Allergic rhinitis 2
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

Allergic rhinitis 2

on

  • 1,103 views

 

Statistics

Views

Total Views
1,103
Views on SlideShare
629
Embed Views
474

Actions

Likes
0
Downloads
8
Comments
0

2 Embeds 474

http://www.nathanhare.com 473
http://www.blogger.com 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Allergic rhinitis 2 Presentation Transcript

  • 1. Nathan Hare MD2/19/13Allergic Rhinitis
  • 2. Outline Epidemiology Description Pathophysiology Triggers Co-morbidities Local Allergic Rhinitis Treatment Environmental Modifications Medications Subcutaneous Immunotherapy Sublingual Immunotherapy
  • 3. Allergic Rhinitis (AR) Affects 10-40% of children world-wide 1 Affects up to 40% of children in the U.S. Affects 10-30% of adults in the U.S.21. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Editorial Group: Topical nasal steroids forintermittent and persistent allergic rhinitis in children Cochrane Ear, Nose and Throat Disorders Group, Published Online:21 JAN 20092. http://www.aaaai.org/conditions-and-treatments/library/allergy-library/rhinitis.aspx
  • 4. Symptoms of Allergic Rhinitis Nasal Congestion Nasal Pruritus Sneezing Rhinorrhea Post Nasal Drainage Daytime inattention Irritability Hyperactivity
  • 5. Bischoff Nature Reviews Immunology 7, 93–104 (February 2007) | doi:10.1038/nri2018Pathophysiology
  • 6. Common Triggers for Allergic RhinitisSeasonal Perennial Tree Pollen Grass Pollen Weed Pollen Mold Spores Dust Mites Cockroaches Cat Dog Mouse (inner cityschools) *Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W.Allergens in urban schools and homes of children with asthma.Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.•Exposure is to airborne allergens•Have to think of indoor exposure beyond the home
  • 7. Inner City School Allergen Exposures Settled dust and airborne allergen levels 12 schools, vs homes Mouse levels were “substantial” Cat and Dog levels low, but were higher at school Dust mite and cockroach levels were lowPermaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W.Allergens in urban schools and homes of children with asthma.Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.
  • 8. Allergic Rhinitis: Comorbidities Important to remember impacts on childrenbeyond the nose Asthma , eczema, food allergy(28%, 50%, 38% of 108 4 yo pts w AR1) Oral Allergy Syndrome (25% of 8 year olds 1) Sleep Disordered Breathing ADHD (?) Daytime inattention Irritability Hyperactivity1. Westman M, Stjärne P, Asarnoj A, Kull I, van Hage M, Wickman M, Toskala E.Natural course and comorbidities of allergic and nonallergic rhinitis in children.J Allergy Clin Immunol. 2012 Feb;129(2):403-8. doi: 10.1016/j.jaci.2011.09.036. Epub 2011 Nov 5.
  • 9. AR & Sleep Disordered Breathing inChildren Jan 2013 Review, covered last 25 years Ages 7-17 Case-series or Case-Control articles 10 articles studied habitual snoring 6 articles studied OSA 12/18 articles: statistically significant associationbetween AR and SDB Evidence grade BLin SY, Melvin TA, Boss EF, Ishman SL.The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review.Int Forum Allergy Rhinol. 2013 Jan 10. doi: 10.1002/alr.21123. [Epub ahead of print]
  • 10. ADHD & Allergic Rhinitis Taiwan Cross-sectional study: increased prevalence of AR inADHD pts 1 Second study: Significant association among ADHD, ticdisorder, and AR 2 Third study: increased prevalence of ADHD in ARpatients (≥226,000 pediatric patients) 31. Chou PH, Lin CC, Lin CH, Loh EW, Chan CH, Lan TH.Prevalence of allergic rhinitis in patients with attention-deficit/hyperactivity disorder: a population-based study.Eur Child Adolesc Psychiatry. 2012 Dec 30. [Epub ahead of print]2. Chen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, Bai YM.Attention deficit hyperactivity disorder, tic disorder, and allergy: Is there a link? A nationwide population-based study.J Child Psychol Psychiatry. 2012 Nov 12. doi: 10.1111/jcpp.12018. [Epub ahead of print]3.. Tsai MC, Lin HK, Lin CH, Fu LS.Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study.Allergy Asthma Proc. 2011 Nov-Dec;32(6):41-6. doi: 10.2500/aap.2011.32.3489
  • 11. Local Allergic Rhinitis Negative prick skin tests, negative intradermalskin tests, negative allergen-specific serum IgE Symptoms after nasal challenge with allergen Local allergen-specific IgE produced afterchallenge with allergen 47-62.5% prevalence in European studiesRondón C, Campo P, Togias A, Fokkens WJ, Durham SR, Powe DG, Mullol J, Blanca M.Local allergic rhinitis: concept, pathophysiology, and management.J Allergy Clin Immunol. 2012 Jun;129(6):1460-7. doi: 10.1016/j.jaci.2012.02.032. Epub 2012 Apr 18. Review.
  • 12. Allergic Rhinitis: Treatment Can we change the environment to reduce thepatient‟s exposure to triggers? Can we modify the patient‟s symptoms? Can we modify the patient‟s immune system?
  • 13. Environmental Modifications Does pet ownership make a difference in thedevelopment of AR? Dust Mite Avoidance Measures Getting Rid of Pets if the patient is allergic Washing the pet Keep windows closed and run the AC duringpollen and mold seasons Clean any visible mold
  • 14. Does Pet Ownership in ChildrenChange Anything? 2012 International Survey “Early-life exposure to cats is a risk factor for …rhinoconjunctivitis … in 6- to 7-year-oldchildren, especially in less-affluent countries. “Brunekreef B, Von Mutius E, Wong G, Odhiambo J, García-Marcos L, Foliaki S; ISAAC Phase Three Study Group.Exposure to cats and dogs, and symptoms of asthma, rhinoconjunctivitis, and eczema.Epidemiology. 2012 Sep;23(5):742-50.
  • 15. Does Pet Ownership in ChildrenChange Anything? Australian Birth Cohort Followed 620 infants for first 12 yrs of life “Pets at birth either decreased or had no effect onallergic disease up to age 12. “ “We found no evidence that exposure to cats ordogs at birth increases the risk of allergic diseasein high-risk children.”Lodge CJ, Lowe AJ, Gurrin LC, Matheson MC, Balloch A, Axelrad C, Hill DJ, Hosking CS, Rodrigues S, Svanes C, Abramson MJ, Allen KJ, Dharmage SPets at birth do not increase allergic disease in at-risk children.Clin Exp Allergy. 2012 Sep;42(9):1377-85. doi: 10.1111/j.1365-2222.2012.04032.x.
  • 16. Does Pet Ownership in ChildrenChange Anything? 2012 Meta-analysis Children ages 6-10 ≥22,000 children from 11 European Birth Cohortsfrom 1990s Owning a furry pet or bird during the first 2 yearsof life did not affect the risk of developing allergicrhinitis.Lødrup Carlsen KC, Roll S, Carlsen KH, Mowinckel P, Wijga AH, Brunekreef B, Torrent M, Roberts G, Arshad SH, Kull I, Krämer U, von Berg A, Eller E, HKuehni C, Spycher B, Sunyer J, Chen CM, Reich A, Asarnoj A, Puig C, Herbarth O, Mahachie John JM, Van Steen K, Willich SN, Wahn U, Lau S, Keil T;GALEN WP 1.5 „Birth Cohorts‟ working group.Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of Individual participant data from 11 European birth coPLoS One. 2012;7(8):e43214. doi: 10.1371/journal.pone.0043214. Epub 2012 Aug 29.
  • 17. House dust mite avoidancemeasures for perennial AllergicRhinitis 2010 Cochrane Review, assessed as up to date endof 2009.1 9 trials (501 participants satisfied criteria) Mite-impermeable bedding covers (2 studies weregood quality) Acaricides (2 studies) HEPA filters (2 studies) Acaricides +/- covers (1 study)1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:House dust mite avoidance measures for perennial allergic rhinitisCochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
  • 18. House dust mite avoidancemeasures for perennial AllergicRhinitis Conclusions: Trials to date … small and of poor methodological quality…difficultto offer any definitive recommendations on the role … of housedust mite avoidance measures in the management of house dustmite sensitive perennial allergic rhinitis. Use of acaricides and extensive bedroom-based environmentalcontrol programmes may be of some benefit in reducing rhinitissymptoms and, if considered appropriate, these should be theinterventions of choice. Isolated use of house dust mite impermeable bedding is unlikely toprove effective.1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:House dust mite avoidance measures for perennial allergic rhinitisCochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
  • 19. Washing the PetDogs:Hodson T, Custovic A, Simpson A, Chapman M, Woodcock A, Green R.Washing the dog reduces dog allergen levels, but the dog needs to be washed twice a weekJ Allergy Clin Immunol. 1999 Apr;103(4):581-5.Cats:Nageotte C, Park M, Havstad S, Zoratti E, Ownby D.Duration of airborne Fel d 1 reduction after cat washing.J Allergy Clin Immunol. 2006 Aug;118(2):521-2. Epub 2006 Jun 27.Drop in Cat allergen levels lasted only 1 day after washing. But, it was pointed out thatGoetz DW.Washing the cat requires shampoo.J Allergy Clin Immunol. 2007 Mar;119(3):758; author reply 758-9. Epub 2007 Jan 19.
  • 20. What about HypoallergenicDogs? Hypoallergenic Breeds do not exist. In this study, dogs from “hypoallergenic breeds”had higher allergen levels in hair and coatsamples than control dogs. Differences between breeds were small.Vredegoor DW, Willemse T, Chapman MD, Heederik DJ, Krop EJ.Can f 1 levels in hair and homes of different dog breeds: lack of evidence to describe any dog breed as hypoallergenJ Allergy Clin Immunol. 2012 Oct;130(4):904-9.e7. doi: 10.1016/j.jaci.2012.05.013. Epub 2012 Jun 22.
  • 21. Treating Symptoms Nasal Saline Irrigation Medications
  • 22. Nasal Saline Irrigation (SNI) “Meta-analysis”: 50 trials, >400 participants Performed regularly up to 7 weeks 27.66% improvement in nasal symptoms 62.1% reduction in medicine consumption 31.19% acceleration of mucociliary clearancetime 27.88% improvement in quality of life. “no evidence showing that regular, daily SNIadversely affects the patients health or causesunexpected side effects.”Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R.Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis.Am J Rhinol Allergy. 2012 Sep-Oct;26(5):e119-25. doi: 10.2500/ajra.2012.26.3787.
  • 23. Nasal Saline Irrigation in Children 4 week RCT, investigator blinded 220 children aged 5-9 yrs with seasonal AR 80 used hypertonic saline (2.7%), 80 used normalsaline, 60 control subjects (no treatment) Evaluated effect on Nasal symptoms(rhinorrhea, itching, sneezing, nasalobstruction), swelling of turbinates, adenoidhypertrophy or middle ear effusionMarchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi NHypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children.Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.
  • 24. Nasal Saline Irrigation in Children Hypertonic Saline: “significant reduction” in allareas Normal Saline: “significant reduction” inrhinorrhea and sneezing Control: no significant changeMarchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi NHypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children.Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.
  • 25. Medications Anti-histamines Oral, Intranasal Leukotriene-modifyingagents Oral Steroids Oral, Intranasal Mast-cell stabilizers Intranasal
  • 26. Bischoff Nature Reviews Immunology 7, 93–104 (February 2007) | doi:10.1038/nri2018Pathophysiology
  • 27. Antihistamines1st Generation 2nd Generation Diphenhydramine Hydroxyzine Chlorpheniramine Brompheniramine Loratadine, Desloratadine Cetirizine, Levocetirizine Fexofenadine Azelastine (Astelin, ≥5yrs, Astepro, ≥12yrs, intranasal) Olopatadine(Patanase, ≥6*Also thought to work as a mast cell stabilizer(http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021545s013lbl.pdf)
  • 28. Leukotriene-Modifiers Montelukast (Singulair, ≥6 mo) Zafirlukast (Accolate, ≥5 yrs) Zileuton (Zyflo, ≥ 12 yrs)
  • 29. Intranasal SteroidsLiquid Dry Powder Fluticasone(Flonase, ≥4 yrs) Mometasone(Nasonex, ≥2yrs) Ciclesonide(Omnaris, ≥6 yrs) Triamcinolone(Nasacort AQ, ≥2 yrs) Beclomethasone(Qnasl, ≥12 yrs old) Ciclesonide(Zetonna, ≥12 yrs old)
  • 30. Intranasal Steroids 6 week study of beclomethasone, placebo, andplacebo/prednisone: beclomethasone NOT INFERIOR to placebo inregards to suppression of hypothalamic-pituitary-adrenal axis functionRatner PH, Miller SD, Hampel FC Jr, Melchior A, Dunbar SA, Tantry SK.Once-daily treatment with beclomethasone dipropionate nasal aerosol does not affect hypothalamic-pituitary-adrenal axisAnn Allergy Asthma Immunol. 2012 Nov;109(5):336-41. doi: 10.1016/j.anai.2012.08.005.
  • 31. Intranasal Steroids in Children Cochrane Review published online 2009, assessedas up to date 2006 3 trials, total 79 children Beclomethasone or flunisolide vs. placebo Weak or unreliable evidence for effectiveness.11. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Topical nasal steroids for intermittent andpersistent allergic rhinitis in children Editorial Group: Cochrane Ear, Nose and Throat Disorders Group, Published Online:21 JAN 2009
  • 32. Intranasal Steroids with add-on oralAntihistamine therapy in children 2010 Cochrane Review found only 1 RCT with 24children (defined as under age 18).1 Sufficient data not provided to answer question Conclusion: no evidence available for benefit of add-onantihistamine treatment to intranasal steroids for children withintermittent or persistent allergic rhinitis. Take-away message: don‟t forget potential side effects ofantihistamines, and keep in mind costs of adding a secondmedication.1. Mona Nasser1,*, Zbys Fedorowicz2, Hamad Aljufairi3, William McKerrow4Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in childrenEditorial Group: Cochrane Ear, Nose and Throat Disorders GroupPublished Online: 7 JUL 2010 Assessed as up-to-date: 20 SEP 2009
  • 33. Total Nasal Symptom Score Intensity of nasal symptoms Rhinorrhea, Nasal itching, NasalObstruction, Sneezing0 = No symptoms1 = Mild2= Moderate3= Severe Total Possible Score ranges from 0 (no symptoms) to12 (maximum symptom intensity)Valero A, Izquierdo I, Giralt J, Bartra J, del Cuvillo A, Mullol J.Rupatadine improves nasal symptoms, quality of life (ESPRINT-15) and severity in a subanalysis of a cohort of Spanishallergic rhinitis patients.J Investig Allergol Clin Immunol. 2011;21(3):229-35.
  • 34. Combination Therapy: Intranasalsteroid & Intranasal antihistamine TNSS: Total Nasal Symptom Score The TNSS improved 27.1% with fluticasone nasalspray, 24.8% with azelastine nasal spray, and37.9% with the 2 agents in combinationRatner PH, Hampel F, Van Bavel J, Amar NJ, Daftary P, Wheeler W, Sacks H.Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal sprayin the treatment of patients with seasonal allergic rhinitis.Ann Allergy Asthma Immunol. 2008 Jan;100(1):74-81. doi: 10.1016/S1081-1206(10)60408-5.
  • 35. Combination Intranasal steroid andAntihistamine Fluticasone and azelastine in the samedelivery device Meta-analysis of 3 separatemulticenter, randomized, double-blind, placebo- and active-controlled, parallel-group trials Each trial conducted for 14 days duringdifferent allergy seasons 3398 patients (>11 yrs old) Moderate to severe seasonal allergicrhinitisCarr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J.A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis.J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.
  • 36. Combination Intranasal steroid andAntihistamine Combination reduced mean reflectivetotal nasal symptom score from baseline(-5.7 [SD, 5.3]) Fluticasone (-5.1 [SD, 4.9], P < .001) Azelastine (-4.4 [SD, 4.8], P < .001) Placebo (-3.0 [SD, 4.2], P < .001). Available now as Dymista (≥12 yrs)Carr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J.A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis.J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.
  • 37. Fig E1Source: Journal of Allergy and Clinical Immunology 2012; 129:1282-1289.e10 (DOI:10.1016/j.jaci.2012.01.077 )Copyright © 2012 American Academy of Allergy, Asthma & Immunology Terms and Conditions
  • 38. Inferior Turbinate Surgery after failedMedical Treatment of Allergic Rhinitis 2010 Cochrane review was unable to find anyrandomized controlled trials comparing this surgery tocontinued medical treatment.11. Jemy Jose1,*, Andrew P Coatesworth2, Inferior turbinate surgery for nasal obstruction in allergic rhinitis after failedmedical treatment Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 8 DEC 2010Assessed as up-to-date: 5 JUL 2010
  • 39. Altering the Immune Response Helminths (Worms) Subcutaneous Immunotherapy (Allergy Shots) Sublingual Immunotherapy
  • 40. Worms• Why look? Helminths modulate the naturalimmune responses of their human hosts, andmay prevent or cure immune-mediated or allergicdiseases (e.g. allergic rhinitis) in the host. Non-randomized studies support this hypothesis.1 “Trials using helminths like hookworm (Necatoramericanus) or porcine whipworm (Trichuris suis)show that they are safe and may be effectivetherapies for the control of the aberrant intestinalinflammation seen in Crohns disease andulcerative colitis.”21. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date: 24 JUN 20112. Elliott DE, Weinstock JV. Where are we on worms? Curr Opin Gastroenterol. 2012 Nov;28(6):551-6. doi: 10.1097/MOG.0b013e3283572f73.
  • 41. Helminth therapy (worms) forAllergic Rhinitis 2012 Cochrane Review, assessed as up to date2011.1 They found 130 people… 1.8 to 7.7x increase in GI side effects vs placebo Insufficient evidence, appears to be safe1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date:24 JUN 2011
  • 42. Allergy Injection Immunotherapy (IT)for Seasonal Allergic Rhinitis 2009 Cochrane Review1, assessed as up to date2006 51 of 1111 publications met criteria 2871 participants (1645 active, 1226 placebo) Averaged 18 injections per participant Duration of IT 3 days to 3 years1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6Allergen injection immunotherapy for seasonal allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13NOV 2006
  • 43. Allergy Injection Immunotherapy (IT)for Seasonal Allergic Rhinitis Symptom Scores from 15 trials an overall reduction in the immunotherapy group(SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication score data from 13 trials an overall reduction in the immunotherapy group(SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)).1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6Allergen injection immunotherapy for seasonal allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13NOV 2006
  • 44. Allergy Injection Immunotherapy (IT)for Seasonal Allergic Rhinitis Epinephrine (adrenaline) given in 0.13% (19 of 14085 injections) of those on activetreatment given in 0.01% (1 of 8278 injections) of the placebo groupfor treatment of adverse events. Fatalities: None1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6Allergen injection immunotherapy for seasonal allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13NOV 2006
  • 45. Allergy Injection Immunotherapy (IT)for Seasonal Allergic Rhinitis Authors‟ Conclusions: Specific allergen injection immunotherapy insuitably selected patients with seasonal allergicrhinitis results in a significant reduction in symptomscores and medication use. Injection immunotherapy has a known and relativelylow risk of severe adverse events. We found no long-term consequences from adverseevents.11. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6Allergen injection immunotherapy for seasonal allergic rhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13NOV 2006
  • 46. Sublingual immunotherapy (SLIT) forAllergic Rhinitis 2011 Cochrane Review, assessed as up to date2009.1 49/60 RCTs suitable for meta-analysis pooling 2333 SLIT, 2256 placebo participants Significant reduction in symptoms (SMD -0.49; 95% confidence interval (CI) -0.64 to -0.34, P <0.00001) Significant reduction in medication requirements (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001)1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergicrhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date:13 AUG 2009
  • 47. Sublingual immunotherapy (SLIT) forAllergic Rhinitis SLIT appears to be safe None of the trials in this review reported Severe systemic reactions Anaphylaxis Use of epinephrine1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergicrhinitisEditorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date:13 AUG 2009
  • 48. Subcutaneous (SCIT) vs Sublingual(SLIT) ImmunotherapySCIT SLIT Symptoms(SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication need(SMD of -0.57 (95% CI -0.82 to-0.33, p<0.00001)). Epinephrine: 0.13% oftreatment injections, vs. 0.01%of placebo Fatalities: None Symptoms(SMD -0.49; 95%confidence interval (CI) -0.64 to -0.34, P <0.00001) Medication need(SMD -0.32; 95% CI -0.43 to-0.21, P < 0.00001) Epinephrine: No use Severe systemic reactions:None Anaphylaxis: None
  • 49. When to consider AllergyImmunotherapy Symptoms are not well controlled withmedication. Patient prefers to avoid medication Patient is unable to tolerate medication Possible decreased long-term cost of treatment Co-existing Allergic Rhinitis and Asthma Possible prevention of asthma
  • 50. Subcutaneous immunotherapy for allergicrhinitis: an evidence based review of therecent literature with recommendations. Safe when administered to carefully selectedpatients and in settings capable of responding tosystemic reactions. Recommended for patients with seasonal orperennial allergic rhinitis not responsive toconservative medical therapy, and whosesymptoms significantly affect quality of life.Purkey MT, Smith TL, Ferguson BJ, Luong A, Reisacher WR, Pillsbury HC 3rd, Toskala E.Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendatioInt Forum Allergy Rhinol. 2013 Jan 11. doi: 10.1002/alr.21141. [Epub ahead of print]
  • 51. Thank you!