Allergic Rhinitis

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Allergic Rhinitis

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Allergic Rhinitis

  1. 1. ALLERGIC RHINITIS
  2. 2. DEFINITIONS <ul><li>Hypersensitivity </li></ul><ul><ul><li>Causes objectively reproducible symptoms or signs initiated by exposure to0 a defined stimulus at a dose tolerated by normal subjects </li></ul></ul><ul><li>Atopy </li></ul><ul><ul><li>A personal or familial tendency to produce IgE antibodies in response to low dose allergens, usually proteins, and to develop typical symptoms such as asthma, rhino-conjunctivitis, or eczema/dermatitis </li></ul></ul><ul><li>Allergy </li></ul><ul><ul><li>Hypersensitivity reaction initiated by specific immunologic mechanisms </li></ul></ul>
  3. 3. Classification <ul><li>No widely or universally accepted criteria </li></ul><ul><li>Several proposals </li></ul><ul><ul><li>Rhinitis in general </li></ul></ul><ul><ul><li>Allergic rhinitis </li></ul></ul>
  4. 4. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  5. 5. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  6. 6. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Vasomotor </li></ul></ul>
  7. 7. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  8. 8. Classification <ul><li>Mackay (1989) </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><ul><li>Seasonal </li></ul></ul></ul><ul><ul><ul><li>Perennial </li></ul></ul></ul><ul><ul><li>Nonallergic </li></ul></ul><ul><ul><ul><li>Infectious </li></ul></ul></ul><ul><ul><ul><ul><li>Acute / Chronic / Nonspecific </li></ul></ul></ul></ul><ul><ul><ul><li>Noninfectious </li></ul></ul></ul><ul><ul><ul><ul><li>Hyperreactive (vasomotor) / Anatomic / Mechanical / Tumors </li></ul></ul></ul></ul>
  9. 9. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  10. 10. Classification <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><ul><li>Seasonal </li></ul></ul></ul><ul><ul><ul><li>Perennial </li></ul></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Others </li></ul></ul>
  11. 11. Classification <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><ul><li>Positive identification of an allergen </li></ul></ul><ul><ul><li>Establishment of causal relationship between exposure of Ag and Sy </li></ul></ul><ul><ul><li>Positive identification of immunologic mechanism </li></ul></ul>
  12. 12. Classification <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><ul><li>Seasonal </li></ul></ul></ul><ul><ul><ul><li>Perennial </li></ul></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Others </li></ul></ul>
  13. 13. Classification <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><ul><li>Allergic </li></ul></ul><ul><ul><ul><li>Seasonal </li></ul></ul></ul><ul><ul><ul><li>Perennial </li></ul></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Others (non-infectious, nonallergic) </li></ul></ul>
  14. 14. Classification <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><ul><li>Others (non-infectious, nonallergic) </li></ul></ul><ul><ul><ul><li>Idiopathic (previously, Vasomotor) </li></ul></ul></ul><ul><ul><ul><li>Idiopathic neonatal </li></ul></ul></ul><ul><ul><ul><li>NARES </li></ul></ul></ul><ul><ul><ul><li>Food-induced </li></ul></ul></ul><ul><ul><ul><li>Mucosal abnoramalites </li></ul></ul></ul><ul><ul><ul><li>Hormonal </li></ul></ul></ul><ul><ul><ul><li>Drug-induced </li></ul></ul></ul>
  15. 15. Classification (CHRONIC RHINITIS) <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) – PSO-HNS modification </li></ul><ul><ul><li>Perennial Allergic Rhinitis (PAR) </li></ul></ul><ul><ul><li>Perennial Non-allergic Rhinitis (PNAR) </li></ul></ul>
  16. 16. Classification (CHRONIC RHINITIS) <ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) – PSO-HNS modification </li></ul><ul><ul><li>Perennial Allergic Rhinitis (PAR) </li></ul></ul><ul><ul><ul><li>Chronic or recurrent </li></ul></ul></ul><ul><ul><ul><li>Ig-E mediated </li></ul></ul></ul><ul><ul><ul><li>No seasonal variation </li></ul></ul></ul><ul><ul><li>Perennial Non-allergic Rhinitis (PNAR) </li></ul></ul>
  17. 17. <ul><li>I C R D M R (1994) – PSO-HNS modification </li></ul><ul><ul><li>Perennial Allergic Rhinitis (PAR) </li></ul></ul><ul><ul><li>Perennial Non-allergic Rhinitis (PNAR) </li></ul></ul><ul><ul><ul><li>NARES </li></ul></ul></ul><ul><ul><ul><li>Environmental </li></ul></ul></ul><ul><ul><ul><li>Occupational </li></ul></ul></ul><ul><ul><ul><li>Hormonal </li></ul></ul></ul><ul><ul><ul><li>Drug-induced </li></ul></ul></ul><ul><ul><ul><li>Food-induced </li></ul></ul></ul><ul><ul><ul><li>Emotional </li></ul></ul></ul><ul><ul><ul><li>Idiopathic (vasomotor) </li></ul></ul></ul>Classification (CHRONIC RHINITIS)
  18. 18. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  19. 19. Classification <ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><ul><li>Questions: </li></ul></ul><ul><ul><ul><li>Rhinitis: Infectious or Noninfectious? </li></ul></ul></ul><ul><ul><ul><li>If noninfectious: Allergic or Nonallergic? </li></ul></ul></ul><ul><ul><ul><li>If nonallergic: Vasomotor or Eosinophilic? </li></ul></ul></ul>
  20. 20. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) </li></ul>
  21. 21. Classification <ul><li>Mygind et al. (1996) </li></ul><ul><ul><li>Seasonal vs. Perennial Allergic Rhinitis </li></ul></ul><ul><ul><li>Perennial Nonallergic Rhinitis </li></ul></ul><ul><ul><li>3 Categories of Differential Diagnosis: </li></ul></ul><ul><ul><ul><li>Mechanical Factors </li></ul></ul></ul><ul><ul><ul><li>Infections </li></ul></ul></ul><ul><ul><ul><li>Miscellaneous </li></ul></ul></ul>
  22. 22. Why these classifications were not satisfactory <ul><li>symptoms of perennial allergy may not always be present all year round </li></ul><ul><li>Perennial allergens may differ from one place to another </li></ul><ul><li>Majority of patients are sensitized simultaneously to different allergens and therefore present symptoms throughout the year </li></ul><ul><li>Because it is quite difficult to define the pollen season </li></ul><ul><li>Due to the priming effect of the nasal mucosa induced by low levels of pollen allergens and minimal persistent inflammation of the nose in patients with symptom free rhinitis, symptoms do not necessarily occur strictly in conjunction with the allergen season. </li></ul>
  23. 23. Classification <ul><li>Mygind & Weeke (1985) </li></ul><ul><li>Mackay (1989) </li></ul><ul><li>International Consensus Report on the Diagnosis and Management of Rhinitis (1994) </li></ul><ul><li>Van Cauwenberge & Ingels (1995) </li></ul><ul><li>Mygind et al. (1996) </li></ul><ul><li>ARIA (2001) – (specifically, Allergic Rhinitis) </li></ul>
  24. 24. Classification <ul><li>ARIA (2001) </li></ul><ul><ul><li>A llergic R hinitis and its I mpact on A sthma </li></ul></ul><ul><ul><li>WHO initiative, workshop </li></ul></ul><ul><ul><li>Link between Asthma Allergic Rhinitis </li></ul></ul><ul><ul><li>United Airways: 1 airway, 1 disease </li></ul></ul><ul><ul><li>Link </li></ul></ul><ul><ul><ul><li>Upper (ENT) & Lower (pulmonologist) airway </li></ul></ul></ul>
  25. 25. Classification <ul><li>ARIA </li></ul><ul><ul><li>New classification </li></ul></ul><ul><ul><ul><li>New perspective </li></ul></ul></ul><ul><ul><ul><li>New approach to management </li></ul></ul></ul>
  26. 26. ARIA - New Classification <ul><li>Intermittent </li></ul><ul><ul><li>< 4 d / wk </li></ul></ul><ul><ul><li>< 4 wks </li></ul></ul><ul><li>Persistent </li></ul><ul><ul><li>> 4 d / wk </li></ul></ul><ul><ul><li>> 4 wks </li></ul></ul><ul><li>Mild </li></ul><ul><li>(Absence of) </li></ul><ul><ul><li>Sleep disturbance </li></ul></ul><ul><ul><li>Impaired school / work / leisure / sport </li></ul></ul><ul><ul><li>Troublesome symptoms </li></ul></ul><ul><li>Moderate to Severe (Presence of) </li></ul><ul><ul><li>Sleep disturbance </li></ul></ul><ul><ul><li>Impaired school / work / leisure / sport </li></ul></ul><ul><ul><li>Troublesome symptoms </li></ul></ul>
  27. 27. New Trends <ul><li>ARIA </li></ul><ul><li>GLORIA </li></ul><ul><li>GINA </li></ul>
  28. 28. Other New Trends <ul><li>GLORIA: GLO bal R esources I n A llergy </li></ul><ul><ul><li>flagship program:World Allergy Organization </li></ul></ul><ul><ul><li>educate medical professionals worldwide </li></ul></ul><ul><ul><li>guidelines: national presentations, local programs </li></ul></ul><ul><ul><li>Module 1: Allergic Rhinitis / Conjunctivitis </li></ul></ul><ul><ul><li>Module 2: Prevention of Allergy & Asthma (Sept 03) </li></ul></ul><ul><ul><li>Module 3: Allergic Emergencies (2004) </li></ul></ul>
  29. 29. Other New Trends <ul><li>GLORIA </li></ul><ul><ul><li>GLO bal </li></ul></ul><ul><ul><li>R esources </li></ul></ul><ul><ul><li>I n </li></ul></ul><ul><ul><li>A llergy </li></ul></ul><ul><li>GINA </li></ul><ul><ul><li>G lobal </li></ul></ul><ul><ul><li>IN itiative for </li></ul></ul><ul><ul><li>A sthma </li></ul></ul>
  30. 30. Definition: Allergic Rhinitis <ul><li>Inflammation of the lining of the nose charcterized by one or more of the following: </li></ul><ul><li>Nasal congestion </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Sneezing </li></ul><ul><li>Itching </li></ul>
  31. 31. History <ul><li>Discharge </li></ul><ul><ul><li>watery (nose) </li></ul></ul><ul><ul><li>post nasal drip / snorting (NP) </li></ul></ul><ul><ul><li>phlegm (larynx) </li></ul></ul><ul><li>Itchiness </li></ul><ul><ul><li>ticklish, feathery, sand-like </li></ul></ul><ul><ul><li>nose, throat (coughing, clearing, ehem), eyes, ears (referred) </li></ul></ul><ul><li>Sneezing </li></ul><ul><li>Congestion </li></ul><ul><ul><li>globus / “ sambol” </li></ul></ul>
  32. 32. “ Sneezers and Runners” <ul><li>Sneezing </li></ul><ul><li>Watery rhinorrhea </li></ul><ul><li>Itchy nose </li></ul><ul><li>Diurnal rhythm </li></ul><ul><li>Often associated with conjunctivitis </li></ul><ul><li>Nasal blockage (variable) </li></ul>
  33. 33. “ Blockers” <ul><li>Little or no sneezing </li></ul><ul><li>Thick nasal mucus (usually posterior) </li></ul><ul><li>No itch </li></ul><ul><li>Severe nasal blockage </li></ul><ul><li>Constant, but may be worse at night </li></ul>
  34. 34. Differential Diagnosis <ul><li>Polyps </li></ul><ul><li>Tumors </li></ul><ul><li>Granulomas </li></ul><ul><li>CSF rhinorrhea </li></ul><ul><li>Mechanical factors </li></ul><ul><ul><li>Deviated nasal septum </li></ul></ul><ul><ul><li>Foreign body </li></ul></ul>
  35. 35. History <ul><li>Family Hx </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Allergic rhinitis </li></ul></ul><ul><ul><li>ARIA (“United Airways”) </li></ul></ul><ul><ul><ul><li>Check one for the other and vice versa </li></ul></ul></ul>
  36. 36. History <ul><li>Part of management </li></ul><ul><li>Illicit factors </li></ul>
  37. 37. ENVIRONMENT CONTROL The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>
  38. 38. History <ul><li>Home </li></ul><ul><ul><li>Cats, dogs, birds, chickens </li></ul></ul><ul><ul><li>Carpets, curtains, screens  blinds </li></ul></ul><ul><ul><li>Floor, aparador , cabinet, corners, ceiling </li></ul></ul><ul><ul><li>Clothes, closets </li></ul></ul><ul><ul><li>Stuffed toys, woolen blankets, kapok pillows </li></ul></ul><ul><ul><li>Books, newspapers, mags </li></ul></ul><ul><ul><li>bodega in the bedroom, eating in bed </li></ul></ul><ul><ul><li>Spartan living : bed, TV, no sagbot! </li></ul></ul>
  39. 39. History <ul><li>Home </li></ul><ul><ul><li>Aircon filter/cover </li></ul></ul><ul><ul><li>Electric fan blades/grilles </li></ul></ul><ul><ul><li>Baby powder, make-up </li></ul></ul><ul><ul><li>Busy street, pollution (DEP) </li></ul></ul><ul><ul><li>Adjacent lots: </li></ul></ul><ul><ul><ul><li>Vacant (cut grass) </li></ul></ul></ul><ul><ul><ul><li>neighbors (agri, animals, rattan, motor shop, factory, pier,) </li></ul></ul></ul><ul><ul><li>Suggest: humidifier, vaporizer </li></ul></ul>
  40. 40. History <ul><li>School - Place </li></ul><ul><ul><li>Grass: </li></ul></ul><ul><ul><ul><li>Boy scout </li></ul></ul></ul><ul><ul><ul><li>Soccer </li></ul></ul></ul><ul><ul><li>Trees </li></ul></ul><ul><ul><li>Library </li></ul></ul><ul><ul><li>Aircon, fan </li></ul></ul><ul><ul><li>Carpet, screen </li></ul></ul>
  41. 41. History <ul><li>Work - Place </li></ul><ul><ul><li>Aircon filter/cover </li></ul></ul><ul><ul><li>Electric fan blades/grilles </li></ul></ul><ul><ul><li>Wool dividers </li></ul></ul><ul><ul><li>Carpet </li></ul></ul><ul><ul><li>Screen </li></ul></ul>
  42. 42. History <ul><li>Work - Occupation: Important! </li></ul><ul><ul><ul><li>Jeweler: acid </li></ul></ul></ul><ul><ul><ul><li>Bank: money, paperwork </li></ul></ul></ul><ul><ul><ul><li>Bakery owner </li></ul></ul></ul><ul><ul><ul><li>Manager/supervisor/clerk: stockroom, records </li></ul></ul></ul><ul><ul><ul><li>Rice mill, poultry, piggery, rattan, machine shop </li></ul></ul></ul><ul><ul><ul><li>Agri business: feeds </li></ul></ul></ul><ul><ul><ul><li>Teacher: chalk, conference rooms </li></ul></ul></ul><ul><ul><ul><li>Seaman: asymptomatic until anchorage </li></ul></ul></ul><ul><ul><ul><li>Garments, printing press </li></ul></ul></ul>
  43. 43. GOAL of Pharmacotherapy in AR <ul><li>The goal in managing allergic rhinitis pharmacologically is to begin treatment prophylactically so that inflammatory responses are modified and symptoms prevented. </li></ul>
  44. 44. ENVIRONMENT CONTROL The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal )
  45. 45. Antihistamines - History <ul><li>1937 1942 1979 1988 1996 2K1 </li></ul>Daniel Phenbenzamine Chlorphenamine Terfenadine Astemizole Fexofenadine Bovet Cetirizine Loratadine Levocetirizine Desloratadine
  46. 46. <ul><li>1 st Generation </li></ul><ul><ul><li>Chlorphenamine </li></ul></ul><ul><ul><li>Mepyramine </li></ul></ul><ul><ul><li>Diphenhydramine </li></ul></ul><ul><ul><ul><li>- drowsiness (good/bad) </li></ul></ul></ul>Antihistamines – History & Classification
  47. 47. <ul><li>2 nd Generation </li></ul><ul><ul><li>Terfenadine </li></ul></ul><ul><ul><li>Loratadine (Claritin) </li></ul></ul><ul><ul><li>Cetirizine </li></ul></ul><ul><ul><ul><li>- minimal sedation (not 0) </li></ul></ul></ul>Antihistamines – History & Classification
  48. 48. <ul><li>NEXT Generation (3 rd Generation) </li></ul><ul><ul><li>Terfenadine Fexofenadine </li></ul></ul><ul><ul><li>Loratadine (Claritin) Desloratadine (AERIUS) </li></ul></ul><ul><ul><li>Cetirizine Levocetirizine </li></ul></ul><ul><ul><ul><li>- no clear criteria for 3G </li></ul></ul></ul>Antihistamines – History & Classification
  49. 49. Antihistamine – Mechanism of Action <ul><li>H 1 Receptors </li></ul><ul><ul><li>Mid brain receptors (awake) </li></ul></ul><ul><ul><ul><li>Competitive inhibition </li></ul></ul></ul><ul><ul><ul><li>Antihistamine effect = sedation </li></ul></ul></ul><ul><ul><li>Vasodilatation </li></ul></ul><ul><ul><li>Bronchial, GI smooth muscles </li></ul></ul><ul><li>H 2 Receptors </li></ul><ul><ul><li>Gastric stimulation </li></ul></ul><ul><ul><li>Cardiac stimulation </li></ul></ul>
  50. 50. Antihistamine – Mechanism of Action <ul><li>H 3 Receptors </li></ul><ul><ul><li>Neuronal </li></ul></ul><ul><li>H 4 Receptors </li></ul><ul><ul><li>? </li></ul></ul>
  51. 51. Antihistamine- Ideal Characteristics <ul><li>Good bioavailability </li></ul><ul><li>Rapid onset of effect </li></ul><ul><li>NO significant drug interaction </li></ul><ul><li>Half-life to enable 1X daily dosing </li></ul><ul><li>Maintenance of effect </li></ul><ul><li>Suitable for all patient population </li></ul><ul><li>Clinically relevant anti-allergic activity </li></ul><ul><li>NO cardiotoxicity </li></ul><ul><li>Non-sedating </li></ul><ul><li>Maximizes quality of life </li></ul>
  52. 52. ENVIRONMENT CONTROL Nasal steroid sprays (Nasonex, Flixotide, Budecort) The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal )
  53. 53. Topical Corticosteroids <ul><li>Most potent anti-inflammatory agents </li></ul><ul><li>Effective in treatment of all nasal symptoms including obstruction </li></ul><ul><li>Once or twice daily administration </li></ul><ul><li>Superior to antihistamines for all nasal symptoms </li></ul><ul><li>First line pharmacotherapy for moderate-severe persistent allergic rhinitis </li></ul>
  54. 54. Action of topical corticosteroids <ul><li>Induce anti-inflammatory effects </li></ul><ul><li>Inhibit microvascular leakage </li></ul><ul><li>Upregulate B-adrenoreceptors </li></ul>
  55. 55. Safety of Topical CS <ul><li>Inhaled and intranasal CS </li></ul><ul><ul><li>May affect 24-hr urinary cortisol </li></ul></ul><ul><ul><li>May affect growth velocity in children especially with concomitant use of inhaled/systemic steroids </li></ul></ul><ul><ul><li>May cause epistaxis </li></ul></ul><ul><ul><ul><ul><ul><li>Passalacqua et al: Allergy 2000; 55: 16-33 </li></ul></ul></ul></ul></ul>
  56. 56. Safety of Topical CS <ul><li>Bioavailability <0.1%* </li></ul><ul><li>No effect of HPA up to 4000 mcg daily* </li></ul><ul><li>Long term use is not associated with adverse tissue changes** </li></ul>*Meltzer et al; J Allergy Clin Immunol 1999;204: 107-114 **Minshall et al; Otolaryn Head Neck Surg 1998; 118:648-54
  57. 57. Use of Inhaled Steroids in Pregnancy <ul><li>Objective of the study </li></ul><ul><ul><li>To evaluate the association between maternal use of specific inhaled steroids and inhaled steroid dose during pregnancy and the incidence of infants who are small for gestational age (SGA) with mean birth weight </li></ul></ul>
  58. 58. Use of Inhaled Steroids in Pregnancy <ul><li>Methodology </li></ul><ul><ul><li>Pregnant asthmatic women treated with inhaled steroids were enrolled in the study before delivery by managing allergists </li></ul></ul><ul><ul><li>Past/Personal history of Pregnancy obtained </li></ul></ul><ul><ul><li>SGA defined through use of a published normative sample of American births </li></ul></ul>
  59. 59. Use of Inhaled Steroids in Pregnancy <ul><li>Results </li></ul><ul><ul><li>396/474 (88%) completed the study </li></ul></ul><ul><ul><li>Incidence of low birth weight, preterm births and congenital malformations was not greater than expected in the general population </li></ul></ul><ul><ul><li>No significant relationships between specific inhaled steroid or dose of inhaled steroid used and either SGA or mean birth weight were observed </li></ul></ul>
  60. 60. Relationships between ICS and SGA infants and mean birth weight 3452 + 120.3 8.0 347 flunisolide 3393 + 69.0 9.3 393 Budesonide 3508 + 60.1 4.9 193 Triamcinolone 3428 + 51.7 7.6 720 Fluticasone 3421 + 37.5 6.0 277 Beclomethasone Birth wt (g) Mean + SEM SGA percent μ g Drug
  61. 61. Use of Inhaled Steroids in Pregnancy <ul><li>Conclusion </li></ul><ul><ul><li>Use of inhaled steroids by pregnant asthmatic women does not reduce intrauterine growth and supports the recommendation that inhaled steroids should be used in the management of persistent asthma during pregnancy </li></ul></ul>JACI 2004; 113:427-32
  62. 62. ENVIRONMENT CONTROL Nasal steroid sprays (Nasonex, Flixotide, Budecort) Nasal antihistamine sprays (Azep) The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal )
  63. 63. Decongestants <ul><li>Oral </li></ul><ul><ul><li>phenylpropanolamine </li></ul></ul><ul><li>Topical </li></ul><ul><ul><li>oxymethazoline </li></ul></ul><ul><ul><li>xylomethazoline </li></ul></ul><ul><ul><li>pseudoephedrine </li></ul></ul><ul><li> - adrenergic vasoconstrictor </li></ul>
  64. 64. Decongestants <ul><li>Not routinely used </li></ul><ul><li>Some indications </li></ul><ul><ul><li>extremely congested, can’t breathe </li></ul></ul><ul><ul><li>sinusitis </li></ul></ul><ul><ul><li>ear symptoms </li></ul></ul><ul><li>Side effect: </li></ul><ul><ul><li>Rhinitis medicamentosa </li></ul></ul><ul><ul><li>HPN </li></ul></ul>
  65. 65. Rhinitis medicamentosa <ul><li>Rebound congestion </li></ul><ul><li>Prolonged use of topical decongestants </li></ul>
  66. 66. Rhinitis medicamentosa <ul><li>Pathological changes: </li></ul><ul><ul><li>Ciliary loss </li></ul></ul><ul><ul><li>Epithelial ulceration </li></ul></ul><ul><ul><li>Inflammatory cell infiltration </li></ul></ul><ul><ul><li>Interstitial edema </li></ul></ul><ul><ul><li>Vasodilatation </li></ul></ul><ul><ul><li>Decrease sensitivity at receptor site </li></ul></ul>
  67. 67. Rhinitis medicamentosa <ul><li>Corticosteroid </li></ul><ul><ul><li>Tx </li></ul></ul><ul><ul><li>alternative </li></ul></ul>
  68. 68. ENVIRONMENT CONTROL Nasal steroid sprays (Nasonex, Flixotide, Budecort) Nasal antihistamine sprays (Azep) Oral steroids (Prednisone) The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal )
  69. 69. ENVIRONMENT CONTROL Nasal steroid sprays (Nasonex, Flixotide, Budecort) Nasal antihistamine sprays (Azep) Oral steroids (Prednisone) Immunotherapy The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal )
  70. 70. ENVIRONMENT CONTROL Nasal steroid sprays (Nasonex, Flixotide, Budecort) Nasal antihistamine sprays (Azep) Oral steroids (Prednisone) Immunotherapy The Stepladder Approach to the Management of Allergic Rhinitis <ul><li>Robert Davies, MA, MD, FRCP </li></ul><ul><li>Academic Department of Respiratory Medicine, London Chest Hospital </li></ul>Oral antihistamines (Aerius, Zyrtec, Telfast, Virlix, Xyzal ) 1 2 3
  71. 71. Highlights <ul><li>History </li></ul><ul><ul><li>Signs, symptoms </li></ul></ul><ul><ul><li>Environment, activities, occupation </li></ul></ul><ul><li>No cure, just treatment </li></ul><ul><ul><li>Not elimination, just cure </li></ul></ul><ul><ul><li>Patient expectation, no frustrations </li></ul></ul>
  72. 72. Highlights <ul><li>Patient education </li></ul><ul><ul><li>Most important </li></ul></ul><ul><ul><li>Explain allergy and symptoms </li></ul></ul><ul><ul><ul><li>” coup” : antibodies = soldiers </li></ul></ul></ul><ul><ul><ul><li>Hypersensitive : easily irritated, exaggerated effects </li></ul></ul></ul><ul><ul><ul><li>Open up mast cell, release Histamine  SSX </li></ul></ul></ul><ul><ul><ul><li>Genetic: no drug to eliminate allergy/asthma (live with it, grow old) </li></ul></ul></ul>
  73. 73. Highlights <ul><li>Patient education </li></ul><ul><ul><li>Avoidance: allergens, complications (sinusitis) </li></ul></ul><ul><ul><li>Describe typical day/ activities/ places frequented/ surroundings </li></ul></ul><ul><ul><li>Assurance: not deadly, 30M, even MDs </li></ul></ul><ul><li>Physician education </li></ul><ul><ul><li>Updates: Dx, Sx, Sy, Rx, concepts, classification </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>proper use (decongestants, antibiotics) </li></ul></ul></ul><ul><ul><ul><li>logical, stepwise, systematic </li></ul></ul></ul>
  74. 74. Highlights <ul><li>Class effect </li></ul><ul><ul><li>Whatever works best for the patient </li></ul></ul><ul><ul><li>“ trial and error” </li></ul></ul><ul><li>Follow up </li></ul><ul><ul><li>constant follow up to see pattern and thus determine proper treatment (stepladder) </li></ul></ul>
  75. 75. <ul><li>http://crisbertcualteros.page.tl </li></ul>

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