More Related Content
Similar to Allergic Rhinitis.ppt
Similar to Allergic Rhinitis.ppt (20)
Recently uploaded
Recently uploaded (20)
Allergic Rhinitis.ppt
- 1. ALLERGIC RHINITIS Dr . Vaishnavi Sreeram
- 2. RHINITIS Clinical Definition : Having 2 or more symptoms of Anterior or Posterior Rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during 2 or more consecutive days for more than 1 hour on most days
- 3. CLASSIFICATION Allergic Infectious Non-allergic non-infective
- 6. OTHERS Occupational NARES Hormonal Drug induced Irritants Food GERD Ideopathic
- 7. ALLERGIC RHINITIS Rhinorrhoea, blocking, itching & sneezing as a result of Ig E mediated inflammation following exposure to an allergen. 10-25% population Male predominance Peak age – young adulthood
- 8. ALLERGIC RHINITIS Characterized by inflammatory changes in the nasal mucosa caused by exposure to inhaled allergens Diagnosed when the symptoms are caused by allergen exposure leading to an IgE mediated reaction
- 10. AETIOLOGY I. Genetics • Chromosome 5q- IL-4, IL-13 • Chromosome 11q, 13, 12q II. Family history • Allergic Rhinitis • Asthma
- 11. AETIOLOGY contd… III. Atopy Tendency to develop exaggerated IgE antibody response in response to one or more aero allergens Predispose to rhinitis, asthma, eczema AD Gene on 11q, 13 Maternal influence Allergen exposure to dispose to atopy
- 12. AETIOLOGY contd… IV. Allergens Foreign substances which are capable of provoking an IgE mediated response Proteins 5-20 micron size 10-40 k dalton molecular weight
- 13. Allergens - Intermittent rhinitis Symptoms in &around a particular season when pollen of a particular plant to which the patient is sensitive is present.
- 14. Allergens - Intermittent rhinitis Most common grass pollen Pollen count >50/m3 develop symptoms Pollen count maximum in evening & night More symptomatic
- 15. Intermittent… Other allergens Weeds – Rag weed,Nettle,Dock Trees-Western red cidar,ash,pine etc. Fungal spores- Aspergillus,Alternaria,Basidiospores etc.
- 16. Allergen-persistent rhinitis Most common cause- House dust mite Genus –Dermatophagoides Most common type-D.pterosynnus Optimal growth at 15-20°C & at a relative humidity of 60 – 70% Feed on human skin scales Digestive enzymes-cystiene proteases eg –Der p1- Excreted through mite faeces –dried up –become air borne
- 17. Allergen- persistent… Domestic pets-cats, dogs, rabbits.. Cat allergen Fel d1 Salivary protein Preened on to fur- dried up –air borne Remain in air for prolonged period
- 18. Allergen- persistent… Cockroach –a recently identified allergen
- 19. Occupational allergens Presence of work related symptoms with improvement during periods away from work place s/o Flour-bakers,grain workers Laboratory animals-guinea pigs,rats , mice-in lab workers Wood dust-saw mill workers Biological products enzymes Latex –surgeons,nurses etc. Chemicals –di iso cyanates ,polyamines
- 20. Food Induced rhinitis IgE mechanisms Sensitivity to food preservatives- sulphites,benzoates,tartrazine More common in children Triggers- milk,egg,cheese In adults-nuts,fish,shellfish,citrus fruits “Pseudo allergy” –histamine containing foods like cheese,wines,poorly kept fish Flushing, headache,rhinitis
- 21. Drug induced rhinitis Aspirin sensitivity –important cause With nasal polyp& Intrinsic asthma Other NSAIDS Anti hypertensives-propranolol ,other beta blockers,ACE Inhibitors
- 22. Rhinitis medicamentosa Rebound hyperemia,nasal congestion& obstruction with tachyphylaxis occurs following prolonged use of topical vasoconstrictors Not to use topical vasoconstrictors for >2weeks at a time
- 23. Air pollution More in developed countries Life style changes,dietary modifications, Diesel exhausts ,tobacco smoke, domestic spray Ozone Nasal hyper reactivity- sensitivity of nasal mucosa to non specific allergens Seen in ideopathic rhinitis Lower level of allergen provokes symptoms
- 24. PATHOGENESIS IG E Heat labile Mol. Wt-188000 2 heavy chains(epsilon) 2 light chains(kappa or lambda) Fc & Fab ends
- 26. Pathogenesis contd… Early phase
- 27. Pathogenesis contd.. (Early phase) Preformed mediators Histamine Heparin Chondroitin SO4 ECF-A NCF-A Newly generated mediators PAF PGD2 LT-B4, C4, D4 TX-A2 TNF
- 28. Pathogenesis contd.. (Early phase) Histamine : VD plasma exudation oedema Heparin : Enhance phagocytosis PGs <s : Vasoactive,bronchospastic PAF : Plt aggregation, histamine& serotonin release, chemotaxis of neutrophils & eosinophils TX A2 : Spasmogenic TNF : Transmigration of neutrophils, eosinophils
- 29. Late phase Starts by 6-12 hrs Lasts~24hrs Cellular inflammation is characteristic Ingress of eosinophils,basophils, mastcells, neutrophils etc. VCAM-1, ICAM-1, E selectin Recurrence of sneezing,rhinorrhoea, with congestion predominating.
- 30. Eosinophils Synthesis& release of Cytokines –IL-3,5 MIP-1 ,TGF PG-E1 ,PAF ROIs Histaminase Cellular permeability & mucous secretion
- 31. Endothelial cells Release chemotactic factors,adhesion molecules Increased expression of adhesion molecules in allergic rhinitis individuals
- 32. Epithelial cells Barrier & mucociliary clearance function Expression of inflammatory mediators & adhesion molecules More sensitive to air pollutants in allergic rhinitis
- 33. Systemic activation Upregulation of production & release of inflammatory cells from bone marrow Attracted to reaction site & other parts of respiratory tract ,produce inflammatory response
- 34. Ig E independent response By directly inducing cytokines& chemokines Eg . House dust mite By mast cell degranulation Eg morphine,codeine
- 35. CLINICAL FEATURES -SYMPTOMS Paroxysms of morning sneezing,nasal blockage,rhinorrhoea, Itching eye,palate,pharynx Stuffy nose& loss of smell due to mucosal oedema 20 symptoms- loss of taste, sinusitis,ET dysfunction
- 36. CLINICAL FEATURES- SIGNS Rhinoscopy Pale oedematous nasal turbinate with thin clear secretion
- 37. CLINICAL FEATURES -SIGNS Dripping nose wiped off by children with hand Thenar eminence rubbed against tip of nose with rest of hand stretched out “ALLERGIC SALUTE”
- 38. CLINICAL FEATURES -SIGNS Black line across dorsum of nose due to constant upward rubbing of nose Disappears when tip of nose pulled down TRANSVERSE NASAL CREASE “DARIERS LINE”
- 39. CLINICAL FEATURES -SIGNS ‘ALLERGIC SHINERS’ Dark areas under the eyes as a result of venous stasis in the lower orbito palpebral grooves
- 40. CLINICAL FEATURES –SIGNS spasm of mullers muscle venous return from skin & s/c tissue of lower eye lid oedema ‘Bags’ under eye Tearing, conjunctival injection, periorbital swelling
- 41. CLINICAL FEATURES –SIGNS ORAL CAVITY Over riding of maxillary incisors High arched palate Hypertrophied lymph node on posterior pharyngeal wall- ‘cobble stone’
- 42. CLINICAL FEATURES –SIGNS LARYNX Hoarseness of voice Oedema –vocal cord
- 43. COMPLICATIONS C/C Sinusitis Serous otitis media Sleep apnoea Dental& palatal abnormalities Nasal polyp formation
- 44. DIAGNOSIS History –personal history,family history, occupational& environmental exposure dietary &drug use Physical examination Blood-TC&DC eosinophilia Nasal smear Nasal secreation collected smeared on glass slide fixed with ethanol May grunwald/ Giemsa stain eosinophil count +ve if >25% cells are eosinophils
- 45. DIAGNOSIS- SKIN PRICK TEST In vivo test to demonstrate given allergen Principle :–Allergen introduced in skin cause degranulation of mast cell with mediator release wheal & flare. Method:- Drop of allergen extract on volar aspect of forearm, pricked in to skin Positive control-histamine Negative control - saline Wheal diameter at 15 minutes >2mm in below 5 yrs & > 3mm in adults
- 46. DIAGNOSIS- SKIN PRICK TEST +ve result > 2mm than –ve control C/I:- On anti histamines On high dose steroids H/o severe eczema H/o anaphylaxis
- 47. DIAGNOSIS - Patch test To determine delayed type hypersensitivity Allergen placed in skin for 48 hrs Local reaction Used in skin problems & food allergy
- 48. RAST RADIO ALLERGO SORBENT TEST In vitro test to detect specific Ig E conc. in patient’s serum Method:-
- 49. RAST Measurement of specific IgE in blood Usually reserved for patients who require a diagnosis but where SPTs are unavailable or inappropriate. A blood sample is taken and radio- or enzyme-labelled anti-IgE is added to the serum. A positive result is shown by an IgE level of 0.35 kU/l or greater. As for SPTs, a positive result may not necessarily be clinically relevant
- 50. ADVANTAGES Can detect picograms concentration of antibodies No risk of allergic reaction Results are not affected by antihistamines other drugs
- 51. PLASMA REACTIVE IMMUNO SORBENT TEST(PRIST) Total IgE in plasma measured FLUORO ALLERGO SORBENT ASSAY(FAST) Measures antigen specific antibodies MULTIPLE ALLERGEN SIMULTANEOUS TEST(MAST) Test several antigens for specific antibody simultaneously
- 52. SERIAL ENDPOINT TITRATION (SET) Diagnostic test to determine the amount of sensitivity to each inhalant allergen More useful in immunotherapy
- 53. DIAGNOSIS - Nasal allergen challenge Gold standard of allergy diagnosis Used in Positive history with negative SPT Prior to initiate immunotherapy if history is doubtful as in occupational allergy
- 54. Nasal allergen challenge Method :- Relevant allergen obtained without any irritants Diluent of allergen used as placebo An allergen is applied to the nasal mucosa, or the patient exposed to an airborne allergen. Applied in gradually increasing conc. Monitoring of both upper & lower respiratory symptoms
- 55. Nasal allergen challenge Reaction is compared with placebo Subjective:- Symptom scores, Visual analogue scale Objective:- Sneeze count, Nasal inspiratory peak flow, Rhinomanometry, Spirometry, pulmonary peak flow Collect nasal secretions:- Mediators, Cytokines, Cells
- 56. Nasal allergen challenge Disadvantages Time consuming Risk of inducing anaphylaxis Require extensive laboratory facilities Resuscitation equipment & trained staff necessary
- 57. Treatment Allergen Avoidance& Environmental control Pharmacotherapy Immunotherapy Surgical treatment
- 58. Allregen Avoidance & Environmental control PRIMARY PREVENTION Avoid smoking during pregnancy Promote breast feeding for atleast first 3 months after birth Reducing exposure to house dust mite
- 59. SECONDARY PREVENTION Avoidance of allergens House dust mite control measures Wash bedding regularly (every 1–2 weeks) at 55– 60°C to kill mites Wash pillows and duvets in hot water (55–60°C) Encase pillows and mattresses with protective coverings that have a pore size of 6µm or less Sufficient ventilation of dwellings to decrease humidity
- 60. Use a damp duster when dusting and cleaning surfaces Use a good quality vacuum cleaner (if possible, one fitted with a HEPA filter) Remove/reduce curtains and soft furnishings in the bedroom Replace fabric-covered seating with leather or vinyl Remove soft toys from the bedroom; wash them at 55– 60°C or freeze them (in a kitchen deep-freezer) to kill house dust mites Exposure of mattresses, rugs and carpets to direct strong sunlight (for >3 hours) kills mites
- 61. Pollen Avoidance measures : Keep windows closed at peak pollen times Wear glasses or sunglasses to help prevent pollens entering the eyes Consider wearing a mask over nose and mouth to prevent inhalation of pollens at peak time Use air-conditioning where possible Install car pollen filters where possible
- 62. Pet Allergen avoidance measures : If possible, find another home for the pet and do not introduce new animals into the home. If the pet is not removed from the home then: ❍ Exclude pets from bedrooms and if possible keep pets outdoors ❍ Vacuum carpets, mattresses and upholstery regularly ❍ Change clothes before going to school or work if you have had contact with any animal (e.g. horse/ cat/dog).
- 63. Cockroach allergen avoidance: Eradicate cockroaches with appropriate insecticidal bait Seal cracks in floors and ceilings Enclose all food Do not store waste in the home Scrub floors with water and detergent to remove allergens.
- 64. Mould allergen avoidance: Use dehumidifiers in the home if relative humidity is consistently high (above 50%) Ensure heating, ventilation or air-conditioning systems are properly maintained Use 5% ammonia solution to remove mould from bathrooms and other contaminated surfaces Replace carpets with hard flooring and replace wallpaper with paint Repair indoor water damage immediately.
- 65. TREATMENT The most widely used and effective medications to treat allergic rhinitis are oral or topical antihistamines and topical nasal steroids. These medications aim to achieve improved symptom control and are not a cure for allergy. Symptom control is better for patients with intermittent allergic rhinitis if they start treatment prior to exposure to the allergen to which they are sensitized. The basic summary of recommendations for treatment is according to the ARIA guidelines
- 67. Antihistamines First-line treatment for symptoms of runny nose, sneezing and nasal and eye itching Little effect on nasal blockage Rapid onset of action (usually less than an hour) Symptom reduction on a once daily dosing Better symptomatic control when used regularly rather than on an as required basis.
- 68. Antihistamines First generation:- Cross BBB & interact with central histamine receptor Sedation, psychomotor retardation, learning impairment Chlorpheniramine: 4mg tid/qid Diphenhydramine:25-50mg tid/qid, Hydroxyzine :10-25mg tid/qid
- 69. Antihistamines Second generation:- Terfinadine - Rapid onset(1-2hrs) & moderate duration(12-24hrs) of action 60 mg BD S/E - QT Prolongation ECG Ventricular arrhythmias in impaired liver function test & with Ketoconazole, Erythromycin etc.
- 70. Antihistamines Second generation Astemizole :- Slow onset(2-4hrs) & long duration(2-5days) of action Dose 10 mg OD D/A – Long t1/2 stop ~6 weeks before SPT Increased appetite, weight gain D/I with Terfinadine- VT
- 71. Antihistamines Second generation Loratidine Dose 10 mg O D Rapid onset of action No cardiac S/E No interaction with macrolides, antifungals
- 72. Antihistamines Second generation Cetrizine Dose 10 mg OD/BID MOA Anti histaminic effect Inhibit release of mediators from platelets Inhibit eosinophil chemotaxis Disadvantage : Sedation at higher doses
- 73. Antihistamines Second generation Azelastine Topical – as nasal spray Adult dose –2puffs/nostril D/A –stinging in nose, altered taste perception
- 74. Antihistamines Second generation Fexofenadine Dose - 60mg BD Mizolastine Clemastine Luvistine
- 75. Topical Corticosteroids Extremely effective in controlling nasal symptoms, eye symptoms, reduce inflammation& hyper reactivity, improve sense of smell Intra-nasal application allows a high concentration of the active drug to be delivered to the nasal mucosa with minimal systemic absorption. Onset of action is slow - some improvement after 6~12hrs. Can take 2 weeks for full benefit to be noticed Dexamethasone(.01%), Budesonide(100mcg/dose) fluticasone(.05%), Triamcinalone(.1%), Mometasone(.1%) Lowest bioavailability with fluticasone & mometasone
- 76. Topical corticosteroids SideEffects : Nasal irritation Slight bleeding Candida super infection Septal perforation
- 77. Oral steroids Short courses are effective for Severe peak pollen seasonal symptoms When complete nasal blockage prevent penetration of steroid nasal spray Eg: Prednesolone 20-40 mg/day
- 78. Decongestants Oral Pseudoephedrine ,Phenylpropanolamine MOA- Vasoconstriction, Reduced nasal congestion & oedema CNS stimulation –counteract drowsiness of anti histamines
- 79. Decongestants Topical Phenylephrine, Xylometazoline (0.1%), Oxymetazoline (0.05%) Dose : 2-3 drops in each nostril 8-12 hrly D/A Continued use cause rebound congestion
- 80. Topical anticholinergics Ipratropium bromide (0.03%) Dose : 2 puffs/nostril BD or TID Indication : Excessive watery rhinorrhoea S/E : Excess use cause nasal drying and crusting
- 81. Mast cell stabilisers Sodium chromoglycate Effective for prophylaxis of allergic rhinitis Dose : 2% solution, one spray into each nostril 4-6 times a day before the onset of symptoms Safe, non-toxic Drug of choice in children
- 82. Leukotriene Inhibitors Montelukast Dose : 10mg O D Zafirlukast Zileuton Combined use of cetirizine and montelukast was shown not to improve symptom control above each drug individually in one study; but to be more effective when combined in another.
- 83. Immuno Therapy First systemic desensitisation – Noon of London (1911) Method of inducing tolerance to an allergen and therefore reducing unwanted symptoms. Can reduce the symptoms of allergic rhinitis, offer long- lasting reduction of symptoms (even when treatment has stopped) and can prevent the progression of allergic disease.
- 84. Immuno Therapy… Indications : IgE mediated disease (+ve SPT/RAST) Inability to avoid allergen Inadequacy of drug treatment Limited spectrum of allergens Patients who understood risk & limitations of treatment
- 85. Immuno Therapy… Contraindications Coexistent asthma Patients taking beta-blockers Medical/Immunological diseases Children below 5 years Pregnancy
- 86. Immuno Therapy… Efficacy 50% reduction in symptoms & 80% reduction in rescue medication requirement Reduction in bronchial hyper responsiveness
- 87. Immuno Therapy… Method : 2 phases Updosing phase : weekly injections of small doses of allergen subcutaneously for 8-16 weeks Maintenance phase : Injections at 4-8 weeks intervals for 3-5 years
- 88. Immuno Therapy… Side effects : Local reactions Trivial,require no treatment Systemic reaction In 10% of people Occur within 30 minutes In updosing phase Mild – rhinitis or asthma, respond to anti histamines or inhaled broncho dilators Severe – general urticaria, asthma, anaphylaxis
- 89. Immuno Therapy… Mechanism Blunting of seasonal increase in allergen specific IgE Increase in blocking IgG antibodies Induce shift from Th 2 type immune response to Th 1 type response Inhibition of recruitment & activation of inflammatory cells to mucosal surface
- 90. Immuno Therapy Novel strategies: Sub lingual route: Allergen as drops or tab. S/L Moderate efficacy compared to S/C route Conjugated to adjuvant: Bacterial DNA sequence Induce Th1 type response
- 91. ANTI-IgE ANTIBODY (OMALIZUMAB) Binds to circulating IgE preventing it from binding to mast cells and causing degranulation. Omalizumab reduces all nasal symptoms and improves asthma control, but has the risk of causing anaphylaxis and is expensive. Administered by monthly injection. Currently it is recommended only for patients with severe allergic asthma with or without rhinitis symptoms.
- 92. Surgical treatment Surgery cannot cure allergy but can give relief of nasal blockage if other methods fail. Septal deviation Septoplasty/SMR Hypertrophied turbinate Turbinate reduction: SMD, cryosurgery, Laser cautery Turbinate resection: Partial excision, Submucosal turbinectomy, Radical turbinectomy Excessive rhinorrhoea: Vidian neurectomy
- 93. Thank You