Aria

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Good updated guidelines for Allergy

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Aria

  1. 1. In collaboration with the World Health Organization
  2. 2. The ARIA initiative was developed as a state-of-the-art for the specialist, the general practitioner and for health care workers: • to update their knowledge of allergic rhinitis, • to highlight the impact of allergic rhinitis on asthma, • to provide an evidence-based documented revision on the diagnosis methods, • to provide an evidence-based revision on the treatments available, • to propose a stepwise approach to the management of the disease, • to assess the magnitude of the problem in developing countries and to implement guidelines (with IUATLD)
  3. 3. ARIA program First phase: • Development of evidence-based guidelines during a workshop held at WHO in December 1999 (J Allergy Clin Immunol, suppl, Nov 2001). • Document has been endorsed by several allergy, respiratory, ENT and paediatric associations.
  4. 4. ARIA program First phase: • Development of evidence-based guidelines during a workshop held at WHO in December 1999 (J Allergy Clin Immunol, suppl, Nov 2001). • Document has been endorsed by several allergy, respiratory, ENT and pediatric associations. Second phase: • To produce materials to help improve delivery of care to those with rhinitis. In particular a pocket guide • To implement ARIA guidelines • To update the workshop report
  5. 5. 1- Why ARIA ? 2- New classification of rhinitis 3- Importance of nasal inflammation 4- Treatment based on evidence 5- Impact of rhinitis on asthma
  6. 6. Prevalence of hay fever: 13-14 yr olds - ISAAC Strachan et al, Pediatr Allergy Immunology 1997 ≥20% 10-20% <10%
  7. 7. Asthma - ISAAC (1997-8) Source: N Aït Khaled, IUATLD Morocco Casablanca:12% Rabat: 6.6% Marrakech: 17% Algeria Algiers West: 4.8% Algiers Centre: 6.6% Tunisia Sousse15.2% Ethiopia Addis Ababa: 2.8% Jima: 2.2 % Conakry Guinea 10.3% Abidjan Ivory Coast 11.8% Kenya Nairobi: 15.4% Eldoret: 6.8% Nigeria Ibadan: 18.4% South Africa Cape Town: 13.1%
  8. 8. “Hay fever ever” - ISAAC (1997-8) Source: N Aït Khaled, IUATLD Morocco Casablanca: 27% Rabat: 18% Marrakech: 21% Algeria Algiers West: 13% Algiers Centre: 24% Tunisia Sousse:15.2% Ethiopia:2% Guinea Conakry:48% Ivory Coast Abidjan: 49% Kenya: 12% Nigeria Ibadan: 40% South Africa 15%
  9. 9. Increase in prevalence of rhinitis with age in Denmark - Study 1: children 7-17 yrs studied at 6 yr intervals Ulrik et al, Allergy 2000 - rhinitis increased from 15 to 22% - often linked with IgE sensitization - Study 2: adults 15-41s yr studied at 8 yr intervals Linneberg et al, J Allergy Clin Immunol 2000 - rhinitis increased from 25 to 32% - often linked with IgE sensitization
  10. 10. SF-36 in seasonal and perennial rhinitis Bousquet, Burtin et al J Allergy Clin Immunol 1994 Ciprandi et al, Allergy 2002 100 controls Mean score perennial rhinitis 75 pollen rhinitis 50 25 0 PF SF PA SA MH EF BP GH
  11. 11. Needs for new guidelines in the management of allergic rhinitis • The International Consensus on Rhinitis was a • • major step forward and was recently validated for the treatment of seasonal allergic rhinitis. However, • it was not evidence-based • new drugs have been available since 1995. • it was mainly applicable to developed countries. Moreover, the ARIA guidelines are targeting the patient globally instead of treating each target organ individually
  12. 12. Needs for guidelines in the management of allergic rhinitis • Allergic rhinitis is a global health problem affecting 5 to 50 % of the population • Its prevalence is increasing. • Although it is not usually a severe disease, rhinitis alters social life and affects school performance and work productivity. • Costs incurred by rhinitis are substantial. • Implementation of guidelines improves the condition of patients with allergic rhinitis.
  13. 13. Needs for guidelines in the management of allergic rhinitis in developing countries • ISAAC study: seasonal allergic rhinitis (hay fever) affects up to 50% of adolescents in certain developing countries: Guinea (Conakry), Ivory Coast (Abidjan) or Nigeria (Lagos). • However, the validity of the questionnaire used should be checked in these countries • Rhinitis may be a problem in some parts of developing countries only • Risk factors should be understood for preventive measures
  14. 14. 1- Why ARIA ? 2- New classification of rhinitis
  15. 15. ARIA The classification "seasonal" and "perennial" allergic rhinitis has been changed to "intermittent" and "persistent" allergic rhinitis
  16. 16. Pollen season in Montpellier (1990) 6000 grass cypress pollens/m 3 air . 5000 4000 3000 2000 1000 0 0 10 20 weeks 30 40 threshold level for symptoms
  17. 17. Concept of "minimal persistent inflammation" Ciprandi et al, J Allergy Clin Immunol 1996 mite allergen (µg/g of dust) Mechanisms of house dust mite induced rhinitis 100 10 . theshold level for symptoms 1 0,1 0 2 minimal persistent symptoms inflammation inflammation 4 6 8 10 12 Months
  18. 18. ARIA Classification Intermittent Persistent . < 4 days per week . or < 4 weeks . ≥ 4 days per week . and ≥ 4 weeks Mild Moderate-severe normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms in untreated patients one or more items . abnormal sleep . impairment of daily activities, sport, leisure . abnormal work and school . troublesome symptoms
  19. 19. 1- Why ARIA ? 2- New classification of rhinitis 3- Importance of nasal inflammation
  20. 20. Persistent rhinitis histamine
  21. 21. 1- Why ARIA ? 2- New classification of rhinitis 3- Importance of nasal inflammation 4- Treatment based on evidence
  22. 22. allergen allergen avoidance avoidance indicated indicated when possible when possible pharmacotherapy pharmacotherapy safety safety effectiveness effectiveness easily administered easily administered costs patient patient education education always indicated always indicated immunotherapy immunotherapy effectiveness effectiveness specialist prescription specialist prescription may alter the natural may alter the natural course of the disease course of the disease
  23. 23. Statement of evidence: Strength of evidence Shekelle et al, BMJ 1999 A directly based on randomized controlled trials and meta-analyses B C evidence from at least one controlled study without randomization or extrapolated recommendation from category A evidence evidence from at least one other type of quasiexperimental study or extrapolated recommendation from category A or B evidence D evidence from expert committee reports or opinions or clinical experience of respected authorities, or both
  24. 24. Strength of evidence for treatment of rhinitis ARIA intervention SAR adult PAR children adult children oral anti-H1 intranasal anti-H1 intranasal CS intranasal chromone anti-leukotriene subcutaneous SIT sublingual / nasal SIT allergen avoidance A A A A A A A D A A A A A A A D A A A A A A A A A A D A D
  25. 25. Medications of allergic rhinitis ARIA sneezing H1-antihistamines oral intranasal intraocular Corticosteroids Chromones intranasal intraocular Decongestants intranasal oral Anti-cholinergics Anti-leukotrienes rhinorrhea nasal obstruction nasal itch eye symptoms +++ ++ 0 +++ +++ +++ 0 +++ 0 to + + 0 ++ +++ ++ 0 ++ ++ 0 +++ + + 0 + 0 + 0 + 0 0 ++ 0 0 0 + 0 0 +++ ++ ++ + 0 ++ 0 0 0 ? 0 0 0 ++
  26. 26. Mild intermittent rhinitis ARIA Options (not in preferred order) - oral or intranasal anti-H1 - intranasal decongestants - oral decongestants (not in children)
  27. 27. Moderate-severe intermittent rhinitis Mild persistent rhinitis ARIA Options (not in preferred order) - oral or intranasal anti-H1 - oral anti-H1 + decongestant - intranasal CS - (chromones) Patient should be re-assessed after 2-4 wks
  28. 28. Moderate-severe persistent rhinitis ARIA Step-wise approach - intranasal CS as a first line treatment - if major blockage: add short course of oral CS or decongestant Re-assess after 2-4 weeks - if symptoms present add: - oral anti-H1 (± decongestants) - ipratropium
  29. 29. Conjunctivitis rhinitis ARIA Options (not in preferred order) - oral or ocular anti-H1 - ocular chromones - saline Do not use ocular CS without care and eye examination
  30. 30. Treatment of allergic rhinitis (ARIA) Allergic Rhinitis and its Impact on Asthma mild intermittent moderate severe intermittent mild persistent moderate severe persistent intra-nasal steroid local chromone oral or local non-sedative H1-blocker intra-nasal decongestant (<10 days) or oral decongestant allergen and irritant avoidance immunotherapy
  31. 31. ARIA in low-income countries • The rationale for treatment choice in developing countries is based upon: • level of efficacy • low drug cost affordable for the majority of patients • inclusion in the WHO essential list of drugs: only chlorpeniramine and BDP are listed • It is hoped that new drugs will be available on this list
  32. 32. ARIA in low-income countries Stepwise treatment proposed • Mild intermittent rhinitis: oral antihistamine • Moderate/severe intermittent rhinitis: BDP low dose ± oral antihistamine • Mild persistent rhinitis: oral antihistamine or low dose BDP • Moderate/severe persistent rhinitis: high dose BDP. Consider adding oral antihistamine ± oral steroids (short course)
  33. 33. 1- Why ARIA ? 2- New classification of rhinitis 3- Importance of nasal inflammation 4- Treatment based on evidence 5- Impact of rhinitis on asthma
  34. 34. First description of hay fever John Bostock, Med Chir Trans, 1819; 10: 161 "About the beginning or middle of June in every year ….. …. A sensation of heat and fulness is experienced in the eyes …. …. To this succeeds irritation of the nose producing sneezing …. …. To the sneezings are added a further sensation of tightness of the chest, and a difficulty of breathing"
  35. 35. Links between rhinitis and asthma: Epidemiologic evidence 1- Asthma prevalence is increased in allergic and non-allergic rhinitis 2- Rhinitis is almost always present in asthma 3- Rhinitis may be a risk factor for asthma 4- Non-specific bronchial hyperreactivity is increased in persistent rhinitis
  36. 36. Perennial rhinitis: an independent risk factor for asthma Leynaert et al, J Allergy Clin Immunol 1999 % subjects with asthma 25 controls 20 rhinitis 15 10 5 0 atopic non-atopic
  37. 37. Frequency of asthma related to allergens Frequency of asthma related to allergens (%) Linneberg et al, Respir Med 2001 60 50 no rhinitis rhinitis 40 "allergy" assessed by questionnair e 30 20 10 0 pollen animal dander allergy mite
  38. 38. Early allergic rhinitis as a risk factor for asthma Wright et al, Pediatrics 1994 children with symptoms (%) 80 60 cough, wheeze asthma 40 20 0 rhinitis allergic allergic non-allergic none ND in prick test pos. neg. ND ND neg.
  39. 39. Bronchial hyperreactivity in ECHRS patients Leynaert, Bousquet, Neukirch, Am J Respir Crit Care Med 1997 80 - Paris + MPL % subjects 60 - 821 adults - 20-44 yr 40 - PC20 methacholine ≤4mg 20 0 controls seasonal perennial seasonal asthma rhinitis rhinitis + perennial rhinitis non-asthmatic without wheeze
  40. 40. Eosinophils (EG2+ cells) in biopsies of asthmatics Bronchial mucosa Bousquet J et al. N Engl J Med 1990 Nasal mucosa Chanez P et al. Am J Respir Crit Care Med 1999
  41. 41. nose allergens noxious agents epithelial mesenchymal trophic unit bronchus allergens noxious agents epithelial mesenchymal muscular trophic unit
  42. 42. QOL in a population-based study (ECRHS) Leynaert et al, Am J Respir Crit Care Med 2000 60 p<0.001 p<0.001 p<0.001 p<0.001 Mean score 50 allergic rhinitis (N=297) asthma + AR (N=76) 40 30 20 10 0 controls (N=448) Physical Summary Mental summary score
  43. 43. ARIA program • • • • Guideline implementation in low income developing countries in collaboration with IUATLD need of adaptation to the local situation as well as to social and cultural barriers. A joined ARIA-IUATLD program started to assess the magnitude of allergic rhinitis in these countries to confirm the results of the ISAAC study using a more detailed questionnaire. Then, a pocket guide specifically devoted to low income countries will be developed.
  44. 44. Ultimate goals of ARIA • To translate evolving science on rhinitis into recommendations for the management and prevention of the disease • To better assess the interactions between rhinitis and asthma • To increase awareness of rhinitis and its public health consequences • To make the effective treatment of rhinitis available and affordable for every patient in the world
  45. 45. Recommendations 1- Patients with persistent rhinitis should be evaluated for asthma 2- Patients with persistent asthma should be evaluated for rhinitis 3- A strategy should combine the treatment of upper and lower airways in terms of efficacy and safety

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