countries responsible for increased incidence of atopy - Viral potentiation of allergic inflammation - Respiratory Syncytial Virus - Influenza virus - Rhinovirus - Viral infections may induce long-term exacerbations of allergy Infections - “Hygiene Hypothesis” - Decreased incidence of bacterial infection in developed countries responsible for increased incidence of atopy - Viral potentiation of allergic inflammation - Respiratory Syncytial Virus - Influenza virus - Rhinovirus - Viral infections may induce long-term exacerbations of allergy 25

29. Pharmacologic Therapy New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - NIH Expert Panel Report on Asthma 1997 - WHO Position Paper on Allergen Immunotherapy 1998 New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - NIH Expert Panel Report on Asthma 1997 - WHO Position Paper on Allergen Immunotherapy 1998 26

30. Pharmacologic Therapy New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - Comprehensive review of differential diagnosis and treatment of rhinitis - Preferential use of non-sedating second generation antihistamines as first-line agents - Uncontrolled rhinitis is comorbid condition for asthma, sinusitis, otis media New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - Comprehensive review of differential diagnosis and treatment of rhinitis - Preferential use of non-sedating second generation antihistamines as first-line agents - Uncontrolled rhinitis is comorbid condition for asthma, sinusitis, otis media 27

31. Pharmacologic Therapy New Guidelines - NIH Expert Panel Report on Asthma 1997 - Antileukotriene agents became widely available only after publication - WHO Position Paper on Allergen Immunotherapy 1998 New Guidelines - NIH Expert Panel Report on Asthma 1997 - Antileukotriene agents became widely available only after publication - WHO Position Paper on Allergen Immunotherapy 1998 28

32. Pharmacologic Therapy Inhaled Corticosteroids and Bone Metabolism - Increased incidence of posterior cataracts - Suppression of HPA axis and systemic effects at higher doses - Some evidence regarding inhaled corticosteroid effect on growth in moderate to high doses - No evidence of osteoporosis in young adults Inhaled Corticosteroids and Bone Metabolism - Increased incidence of posterior cataracts - Suppression of HPA axis and systemic effects at higher doses - Some evidence regarding inhaled corticosteroid effect on growth in moderate to high doses - No evidence of osteoporosis in young adults 29

33. Immunotherapy (Immune Modulation) Something old and something new - Allergen Immunotherapy New understanding of long-term efficacy New therapies in clinical trials - Anti-IgE antibody therapy - T-cell epitope peptide therapy Something old and something new - Allergen Immunotherapy New understanding of long-term efficacy New therapies in clinical trials - Anti-IgE antibody therapy - T-cell epitope peptide therapy 30

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35. Immunotherapy (Immune Modulation) Allergen Immunotherapy - Decreased allergen-specific T-cell proliferation - Evidence of allergen-specific T-cell anergy - Changes in cytokine synthesis - decreases antigen-specific T-cell production of IL-4, altered IL-4: IFN-gamma ratios - Anergy persists for at least three years after cessation of allergy immunotherapy Allergen Immunotherapy - Decreased allergen-specific T-cell proliferation - Evidence of allergen-specific T-cell anergy - Changes in cytokine synthesis - decreases antigen-specific T-cell production of IL-4, altered IL-4: IFN-gamma ratios - Anergy persists for at least three years after cessation of allergy immunotherapy 32

36. New Methods Of Immune Modulation Anti-IgE Antibody Therapy T-cell Epitope Peptide Therapy Anti-IgE Antibody Therapy T-cell Epitope Peptide Therapy 33

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39. Summary Margherita Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler Prognosis: Expect her to continue to do well during allergy season Margherita Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler Prognosis: Expect her to continue to do well during allergy season 36

40. #1002 Antidepressants Update September 28 to October 1 Nicholas A. Votolato Pharm B. BCPP Clinical Assistant Professor of Pharmacy Department of Psychiatry and Pharmacy The Ohio State University Medical Center Jeffery C. Hutzler, MD. Associate Professor of Psychiatry The Ohio State University Medical Center Staff Psychiatrist The Cleveland Clinic Foundation NEXT WEEK

41. Summary Margherita Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler Prognosis: Expect her to continue to do well during allergy season Margherita Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler Prognosis: Expect her to continue to do well during allergy season 36