Neil L. Kao, M.D., F.A.C.P., Clinical Assistant Professor, U.S.C. School of Medicine WELCOME!

Epidemiology Of Allergic Rhinitis Allergic rhinitis was reported the second most prevalent chronic condition in the United States in 1994 Affects 40 to 50 million people Incidence highest in people ages 15-25 years Affects 10% to 30% of adults, 40% of children In one study, 57% of patients with chronic rhinitis had nonallergic or mixed rhinitis

Epidemiology Of Allergic Rhinitis

Allergic rhinitis was reported the second most prevalent chronic condition in the United States in 1994

Affects 40 to 50 million people

Incidence highest in people ages 15-25 years

Affects 10% to 30% of adults, 40% of children

In one study, 57% of patients with chronic rhinitis had nonallergic or mixed rhinitis

The Burden of Allergic Rhinitis 50% patients symptomatic > 4 months/year 20% patients symptomatic > 9 months/year 10,000 children out of school daily 10,000,000 office visits annually 2,000,000 days of missed school $5.3 billion for direct and indirect costs in year 1996 And this accounts only for allergic rhinitis, nonallergic rhinitis is another issue Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis

The Burden of Allergic Rhinitis

50% patients symptomatic > 4 months/year

20% patients symptomatic > 9 months/year

10,000 children out of school daily

10,000,000 office visits annually

2,000,000 days of missed school

$5.3 billion for direct and indirect costs in year 1996

And this accounts only for allergic rhinitis, nonallergic rhinitis is another issue

Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis

Nasal Anatomy

Definition of Allergic Rhinitis Rhinitis is an inflammation of the mucous membranes of the nose. Allergic rhinitis involves reactions in the nasal mucosa from repeated allergen exposures that causes immediate hypersensitivity. These reactions may be seasonal or perennial.

Rhinitis is an inflammation of the mucous membranes of the nose. Allergic rhinitis involves reactions in the nasal mucosa from repeated allergen exposures that causes immediate hypersensitivity. These reactions may be seasonal or perennial.

Causes of Allergic Rhinitis

Questions of clinical relevance What is wrong with the patient? What can I do for the patient? What will the outcome be? What will it cost? What, specifically, must I do to behave in the best traditions of our profession? J SC Med Assoc 1995; 91: 243-4.

What is wrong with the patient?

What can I do for the patient?

What will the outcome be?

What will it cost?

What, specifically, must I do to behave in the best traditions of our profession?

J SC Med Assoc 1995; 91: 243-4.

Allergy History Screen

Physical Examination Allergic shiner Dennie Morgan line Allergic crease, congested nasal breathing, sniffling Allergic salute, mouth breathing Nasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic Exclude structural problems (polyps, deflected nasal septum) Others : nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability

Allergic shiner

Dennie Morgan line

Allergic crease, congested nasal breathing, sniffling

Allergic salute, mouth breathing

Nasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic

Exclude structural problems (polyps, deflected nasal septum)

Others :

nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability

Diagnosis of Allergic Rhinitis History Physical / Nasal Examination Nasal smear for eosinophils, WBC, bacteria Skin Prick Test (in vivo) > serum RAST, as in more accurate, quicker. Recommended by A.C.P. unless ST can not be done Blood: CBC/diff, IgE levels (poor screening tests)

History

Physical / Nasal Examination

Nasal smear for eosinophils, WBC, bacteria

Skin Prick Test (in vivo) > serum RAST, as in more accurate, quicker. Recommended by A.C.P. unless ST can not be done

Blood: CBC/diff, IgE levels (poor screening tests)

Allergy Prick Skin Tests

Causes of Rhinitis Allergy NARES syndrome Occupational, hobbies Hormonal Drug induced Anatomic defects Infections, viral Irritants Adverse food reaction Emotional Atrophic Ciliary dyskinesia Immunodeficiency diseases

Allergy

NARES syndrome

Occupational, hobbies

Hormonal

Drug induced

Anatomic defects

Infections, viral

Irritants

Adverse food reaction

Emotional

Atrophic

Ciliary dyskinesia

Immunodeficiency diseases

Allergic Rhinitis Therapy Hope, compassion, empowerment Education Avoidance of triggers Medications Allergy Immunotherapy (shots)

Hope, compassion, empowerment

Education

Avoidance of triggers

Medications

Allergy Immunotherapy (shots)

Educational Resources American Academy of Allergy, Asthma, and Immunology -- http://www.aaaai.org American College of Allergy, Asthma, and Immunology – http://www.acaai.org Asthma & Allergy Foundation of America -- http://www.aafa.org Allergy & Asthma Network/Mothers of Asthmatics, Inc. -- http://www.aanma.org My website has links to the above, pollen counts, and more -- http:// www.kaoallergyasthma.blogspot.com

American Academy of Allergy, Asthma, and Immunology -- http://www.aaaai.org

American College of Allergy, Asthma, and Immunology – http://www.acaai.org

Asthma & Allergy Foundation of America -- http://www.aafa.org

Allergy & Asthma Network/Mothers of Asthmatics, Inc. -- http://www.aanma.org

My website has links to the above, pollen counts, and more -- http:// www.kaoallergyasthma.blogspot.com

Weed pollen count Mold spore count Tree pollen count Grass pollen count

Irritants to avoid Smoke or exhaust from any source Paints, glues, cleaning products, aerosols, perfumes Photocopier exhaust Paper dust Dry wall board dust

Smoke or exhaust from any source

Paints, glues, cleaning products, aerosols, perfumes

Photocopier exhaust

Paper dust

Dry wall board dust

Anti-Histamine medications Act by preventing histamine from binding to its receptors Primarily helpful in controlling sneezing, itching, runny nose; ineffective in relieving nasal congestion 1 st generation anti-histamines (short half-life, sedating, older): chlorpheniramine (OTC), diphenhydramine (OTC) (Benedryl) 2 nd generation anti-histamines (long half-life, no or lower sedating, newer, mildly higher cost, preferred): cetirizine (OTC) (Zyrtec), azelastine (Astelin nose spray), fexofenadine (Allegra), loratadine (OTC) (Alavert, Claritin), desloratadine (Clarinex), levocetirizine (Xyzal), olopatadine (Patanase nose spray)

Act by preventing histamine from binding to its receptors

Primarily helpful in controlling sneezing, itching, runny nose; ineffective in relieving nasal congestion

1 st generation anti-histamines (short half-life, sedating, older):

chlorpheniramine (OTC), diphenhydramine (OTC) (Benedryl)

2 nd generation anti-histamines (long half-life, no or lower sedating, newer, mildly higher cost, preferred): cetirizine (OTC) (Zyrtec), azelastine (Astelin nose spray), fexofenadine (Allegra), loratadine (OTC) (Alavert, Claritin), desloratadine (Clarinex), levocetirizine (Xyzal), olopatadine (Patanase nose spray)

Intranasal corticosteroid sprays Potent topical activity: all have equal efficacy Administration of low doses directly at site of action Considerable efficacy at low doses High topical: systemic activity ratios Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity Markedly greater inhibition of EAR than with oral steroids No effect on growth

Potent topical activity: all have equal efficacy

Administration of low doses directly at site of action

Considerable efficacy at low doses

High topical: systemic activity ratios

Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity

Markedly greater inhibition of EAR than with oral steroids

No effect on growth

Additional medications Decongestants: oral (-D, OTC e.g. Sudafed). Do NOT use topical OTC sprays – potent BUT addicting Leukotriene receptor antagonist (Montelukast [Singulair]): not as effect as AH1 or CS, so not first line therapy Expectorant to thin mucus (guaifenesin), long-acting only available as OTC Mucinex, mildly helpful Antibiotic if complicating bacterial infection present Do not forget eyedrops for symptoms Saline rinses for nose and eyes, use lots of volume and repeat throughout the day

Decongestants: oral (-D, OTC e.g. Sudafed). Do NOT use topical OTC sprays – potent BUT addicting

Leukotriene receptor antagonist (Montelukast [Singulair]): not as effect as AH1 or CS, so not first line therapy

Expectorant to thin mucus (guaifenesin), long-acting only available as OTC Mucinex, mildly helpful

Antibiotic if complicating bacterial infection present

Do not forget eyedrops for symptoms

Saline rinses for nose and eyes, use lots of volume and repeat throughout the day

Concept of "minimal persistent inflammation“ causing chronic disease Threshold level for symptoms Symptoms inflammation Ciprandi et al, J Allergy Clin Immunol 1996 An inflammatory process which is actually present even in asymptomatic subjects who are exposed to allergens 0 , 1 1 1 0 1 0 0 0 2 4 6 8 1 0 1 2 M o n t h s mite allergen (µg/g of dust) Minimal persistent inflammation

Allergy Immunotherapy (Injections) When medications and avoidance don’t work Only therapy that can raise T-cell tolerance to allergens so there is no allergic immune response Usually prescribed by a specialist Most effective for dust mites, pollen, cat allergy May also be effective for dog, mold allergy Cost, discomfort, time, normal course 3-5 years

When medications and avoidance don’t work

Only therapy that can raise T-cell tolerance to allergens so there is no allergic immune response

Usually prescribed by a specialist

Most effective for dust mites, pollen, cat allergy

May also be effective for dog, mold allergy

Cost, discomfort, time, normal course 3-5 years

Let us,then, be up and doing, With a heart for any fate; Still achieving, still pursuing, Learn to labor and to wait. Henry Wadsworth Longfellow

Let us,then, be up and doing,

With a heart for any fate;

Still achieving, still pursuing,

Learn to labor and to wait.

Henry Wadsworth Longfellow