Allergic Rhinitis


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This is one version of the lecture that I give to health care providers of all levels.

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  • Is you Itchy DOG [ Allergy ] SAD ?

    4 Options Only 1 Solution !

    Canine Allergy = Constant Paw Chewing, Itching, Biting, Scratching, Ear & Skin Issues & VET $$ Bills !

    Fleas / FOODs ? = NO

    Pollens / Dust mites / Molds ? = YES !

    Often, Pet Owners move their Dogs to special Diets “ Thinking “ that their DOGs Allergy Symptoms of constant Paw Chewing, Licking, Itching, Skin & Ear issues are “Food Allergy Driven”.

    Unfortunately, while special FOODs are nutritious and Food Rotation is always suggested…

    Research indicates that 85% of all Dogs who suffer from Allergies, suffer not from Food Allergy Sources, but from Allergy to Weed / Tree / Grass Pollens, Mites and Mold Spores.

    Canine ALLERGY Overview:

    30 % of all Canine’s have ALLERGIES.

    Some Breeds are Genetically PreDisposed to a higher incidence of Allergy i.e. Retrievers, Labs.

    After Flea issues are ruled out, 85% of all Canine’s who display Allergy Symptoms of constant Paw Chewing, Itching, Scratching, Biting are Allergic to everyday Grass / Tree / Weed Pollens, Mites & Mold Spores.

    Present > DOG Allergy Treatment Options / Only ONE Solution !

    #1) Avoid what your Dog is Allergic to .

    Live Life in a Bubble ? > Impossible.

    Most / all Offending allergens are Omni-Present in Today’s Society.

    #2) Take Medications for the Rest of your DOGs Life !

    Reminder: Allergy is Not a Static Disease.

    Rather, ALLERGY is a > Lifetime, Progressive, Cumulative, Chronic Inflammatory, Auto-Immune Disease !

    Med’s only MASK Symptoms . Fool the Body into believing there is No Problem !

    Leaving the Progression of Allergy Disease Intact..
    To Continue / Exacerbate Unabated..
    Taking EACH Allergy PET on a Lifetime Slippery Slope of further “Allergy Driven” Diseases, recalcitrant Health Issues and compromised Quality of Life for PET and PET Parent.

    Allergy MED’s also suppress the Entire Immune System leaving the Animal vulnerable to Secondary Health Issues on top of their Allergy progression .

    #3) Allergy ( Ouch ) ImmunoTherapy SHOTs !

    While Allergy SHOTs Do Work and Have been Clinically Proven to Stop Allergy Progression / Neutralize the Source of Allergy …

    DOG Allergy Testing & SHOTs = Expensive = Not PET Friendly = Not PET Parent Friendly = PET and Pet Parent leave Program = DOG Suffers !

    #4) Healthy GOO / Doggy GOO Solution !

    NOW ! The Serious Business of Fighting Canine ALLERGY Itch can be FUN !

    FUN for You !
    GOO-Licious Tasting Treat FUN for your DOG !

    Doggy GOO simultaneously Targets, Supports & Balances your DOG’s Immune System and builds tolerance to everyday Environmental Allergens.

    Doggy GOO’s Pet Friendly Sublingual Delivery has been Clinically shown SUPERIOR to Gold Standard Allergy SHOTs in Neutralization of Canine Dust Mite Allergies.

    DVM Veterinary Dermatologist Formulated.

    Supports / Balances 1st Line ( Innate ) Immune System Defenses.

    Builds natural ( Acquired ) Immune System Tolerance to Enviro Allergy Sources ( 3 Tree / 4 Weed / 3 Grass / 2 Mites / 3 Molds / 2 FOODs ( Beef & Wheat ) ).

    Pre & Probiotics foster Healthy GUT Response.

    All 100% GOO-licious Natural !

    Give your Best Friend a Healthy GOO Glow with Doggy GOO !
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  • When was it built? By whom? Why? Art appreciation like in JAMA. The Taj Mahal is a mausoleum located in Agra , India , that was built under Mughal Emperor Shah Jahan in memory of his favorite wife, Mumtaz Mahal . The Taj Mahal is considered the finest example of Mughal architecture , a style that combines elements from Persian , Turkish , Indian , and Islamic architectural styles. Taj Mahal is an integrated symmetric complex of structures that was completed around 1648.
  • Allergic Rhinitis

    1. 1.                                                                                                                                
    2. 2. Neil L. Kao, M.D., F.A.C.P., Clinical Assistant Professor, U.S.C. School of Medicine WELCOME!
    3. 4. <ul><li>Epidemiology Of Allergic Rhinitis </li></ul><ul><li>Allergic rhinitis was reported the second most prevalent chronic condition in the United States in 1994 </li></ul><ul><li>Affects 40 to 50 million people </li></ul><ul><li>Incidence highest in people ages 15-25 years </li></ul><ul><li>Affects 10% to 30% of adults, 40% of children </li></ul><ul><li>In one study, 57% of patients with chronic rhinitis had nonallergic or mixed rhinitis </li></ul>
    4. 5. <ul><li>The Burden of Allergic Rhinitis </li></ul><ul><li>50% patients symptomatic > 4 months/year </li></ul><ul><li>20% patients symptomatic > 9 months/year </li></ul><ul><li>10,000 children out of school daily </li></ul><ul><li>10,000,000 office visits annually </li></ul><ul><li>2,000,000 days of missed school </li></ul><ul><li>$5.3 billion for direct and indirect costs in year 1996 </li></ul><ul><li>And this accounts only for allergic rhinitis, nonallergic rhinitis is another issue </li></ul><ul><li>Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis </li></ul>
    5. 6.                                                                                                                                
    6. 7. Nasal Anatomy
    7. 10. Definition of Allergic Rhinitis <ul><li>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. </li></ul>
    8. 11. Causes of Allergic Rhinitis
    9. 12.                                                                                                                                                                  
    10. 16.                                                                                                                                                       
    11. 17. Questions of clinical relevance <ul><li>What is wrong with the patient? </li></ul><ul><li>What can I do for the patient? </li></ul><ul><li>What will the outcome be? </li></ul><ul><li>What will it cost? </li></ul><ul><li>What, specifically, must I do to behave in the best traditions of our profession? </li></ul><ul><li>J SC Med Assoc 1995; 91: 243-4. </li></ul>
    12. 18. Allergy History Screen
    13. 21. Physical Examination <ul><li>Allergic shiner </li></ul><ul><li>Dennie Morgan line </li></ul><ul><li>Allergic crease, congested nasal breathing, sniffling </li></ul><ul><li>Allergic salute, mouth breathing </li></ul><ul><li>Nasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic </li></ul><ul><li>Exclude structural problems (polyps, deflected nasal septum) </li></ul><ul><li>Others : </li></ul><ul><li>nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability </li></ul>
    14. 24. Diagnosis of Allergic Rhinitis <ul><li>History </li></ul><ul><li>Physical / Nasal Examination </li></ul><ul><li>Nasal smear for eosinophils, WBC, bacteria </li></ul><ul><li>Skin Prick Test (in vivo) > serum RAST, as in more accurate, quicker. Recommended by A.C.P. unless ST can not be done </li></ul><ul><li>Blood: CBC/diff, IgE levels (poor screening tests) </li></ul>                         
    15. 25. Allergy Prick Skin Tests                                                                                                      
    16. 27. Causes of Rhinitis <ul><li>Allergy </li></ul><ul><li>NARES syndrome </li></ul><ul><li>Occupational, hobbies </li></ul><ul><li>Hormonal </li></ul><ul><li>Drug induced </li></ul><ul><li>Anatomic defects </li></ul><ul><li>Infections, viral </li></ul><ul><li>Irritants </li></ul><ul><li>Adverse food reaction </li></ul><ul><li>Emotional </li></ul><ul><li>Atrophic </li></ul><ul><li>Ciliary dyskinesia </li></ul><ul><li>Immunodeficiency diseases </li></ul>
    17. 28.                                                                                                                                
    18. 30. Allergic Rhinitis Therapy <ul><ul><ul><li>Hope, compassion, empowerment </li></ul></ul></ul><ul><ul><ul><li>Education </li></ul></ul></ul><ul><ul><ul><li>Avoidance of triggers </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Allergy Immunotherapy (shots) </li></ul></ul></ul>
    19. 31. Educational Resources <ul><li>American Academy of Allergy, Asthma, and Immunology -- </li></ul><ul><li>American College of Allergy, Asthma, and Immunology – </li></ul><ul><li>Asthma & Allergy Foundation of America -- </li></ul><ul><li>Allergy & Asthma Network/Mothers of Asthmatics, Inc. -- </li></ul><ul><li>My website has links to the above, pollen counts, and more -- http:// </li></ul>
    20. 33. Weed pollen count Mold spore count Tree pollen count Grass pollen count
    21. 37. Irritants to avoid <ul><li>Smoke or exhaust from any source </li></ul><ul><li>Paints, glues, cleaning products, aerosols, perfumes </li></ul><ul><li>Photocopier exhaust </li></ul><ul><li>Paper dust </li></ul><ul><li>Dry wall board dust </li></ul>
    22. 39. Anti-Histamine medications <ul><li>Act by preventing histamine from binding to its receptors </li></ul><ul><li>Primarily helpful in controlling sneezing, itching, runny nose; ineffective in relieving nasal congestion </li></ul><ul><li>1 st generation anti-histamines (short half-life, sedating, older): </li></ul><ul><li>chlorpheniramine (OTC), diphenhydramine (OTC) (Benedryl) </li></ul><ul><li>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) </li></ul>
    23. 40. Intranasal corticosteroid sprays <ul><li>Potent topical activity: all have equal efficacy </li></ul><ul><li>Administration of low doses directly at site of action </li></ul><ul><li>Considerable efficacy at low doses </li></ul><ul><li>High topical: systemic activity ratios </li></ul><ul><li>Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity </li></ul><ul><li>Markedly greater inhibition of EAR than with oral steroids </li></ul><ul><li>No effect on growth </li></ul>
    24. 41. Additional medications <ul><li>Decongestants: oral (-D, OTC e.g. Sudafed). Do NOT use topical OTC sprays – potent BUT addicting </li></ul><ul><li>Leukotriene receptor antagonist (Montelukast [Singulair]): not as effect as AH1 or CS, so not first line therapy </li></ul><ul><li>Expectorant to thin mucus (guaifenesin), long-acting only available as OTC Mucinex, mildly helpful </li></ul><ul><li>Antibiotic if complicating bacterial infection present </li></ul><ul><li>Do not forget eyedrops for symptoms </li></ul><ul><li>Saline rinses for nose and eyes, use lots of volume and repeat throughout the day </li></ul>
    25. 43. Concept of &quot;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
    26. 45. Allergy Immunotherapy (Injections) <ul><li>When medications and avoidance don’t work </li></ul><ul><li>Only therapy that can raise T-cell tolerance to allergens so there is no allergic immune response </li></ul><ul><li>Usually prescribed by a specialist </li></ul><ul><li>Most effective for dust mites, pollen, cat allergy </li></ul><ul><li>May also be effective for dog, mold allergy </li></ul><ul><li>Cost, discomfort, time, normal course 3-5 years </li></ul>
    27. 47. <ul><li>Let us,then, be up and doing, </li></ul><ul><li>With a heart for any fate; </li></ul><ul><li>Still achieving, still pursuing, </li></ul><ul><li>Learn to labor and to wait. </li></ul><ul><li>Henry Wadsworth Longfellow </li></ul>
    28. 48.