Allergic rhinitis

1. ALLERGIC RHINITIS

2. DEFINITION
● RHINITIS IS DEFINED AS AN INFLAMMATION OF THE LINING
OF THE NOSE, CHARACTERISED BY NASAL
SYMPTOMS, INCLUDING:
– ANTERIOR OR POSTERIOR RHINORRHOEA
– SNEEZING
– NASAL BLOCKAGE
– ITCHING OF THE NOSE

3. DEFINITION OF ALLERGIC RHINITIS
● ALLERGIC RHINITIS IS DEFINED AS A
SYMPTOMATIC DISORDER OF THE NOSE
INDUCED AFTER ALLERGEN EXPOSURE,
● BY AN IgE MEDIATED INFLAMMATION,
● CHARACTERISED BY RHINORRHOEA,
NASAL OBSTRUCTION, NASAL ITCHING,
AND SNEEZING;
● WHICH ARE REVERSIBLE
SPONTANEOUSLY OR WITH TREATMENT.

4. CLASSIFICATION
● BASED ON THE FREQUENCY OF EPISODES,
–INTERMITTENT
–PERSISTENT
● BASED ON THE SEVERITY OF SYMPTOMS,
–MILD
–MODERATE/SEVERE

5. INTERMITTENT & PERSISTENT
ALLERGIC RHINITIS
INTERMITTENT PERSISTENT
Symptoms are present:
< 4 days a week > 4 days a week
Or <4 consecutive weeks And > 4 consecutive weeks

6. MILD & MODERATE/SEVERE
ALLERGIC RHINITIS
MILD MODERATE/
SEVERE
Sleep disturbance - +
Impairment of
daily activities,
leisure or sport
- +
Impairment of
school or work
- +
Troublesome
symptoms
- +

7. Exposure to
allergens
PATHOPHYSIOLOGY

8. • Antigen-presenting cells,
which include
macrophages and
Dendritic cells similar to
Langerhans cells in the
skin, take up allergen by
endocytosis

9. •APCs process
allergens, and co-
present it along with
HLA Class 2
molecules to CD4+ T
cells (Th2
lymphocytes)

10. • T cells undergo clonal expansion
• They get activated
• They produce cytokines
• Signal B cells, causing
differentiation into plasma cells
• Plasma cells produce IgE class
antibodies

11. • Allergen specific IgE
produced by Plasma
cells, bind to mast cells,
and Basophils, resulting
in Antigen priming.

12. • Subsequent exposure to
allergen leads to cross linking of
IgE on cell surface
• Opening of Calcium channels
• Degranulation
• Release of preformed
mediators
• Histamine
• Prostaglandins
• Leukotrienes
• Kinins
• Cytokines

13. • Histamine results in Rhinorrhoea, Sneezing, Itching, and some nasal obstruction
(Early allergic response)
• Oedema, vasodilatation and plasma exudation; Increases glandular secretion
• Upregulation of Adhesion molecules on vascular endothelial cells, increased
production of cytokines
• Other mediators of importance in Allergic Rhinitis:
• Prostaglandin D2 – Sustained nasal obstruction
• Leukotrienes (SRS-A) – Vascular permeability, Oedema,
• Eosinophil recruitment
• Kinins-Rhinorrhoea, Sneezing, Obstruction, Pain
• TH2 cytokines-IL-4, 5, 13, 6, 8, 10, TNF-alpha are important in regulation of
immune response
EARLY ALLERGIC
RESPONSE

14. • Severe exposure to allergens can result in a late phase response
• Eosinophils-Activated, increase local vascular permeability, mucus secretion, further
inflammatory cell influx, alteration of nasal epithelium
• Endothelial cells recruit leukocytes by releasing chemotactic factors and modulation of
adhesion factors.
• Trap circulating inflammatory cells at the site of allergic response, especially eosinophils
and basophils
• Basophils are a major source of histamine in the late phase response.
• Epithelial cells – Activated, and show increased expression of adhesion molecules,
expression and production of inflammatory mediators
LATE ALLERGIC RESPONSE

15. DIAGNOSIS
• HISTORY-SYMPTOMS OF NASAL ALLERGY
• PHYSICAL EXAMINATION
• ALLERGIC NASAL MUCOSA-SWOLLEN BILATERALLY, PALE OR
BLUISH, OEDEMATOUS, WATERY DISCHARGE
• FEATURES OF BRONCHIAL ASTHMA, OR ATOPY

16. SKIN PRICK TESTS
• MEAN WHEAL
DIAMETER AT 15 MINS
• >2 MM IN CHILDREN
<5YRS,
• > 3 MM IN OLDER
CHILDREN AND ADULTS
• ALLERGEN
INTRODUCED INTO
SKIN CAUSES MAST
CELL DEGRANULATION,
FORMATION OF WHEAL
AND FLARE

17. TREATMENT GUIDELINES (ARIA 2008, 2010)
INTERMITTENT
MILD
SEVERE
• ORAL H1 BLOCKERS
• INTRANASAL H1
BLOCKERS
• +/-
DECONGESTANT/LTRA
• ORAL H1 BLOCKERS
• INTRANASAL H1 BLOCKERS
• +/- DECONGESTANT/LTRA
• INTRANASAL STEROIDS
• LTRA
• OR CHROMONE
PERSISTENT
MILD

18. REVIEW AFTER 2-4 WEEKS
REASS
ESS
IMPROVED FAILURE
CONTINUE FOR 1 MONTH STEP UP

19. • INTRANASAL STEROIDS
SEVERE
PERSISTENT
• H1 BLOCKERS OR LTRA
REASS
ESS
AFTER
2-4WKS
FAILUREIMPROVED
STEP DOWN AND CONTINUE
FOR >1 MONTH
• REVIEW DIAGNOSIS
• REVIEW COMPLIANCE
• QUERY INFECTIONS OR
OTHER CAUSES
ADD OR
INCREASE
INTRANASAL CS
ADD
IPRATROPIUM
FOR
RHINORRHOEA
ADD
IPRATROPIUM
FOR
RHINORRHOEA
ADD DECONGESTANT
OR ORAL SHORT
TERM CS
ALLERGEN
AVOIDANCE
CONSIDER
IMMUNOTHERA
PY

20. ALLERGEN AVOIDANCE AND
ENVIRONMENTAL CONTROL
• VARIOUS RECOMMENDATIONS FOR ALLERGEN AVOIDANCE HAD BEEN
SUGGESTED IN THE PAST
• TOTAL AVOIDANCE OF EXPOSURE TO PASSIVE SMOKING IN PREGNANT WOMEN
• NO ‘ANTIGEN AVOIDANCE DIET’ IS RECOMMENDED
• REDUCE EARLY LIFE EXPOSURE TO HOUSE DUST MITE
• NO SPECIAL AVOIDANCE OF EXPOSURE TO PETS AT HOME IN INFANTS AND
PRESCHOOL CHILDREN
• SPECIFIC PREVENTION MEASURES ELIMINATING OR REDUCING
OCCUPATIONAL ALLERGEN EXPOSURE

21. • CLINICIANS SHOULD NOT ADMINISTER AND PATIENTS DO NOT USE CURRENTLY
AVAILABLE SINGLE CHEMICAL OR PHYSICAL PREVENTIVE METHODS AIMED AT
REDUCING EXPOSURE TO HOUSE DUST MITES
• AVOID EXPOSURE TO INDOOR MOULDS AT HOME
• AVOID EXPOSURE TO ANIMAL DANDER

22. ANTIHISTAMINES
• Rapidly relieve nasal discharge, sneezing itching (early phase response)
• Minimal effect on nasal blockage (except desloratidine, levocetirizine) (late phase response)
• Avoid first generation
• Azelastine can be given intranasally
• Chronic nasal congestion and headache caused by edema of the paranasal sinus mucosa are
often refractory to antihistamine therapy.
• Single-ingredient products generally are safer than combination products,100while also facilitating
dosage adjustment.
• Oral antihistamine combinations containing an analgesic-antipyretic and/or nasal decongestant; an
antitussive and nasal decongestant; an analgesic-antipyretic, antitussive, and nasal decongestant;
or an antitussive may be rational if each ingredient has demonstrated clinical effectiveness
• Side effects: sedation, toxicity, Anticholinergic effects
• Rarely, agranulocytosis, hemolytic anemia, leukopenia, thrombocytopenia, and pancytopenia have
been reported

23. • Acrivastine, desloratadine, fexofenadine, loratadine, and, possibly,
cetirizine and levocetirizine appear to cause fewer adverse CNS effects
• Antihistamines can cause sensitivity reactions (e.G., Sensitization,
hypersensitivity) following topical application
• Antihistamines can act as haptens and cause Ig E-mediated (type I)
hypersensitivity reactions or T cell-mediated (type IV) sensitization
reactions.
• Adverse cardiovascular effects are uncommon and usually limited to
overdosage situations.
• Patients who were receiving therapy with an azole (ketoconazole] and
triazole derivative [itraconazole]) antifungal, a macrolide (e.G.,
Clarithromycin, erythromycin), quinine appeared to be at substantial risk of
such toxicity, probably secondary to interference with metabolism of
theantihistamine.

24. TOPICAL ANTIHISTAMINES
• Azelastine hydrochloride spray is used intranasally to provide symptomatic
relief of allergic rhinitis
• Intranasal azelastine was more effective than placebo and at least as
effective as oral antihistamines in relieving symptoms
• Administered intranasally, using a spray pump.
• For adults and children 12 years of age or older dose is 2 sprays (274 mcg)
in each nostril twice daily (1096 mcg of azelastine hydrochloride total daily,
equivalent to 1 mg of azelastine base daily).
• Principal adverse effects of intranasal azelastine are local (e.G., Bitter taste,
nasal burning, pharyngitis, paroxysmal sneezing),
• Adverse systemic effects (e.G., Somnolence, headache) also can occur.

25. TOPICAL GLUCOCORTICOIDS
• Most effective treatment for allergic rhinitis
• Regular treatment is necessary
• Generally provides symptomatic relief of watery
rhinorrhea, nasal congestion, sneezing, postnasal drip, and nasalitching.
• Slow onset of action. Maximal effect after several days
• Administration of a topical nasal decongestant about 5-15 minutes before
intranasal corticosteroid administration may be useful during the first 2 or
3 days of therapy in patients with blocked nasalpassages to ensure
adequate penetration of the drug.

26. • Lowest bioavailability is seen with fluticasone and mometasone

27. ADMINISTRATION
• Patients should tilt the head slightly forward,
insert the nasal adapter into one nostril, and
point the tip of the adapter toward the
inflamed nasal turbinates and away from
the nasal septum.
• Patients should pump the drug into one
nostril while holding the other nostril closed and
should concurrently inspire through the nose.
• Repeat for the other nostril.
• If sneezing occurs, patients should wait until
sneezing has stopped, then clear the nasal
passages and repeat administration of the

28. FLUTICASONE PROPIONATE
• Synthetic trifluorinated corticosteroid
• Used for the symptomatic treatment of intermittent or persistent allergic rhinitis.
• Administered by nasal inhalation using a metered-dose nasal spray pump.
• Intranasal fluticasone propionate (200 mcg daily given in 1 or 2 divided doses in adults
and adolescents) is effective in allergic rhinitis
• Children 6-11 years of age with allergic rhinitis, intranasal fluticasone propionate (100
mcg once or twice daily)
• 200 mcg of fluticasone propionate given once daily is as effective as 100 mcg of the
drug given twice daily.

29. MOMETASONE FUROATE
• NON FLUORINATED STEROID
• USEFUL IN PROPHYLAXIS AND TREATMENT OF ALLERGIC RHINITIS
• MAXIMUM BENEFIT USUALLY OCCURS WITHIN 1-2 WEEKS
• AS EFFECTIVE AS OTHER INTRANASAL CORTICOSTEROIDS (E.G.,
BECLOMETHASONE DIPROPIONATE, FLUTICASONE PROPIONATE) IN RELIEVING
MODERATE TO SEVERE NASAL SYMPTOMS, INCLUDING STUFFINESS,
RHINORRHEA, ITCHING, AND SNEEZING
• ADMINISTERED BY NASAL INHALATION USING A SPECIAL NASAL INHALER.
• PRIOR TO INITIAL USE OF THE INHALER, THE PUMP SHOULD BE PRIMED BY
ACTUATING 10 TIMES OR UNTIL A FINE SPRAY APPEARS.
• DOSAGE OF MOMETASONE FUROATE IN ADULTS AND CHILDREN 12 YEARS OF AGE
OR OLDER IS 100 MCG (2 SPRAYS) IN EACH NOSTRIL DAILY (TOTAL DAILY DOSAGE
OF 200 MCG).
• DOSAGE IN CHILDREN 2-11 YEARS OF AGE, 50 MCG (1 SPRAY) IN EACH NOSTRIL

30. CROMOLYN SODIUM (DISODIUM
CROMOGLYCATE)
• MAST CELL STABILIZER
• SAFE FOR YOUNGER CHILDREN
• NEEDS TO BE SPRAYED FOUR TIMES A DAY
• ALSO USEFUL IN BRONCHIAL ASTHMA

31. NASAL DECONGESTANTS
• Very short term topical decongestants are useful in reducing nasal obstruction
• Some degree of rebound congestion usually results.
• Prolonged use can cause rhinitis medicamentosa (tachyphylaxis and rebound
symptoms)
• Oxymetazoline drops/spray applied topically to relieve nasal congestion
• Sprays may be preferable to drops because of the lesser risk of swallowing the drug and
resultant systemic absorption.
• Drops should be applied to the dependent (lower) nostril, with the patient in a lateral,
head-low position. The patient should remain in the same position for 5 minutes
• 0.05% oxymetazoline hydrochloride nasal solution should be used only in adults and
children 6 years of age and older.
• 2 or 3 drops or sprays in each nostril every 10-12 hours
• Systemic decongestants are relatively ineffective, and may cause hypertension in adults,
hyperreactivity and insomnia in young children

32. IPRATROPIUM BROMIDE
• SYNTHETIC ANTOMUSCARINIC AGENT
• USED AS A 0.03% OR 0.06% NASAL SPRAY FOR THE SYMPTOMATIC RELIEF OF
RHINORRHEA
• ADVERSE ANTICHOLINERGIC EFFECTS MAY OCCUR IN OVERDOSE- INCREASED
INTRAOCULAR PRESSURE, MYDRIASIS, URINARY RETENTION, CHEST PAIN,
PALPITATION, DIZZINESS, HEADACHE

33. SYSTEMIC CORTICOSTEROIDS
• RARELY USED TO UNBLOCK THE NOSE AT THE START OF TREATMENT FOR
VERY SEVERE SYMPTOMS
• REGULAR USE ASSOCIATED WITH SERIOUS SIDE EFFECTS, AND NOT
RECOMMENDED

34. LEUKOTRIENE MODIFIERS
• MODEST IMPROVEMENT IN NASAL CONGESTION, NASAL ITCHING,
RHINORRHEA, NASAL PRURITUS, SNEEZING) COMPARED WITH PLACEBO.
• THERAPY WITH MONTELUKAST ALONE OR IN COMBINATION WITH LORATADINE
HAS BEEN ASSOCIATED WITH IMPROVED OCULAR MANIFESTATIONS, DAYTIME
NASAL SYMPTOMS, NIGHTTIME SYMPTOMS, QUALITY OF LIFE
• ZAFIRLUKAST ALSO PRODUCES REDUCED NASAL CONGESTION, SNEEZING,
AND RHINORRHEA COMPARED WITH THE PLACEBO GROUP.

35. IMMUNOTHERAPY
• Involves repeated administration of an allergen extract subcutaneously to induce
immunological tolderance with reduction in clinical symptoms and medication
requirement suring subsequent natural allergen exposure.
• Indicated in patients with patients with severe allergic rhinitis whose symptoms fail
to respond to conventional treatment.
• More useful in patients with a limited spectrum of allergies, esp in seasonal
hayfever, inability to avoid allergens.

36. • Mechanism appears to be modulation of T lymphocyte functions
• IgE sensitivity should be confirmed before starting.
• Reduction in risk of bronchial asthma, may prevent development of new
allergies
• Special protocols are available, which includes an updosing phase of weekly
injections for 8-16 weeks, followed by maintainence injections at 4-8 weekly
intervals for 3-5 years.
• Local reactions may occur
• Systemic reactions are rare, may lead to rhinitis and asthma, which responds
to treatment.
• Rarely anaphylaxis may occur.