1. Clinical Pharmacy in Immunoallergology Medical diseases

2. Allergies Allergic Rhinitis ('hay fever') Asthma Chronic Sinusitis
Eczema (Atopic Dermatitis)
Chronic Hives & Angioedema (swelling)
Food Allergies
Allergies to Insect Stings
Contact Dermatitis
Less common conditions including anaphylaxis, drug allergies and immune deficiencies.

3. What Are Allergies?
Allergies are a reaction by the body's immune system to harmless substances that it sees as harmful.  The allergy causing substances are called allergens.  It is as if the immune system is overly-active in response to otherwise innocuous substances.

4. TERMS Allergen—A substance that provokes an allergic response.
Anaphylaxis—Increased sensitivity caused by previous exposure to an allergen that can result in blood vessel dilation (swelling) and smooth muscle contraction. Anaphylaxis can result in sharp blood pressure drops and difficulty breathing.
Antibody—A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.
Antigen—A foreign protein to which the body reacts by making antibodies.

5. Mast cells, one of the major players in allergic reactions, capture and display a particular type of antibody, called immunoglobulin type E (IgE) that binds to allergens.
Inside mast cells are small chemical-filled packets called granules. Granules contain a variety of potent chemicals, including histamine.

6. How do Alergies occur?
The immune system is the body's natural defense against infection and other foreign material. Before the person can has a reaction to a particular substance, immune system must first be sensitized to it.  This happens in an earlier contact with the substance.  Once sensitized, the body will react when one has contact with that substance.  Many substances cause an allergic reaction.  The most common are: pollens, molds, house dust mites, animal dander, latex, medicines, insect stings and foods.

7. Food allergic reactions may be severe or fatal
Food allergic reactions may be severe or fatal.  Common foods that may cause allergy symptoms include fish, eggs, milk, nuts, peanuts and wheat.  Food allergies often occur in children, who may outgrow them.
It is also possible to have an allergic reaction to sunlight, temperature extremes, water contact and other elements in your physical environment.

8. Allergic reactions
immediate hypersensitivity reactions, which are predominantly mast cell-mediated and occur within minutes of contact with allergen;
delayed hypersensitivity reactions, mediated by T cells (a type of white blood cells) and occurring hours to days after exposure.

9. Inhaled or ingested allergens usually cause immediate hypersensitivity reactions. Allergens bind to IgE antibodies on the surface of mast cells, which spill the contents of their granules out onto neighboring cells, including blood vessels and nerve cells. Histamine binds to the surfaces of these other cells through special proteins called histamine receptors. Interaction of histamine with receptors on blood vessels causes increased leakiness, leading to the fluid collection, swelling and increased redness. Histamine also stimulates pain receptors, making tissue more sensitive and irritable. Symptoms last from one to several hours following contact.

10. Routes: Allergens enter the body through the airways, the skin, the gastrointestinal tract, and the circulatory system
SYMPTOMS
Airborne allergens cause the sneezing, runny nose,
and itchy, bloodshot eyes of hay fever (allergic rhinitis).
Airborne allergens can also affect the lining of the
lungs, causing asthma, or the conjunctiva of the eyes,
causing conjunctivitis (pink eye). Exposure to cockroach
allergans have been associated with the development
of asthma. Airborne allergans from household
pets are another common source of environmental
exposure.

11. SYMPTOMS Allergens in food can cause itching and swelling of the
lips and throat, cramps, and diarrhea. When absorbed
into the bloodstream, they may cause hives (urticaria)
or more severe reactions involving recurrent, noninflammatory swelling of the skin, mucous membranes, organs, and brain (angioedema). Some food allergens may cause anaphylaxis, a potentially life-threatening condition marked by tissue swelling, airwayconstriction, and drop in blood pressure. Allergies to foods such cow’s milk, eggs, nuts, fish, and legumes (peanuts and soybeans) are common. Allergies to fruits and vegetables may also occur.

12. SYMPTOMS In contact with the skin, allergens can cause reddening,
itching, and blistering, called contact dermatitis.
Skin reactions can also occur from allergens introduced
through the airways or gastrointestinal tract.
This type of reaction is known as atopic dermatitis.
Dermatitis may arise from an allergic response (such
as from poison ivy), or exposure to an irritant causing
nonimmune damage to skin cells (such as soap, cold,
and chemical agents).

13. SYMPTOMS
Injection of allergens, from insect bites and stings or drug administration, can introduce allergens directly into the circulation, where they may cause system-wide responses (including anaphylaxis), as well as the local ones of swelling and irritation at the injection site.

14. The following types of drugs commonly cause allergic reactions:
• penicillin or other antibiotics
• flu vaccines
• tetanus toxoid vaccine
• gamma globulin

15. SYMPTOMS (cont’d) Symptoms depend on the specific type of allergic
reaction. Allergic rhinitis is characterized by an itchy,
runny nose, often with a scratchy or irritated throat due
to post-nasal drip. Inflammation of the thin membrane
covering the eye (allergic conjunctivitis) causes redness,
irritation, and increased tearing in the eyes. Asthma causes
wheezing, coughing, and shortness of breath.

16. SYMPTOMS (cont’d)
Symptoms of food allergies depend on the tissues most sensitive to the allergen and whether the allergen spread systemically by the circulatory system. Gastrointestinal
symptoms may include swelling and tingling in the lips,
tongue, palate or throat; nausea; cramping; diarrhea; and
gas. Contact dermatitis is marked by reddened, itchy,
weepy skin blisters, and an eczema that is slow to heal. It
sometimes has a characteritic man-made pattern, such as
a glove allergy with clear demarkation on the hands,
wrist, and arms where the gloves are worn, or on the earlobes by wearing earrings.

17. Skin reactions Skin reactions
include the raised, reddened, and itchy patches called
hives that characteristically blanch with pressure and
resolve within twenty-four hours. A deeper and more
extensive skin reaction, involving more extensive fluid
collection and pain, is called angioedema. This usually
occurs on the extremities, fingers, toes, and parts of the
head,neck,and face.

18. Anaphylaxis
Anaphylaxis is marked by airway constriction, blood pressure drop, widespread tissue swelling, heart rhythm abnormalities, and in some cases, loss of consciousness. Other syptoms may include, dizziness,
weakness, seizures, coughing,flushing, or cramping.
The symptoms may begin within five minutes after
exposure to the allergan up to one hour or more later.
Mast cells in the tissues and basophils in the blood
release mediators that give rise to the clinical symptoms
of this IgE-mediated hypersensitivity reaction. Commonly,
this is associated with allergies to medications, foods,
and insect venoms.

19. Anaphylaxis In some individuals, anaphylaxis can
occur with exercise, plasma exchange, hemodialysis, reaction to insulin, radocontrast media used in certain types of medical tests. and rarely during the administration of local anesthetics.

20. The allergic response

21. Treatment
Avoiding allergens is the first line of defense to reduce the possibility of an allergic attack.
Complete environmental control is often difficult to
accomplish, hence therapuetic interventions may
become necessary. A large number of prescription and
over-the-counter drugs are available for treatment of
immediate hypersensitivity reactions. Most of these
work by decreasing the ability of histamine to provoke
symptoms. Other drugs counteract the effects of histamine
by stimulating other systems or reducing immune
responses in general.

22. Treatment
ANTIHISTAMINES block the histamine receptors on nasal tissue, decreasing the effect of histamine released by mast cells. They may be used after symptoms appear, though they may be even more effective when used preventively, before symptoms appear. Antihistamines are help reduce sneezing, itching, and rhinorrhea.

23. Treatment I generation antihistamines side effect Drowsiness
dry mouth,
tachycardia,
blurred vision,
constipation,
lower the threshold for seizures.
diphenhydramine (Benadryl and generics)
chlorpheniramine (Chlor-trimeton and generics)
brompheniramine (Dimetane and generics)
clemastine (Tavist and generics)
These medicatios care should be taken when operating motor vehicles

24. Treatment
Newer antihistamines that do not cause drowsiness or pass the blood-brain barrier are available by prescription and include the following:
• loratidine (Claritin)
• fexofenadine (Allegra)

25. Treatment MAST CELL STABILIZERS
Cromolyn sodium prevents the release of mast cell granules, thereby preventing the release of histamine and other chemicals contained in them. It acts as a preventive treatment if it is begun several weeks before the onset of the allergy season.
It can also be used for year round allergy prevention. Cromolyn sodium is available as a nasal spray for allergic rhinitis and in aerosol (a suspension of particles in gas) form for asthma.

26. Treatment LEUKOTRIENE MODIFIERS
These medications are useful for individuals with aspirin sensitivity,sinusitis,
poliposis, urticaria. Examples include zafirlukast (Accolate), montelukast (Singulair), and zileuton (Zyflo).
When zileuton is used, care must be taken to measure liver enzymes.

27. ALLERGIC RHINITIS Allergic rhinitis, more commonly referred to as hay fever, is an inflammation of the nasal passages caused by allergic reaction to airborne substances.
Allergic rhinitis (AR) is the most common allergic condition and one of the most common of all minor afflictions.
There are two types of allergic rhinitis: seasonal and perennial. Seasonal AR occurs in the spring, summer, and early fall, when airborne plant pollens are at their highest levels. In fact, the term hay fever is really a misnomer, since allergy to grass pollen is only one cause of symptoms for most people. Perennial AR occurs all year and is usually caused by home or workplace airborne pollutants. A person can be affected by one or both types.
Symptoms of seasonal AR are worst after being outdoors, while symptoms of perennial AR are worst after spending time indoors.

28. ALLERGIC RHINITIS Causes
Allergic rhinitis is a type of immune reaction. Normally, the immune system responds to foreign microorganisms, or particles, like pollen or dust, by producing specific proteins, called antibodies, that are capable of binding to identifying molecules, or antigens, on the foreign particle. This reaction between antibody and antigen sets off a series of reactions designed to protect the body from infection. Sometimes, this same series of reactions is triggered by harmless, everyday substances. This is the condition known as allergy, and the offending substance is called an allergen.

29. Virtually any type of tree or grass may cause AR
Virtually any type of tree or grass may cause AR. A few types of weeds that tend to cause the most trouble for people include the following:
• ragweed
• sagebrush
• lamb’s-quarters
• plantain
• pigweed
• dock/sorrel
This illustration depicts excessive mucus production in the nose after inhalation of airborne pollen

30. ALLERGIC RHINITIS. Symptoms
Inflammation causes
itching, sneezing, runny nose, redness, and tenderness. Sinus swelling can constrict the eustachian tube that connects the inner ear to the throat, causing a congested feeling and “ear popping.”
The drip of mucus from the sinuses down the back of the throat, combined with increased sensitivity, can also lead to throat irritation and redness. AR usually also causes redness, itching, and watery eyes. Fatigue and headache are also common.

31. ALLERGIC RHINITIS. Treatment
Avoidance of the allergens is the best treatment, but this is often not possible. When it is not possible to avoid one or more allergens, there are two major forms of medical treatment, drugs and immunotherapy.
DRUGS
ANTIHISTAMINES. Antihistamines block the histamine
receptors on nasal tissue, decreasing the effect of
histamine release by mast cells. They may be used after
symptoms appear, though they may be even more effective
when used preventively, before symptoms appear. A
wide variety of antihistamines are available.

32. ALLERGIC RHINITIS. Treatment
Older antihistamines often produce drowsiness as a major side effect. Such antihistamines include the following:
• diphenhydramine (Benadryl and generics)
• chlorpheniramine (Chlor-trimeton and generics)
• brompheniramine (Dimetane and generics)
• clemastine (Tavist and generics).

33. ALLERGIC RHINITIS. Treatment
Newer antihistamines that do not cause drowsiness are available by prescription and include the following:
• astemizole (Hismanal)
• loratidine (Claritin)
• fexofenadine (Allegra)
• azelastin HCl (Astelin).
Hismanal has the potential to cause serious heart arrhythmias when taken with the antibiotic erythromycin, the antifungal drugs ketoconazole and itraconazole, or the antimalarial drug quinine.

34. ALLERGIC RHINITIS. Treatment
Decongestants constrict blood vessels to counteract the effects of histamine. Nasal sprays are available that can be applied directly to the nasal lining and oral systemic preparations are available. Decongestants are stimulants and may cause increased heart rate and bloodpressure, headaches, and agitation. Use of topical decongestants for longer than several days can cause loss of effectiveness and rebound congestion, in which nasal passages become more severely swollen than before treatment.

35. ALLERGIC RHINITIS. Treatment
Topical corticosteroids reduce mucous membrane inflammation and are available by prescription. Allergies tend to become worse as the season progresses because the immune system becomes sensitized to particular antigens and can produce a faster, stronger response. Topical corticosteroids are especially effective at reducing this seasonal sensitization because they work more slowly and last longer than most other medication types. As a result, they are best started before allergy season begins.
Side effects are usually mild, but may include headaches, nosebleeds, and unpleasant taste sensations.

36. ALLERGIC RHINITIS. Treatment
MAST CELL STABILIZERS
Cromolyn sodium prevents the release of mast cell granules, thereby preventing release of histamine and the other chemicals contained in them. It acts as a preventive treatment if it is begun severalweeks before the onset of the allergy season. It can be used for perennial AR as well.

37. ALLERGIC RHINITIS. Treatment
Immunotherapy, also known as desensitization or
allergy shots, alters the balance of antibody types in the
body, thereby reducing the ability of IgE to cause allergic
reactions. Immunotherapy is preceded by allergy testing
to determine the precise allergens responsible. Injections
involve very small but gradually increasing amounts of
allergen, over several weeks or months, with periodic
boosters. Full benefits may take up to several years to
achieve and are not seen at all in about one in five
patients.

38. Treatment of anaphylaxis
The emergency condition of anaphylaxis is treated with injection of adrenaline (epinephrine).
Paticular care should be taken to assess the affected individual’s airway status, and he or she should be placed in a recumbent pose and vital signs determined.
If a reaction resulted from insect sting or an injection, a tourniquet may need to be placed proximal to the area where the agent penetrated the skin. This should then be released at intervals of ten minutes at a time, for one to two minutes duration.
Oxygen may be given, as well as intravenous replacement fluids.
Antihistamines may be used for skin rash, and aminophylline for bronchial constriction. If the upper airway is obstructed, placement of a breathing tube or tracheostomy tube may be needed.

39. Immunologic Reactions to Drugs & Drug Allergy
Immediate (Type I) Drug Allergy,
Autoimmune (Type II) Reactions to Drugs,
Serum Sickness & Vasculitic (Type III) Reactions.

40. Drug hypersensitivity is defined as an immune-mediated response to a drug agent in a sensitized patient. Drug allergy is restricted specifically to a reaction mediated by IgE.
Immune-mediated reactions account for 5 to 10 percent of all drug reactions and constitute true drug hypersensitivity, with IgE-mediated drug allergies falling into this category.
Type I reactions (IgE-mediated); Type II reactions (cytotoxic); Type III reactions (immune complex); and Type IV reactions (delayed, cell-mediated).

41. DRUG HYPERSENSITIVITY
The most important drug-related risk factors for drug hypersensitivity concern the chemical properties and molecular weight of the drug. Larger drugs with greater structural complexity (e.g., nonhuman proteins) are more likely to be immunogenic. Heterologous antisera, streptokinase, and insulin are examples of complex antigens capable of eliciting hypersensitivity reactions. Most drugs have a smaller molecular weight (less than 1,000 daltons), but may still become immunogenic by coupling with carrier proteins, such as albumin, to form simple chemical-carrier complexes (hapten).