Allergic Rhinitis

James Gardner

Children’s Allergy Nurse Consultant

Great North Children’s Hospital, Newcastle

Associate Clinical Lecturer, Newcastle University

Allergic Rhinitis

• Prevalance / Impact

• Diagnosis

• Treatment

• When treatment fails..

Prevelence of AR

• Roughly 7.8% of people 18 and over in the U.S. have hay fever.1

• Worldwide, allergic rhinitis affects between 10% and 30 % of the

population.2

• Worldwide, sensitization (IgE antibodies) to foreign proteins in the

environment is present in up to 40% of the population.2

• In 2012, 7.5% or 17.6 million adults were diagnosed with hay fever

in the past 12 months.3

• In 2012, 9.0% or 6.6 million children reported hay fever in the past

12 months.4

• In 2010, 11.1 million visits to physician offices resulted with a

primary diagnosis of allergic rhinitis.5

1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2010. By Jeannine S. Schiller, M.P.H., Jacqueline W. Lucas, M.P.H., Brian W. Ward,

PhD and Jennifer A. Peregory, M.P.H., Division of Health Interview Statistics.

2. World Health Organization. White Book on Allergy 2011-2012 Executive Summary. By Prof. Ruby Pawankar, MD, PhD, Prof. Giorgio Walkter Canonica, MD, Prof.

Stephen T. Holgate, BSc, MD, DSc, FMed Sci and Prof. Richard F. Lockey, MD.

3. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012, table 3, 4.

4. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012, table 2.

5. National Ambulatory Medical Care Survey: 2010 Summary Tables, table 13.

Allergic Rhinitis and Impact on

Quality of Life and Work• In USA

2 million school days lost per year

4 million work days lost per year

28 million impaired work days

• In UK

Performance in school exams in 15-16 yr

olds worsened

0

200

400

600

800

1000

1200

1400

1600

Po

lle

n c

ou

nt/

m3

29th

Apri

l -

5th

May

6th

May -

12th

May

13th

May -

19th

May

20th

May -

26th

May

27th

May -

2nd J

une

3rd

June -

9th

June

10th

June -

16th

June

17th

June -

23rd

June

24th

June -

30th

June

1st

July

- 7

th J

uly

8th

July

- 1

4th

July

15th

July

- 2

1st

July

22nd J

uly

- 2

8th

July

S1

English

Maths

Science

Grass pollen counts 2003

Walker et al: JACI 2007;120:(2) 381-7

Most Patients with Asthma Have Allergic Rhinitis

• Approximately 80% of asthmatics have

allergic rhinitis

Adapted from The Workshop Expert Panel. Management of Allergic Rhinitis and its Impact on Asthma (ARIA) Pocket

Guide. A Pocket Guide for Physicians and Nurses. 2001; Bousquet J and the ARIA Workshop Group J Allergy Clin

Immunol 2001;108(5):S147-S334; Sibbald B, Rink E Thorax 1991;46:895-901; Leynaert B et al Am J Respir Crit

Care Med 2000;162:1391-1396.

Asthmaalone

Allergic rhinitisalone

Allergicrhinitis

+ asthma

Childhood allergic rhinitis increases the risk of developing asthma

Burgess JA et al. J ACI 2007;120:863-9

0

1

2

3

4

5

6

7

Adult lifeAdolescencePreadolescence

Hazard

Rati

o

Incre

ased

asth

ma r

isk

2.19

4.34

7.12All p< 0.001 vs. no

childhood AR

Childhood allergic rhinitis has been associated with a significant 2-7

fold increase in the incidence of asthma in later life

Asthma

OME

Rhinosinusitis

The United Airway

Allergic signs

Denny Morgan lines

Allergic shiner

Nasal crease

Allergic

salute

Allergic

crease

Defining Allergic Rhinitis

Moderate-severe one or more items

Abnormal sleep.

Impairment of daily activities, sport, leisure.

Problems caused at school or work.

Troublesome symptoms.

Intermittent symptoms

< 4 days per week

Or < 4 weeks

Intermittent symptoms

< 4 days per week

Or < 4 weeks

Mild

Normal sleep.

Normal daily activities.

Normal work and school.

No troublesome symptoms.

Persistent symptoms

> 4 days per week and > 4 weeks

Persistent symptoms

> 4 days per week and > 4 weeks

History

Examination

Skin-prick tests/RAST +/-Others

Allergy(seasonal, perennial,

or occupational)

Infection(acute or

chronic)

Structural(polyps, septum,

turbinates, etc)

Other(idiopathic, NARES,

hormonal, drugs, etc)

Allergic Rhinitis Differential

DiagnosisRhinitis

Immunodeficiency

PCD

Cystic fibrosis

Choanal atresia

Foreign body

Hypothyroidism

Menstrual cycle

Oral contraceptive

Courtesy of S.Durham

Differential Diagnosis

Guidelines

Treatment Approach

0

1

2

3

4

5

6

7

8

9

10Guidelines group

Free-choice treatment group

Days 1-7 Days 8-14 Days 15-21 Days 1-21

Modified from Bousquet et al Allergy 2003: 58:733-741

P=0.0001

P=0.0001P=0.0001

P=0.0001

SAR control in relation to therapeutic scheme based on International Guidelines

HCPs Awareness of

Guidelines

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ENT Allergist Paediatrician GP NP

74%

88%

44%

53%60%

Modified from Meltzer E et al: JACI 2009; 124:S43-70

HCPs awareness of professional guidelines for the management of AR

- Bousquet J et al JACI 2001 Nov;108(5 Suppl):S147-334. - Bousquet J et al Allergy 2008: 63 (Suppl. 86): 8–160- Brozek JL et al JACI 2010 Sep;126(3):466-76.

- Scadding G et al CEA, 2008 38, 19–42

bsaciImproving allergy care

Guidelines for Allergic Rhinitis

Roberts G et al Allergy. 2013 Sep;68(9):1102-16

mildintermittent

mildpersistentmoderate

severeintermittent

moderatesevere

persistent

allergen and irritant avoidance

immunotherapy

intra-nasal decongestant (<10 days) or oral decongestant

local cromone

intra-nasal steroid

oral or local non-sedative H1-blocker

Treatment of allergic rhinitis (ARIA)

Allergic rhinitis and its impact on asthma

www.whiar.org

2001

Paediatric Rhinitis Proposed Therapeutic Approach

Roberts G et al Allergy. 2013 Sep;68(9):1102-16

H1Oral or topical NON SED Regular oral NON SED

Intermittent symptoms Persistent symptoms

Rx failure Rx failure

Diagnosis by history ± SPT/RAST

Allergen + irritant avoidance ± douching

Still symptomatic

Check use / concordance

increase dose +/or OC

INTRANASAL STEROIDS (INS)

Surgical referral

Review dose/ compliance

Consider allergy referral -

IMMUNOTHERAPY for SAR

? Infection / structural problem

Rx failure

Rx failure

Rx failure

Add (briefly)

decongestant / OC or (longer

term) LTRA / desloratadine /

levocetirizine

Rx failure

Itch/sneeze

+non sed α H1Rhinorrhoea

+Ipratropium / LTRACatarrh +LTRA Blockage

H1

Treatment of Allergic RhinitisBSACI Guidelines

Treatment-Level of Evidence

Seasonal

Rhinitis

Perennial

Rhinitis

Adult Children Adult Children Persistent

Rhinitis

Oral anti-H1 A A A A A

Intranasal anti-H1 A A A A B*

Intranasal

corticosteroids

A A A A B*

Intranasal cromones A*** A*** A*** A***

Anti-leukotrienes A A B**

Anti-IgE mab A A A A B*

Bousquet et al Allergy 2006 :61:1086-96

*** study conducted with small number of patients

Treatment Satisfaction in

Children

A: Reasons for requesting a

Change in PrescriptionB: Reason for dissatisfaction

with prescription

Meltzer E et al: JACI 2009; 124:S43-70

(4-17 years)

Compliance and Education

• Easy to use device

• Minimal Sensory

Disturbance

• Once daily dosing

• Education

- Device Technique

- Safety of Drug

- Warning of Possible Side

Effect

Newer INS: Low bioavailability

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

11%

% B

ioavaila

bili

ty

44%

0.5%0.1% 0.5%

Nasonex: Summary of Product Characteristics. Data Accessed April 2011

Kariyawasm H and Scadding GK Journal of Asthma and Allergy 2010:3 19-28

Rhinocort: Summary of Product Characteristics. Data Accessed April 2011

Beconase: Summary of Product Characteristics. Data Accessed April 2011

Mometasone

Fluorate

Fluticasone

Fluorate

Fluticasone

Proprionate

Budesonide Beclometasone

Diproprionate

Combination therapy

• A new formulation (Azelastine/FP) has shown superiority when compared to each single drug and placebo.

• These findings have been consistent in:

- 3 separate trials in patients with SAR

- 1 trial in patients with PAR

• These studies have included children ≥12

• Studies in younger children need to be performed with one on-going in 4-11 year old.

Carr W et al; JACI 2012:129(5)

Anti-LRAs Receptor for the treatment of AR

with Co-morbid asthma in Grass Pollen allergic

children.N: 32 SAR (Grass pollen) (age 8-12)

Individual and median decrease in FEF 25-75

measures during the grass pollen season

compared with pre-season in

loratadine/montelukast and loratadine only

groups

Individual and median asthma symptom scores

in loratadine/montelukast and loratadine only

groups

Keskin O et al; PAI 2006 :17

The addition of A-LTRA provided benefit in controlling lower airway symptoms

preventing the seasonal decrease in LF parameters

Nasal Irrigation as adjuvant

treatment in AR

Garavello W et al; PAI 2003:14

Hermelingmeier K et al; Am J Rhinol Allergy 2012:26(5)

Three-times daily nasal irrigation with hypertonic saline in

children (aged 6-12) with seasonal allergic rhinitis

significantly reduces Total Rhinitis Symptoms Score and a

reduction the amount of rescue anti-H1 in the treatment

group.

Nasal Irrigation improves: Symptoms, RQLQ & MCT

Paediatric Rhinitis Proposed Therapeutic Approach

Roberts G et al Allergy. 2013 Sep;68(9):1102-16

Indication for Immunotherapy

• At least 1 year history of AR +/- Asthma

• Evidence of sensitisation

• Evidence for clinical relevance of disease related allergen

• Availability of standardised allergen extract

Bufe A and Roberts G CEA 2011;41:1256-62

Benefits of Immunotherapy

• Able to induced Immune-tolerance

• Sustained prevention of symptoms

• Able to modify disease progression

- Prevention of new sensitization

- Asthma prevention

What’s Available?

Two Routes of Administration

- Used in 75% of children - Potential Severe Side effects- Administration by Specialist- Contraindicated in Asthmatic

- Used in 25% of children- Home Therapy (only 1st Dose Supervised)- Can be used in asthmatic

SCITSLIT

• 51 DB PC RC studies were included (1950-2006)

• Patients with SAR due to grass, tree or weed pollen

• Participants: n=2,871 (1,645 active; 1,226 placebo)

• Adults

Calderon M et al. Cochrane Database Syst

Rev. 2007 (1): CD001936

SCIT for Seasonal Allergic RhinitisSystematic Review and Meta-analysis

Symptom scores

Cochrane Database Syst Rev 2007; (1):CD001936.

Medication scores

Cochrane Database Syst Rev 2007; (1):CD001936.

Subcutaneous immunotherapy in seasonal allergic rhinitis: Cochrane Review

• Significant improvement in rhinitis symptom scores

• Significant reduction in rhinitis medication scores

• Increases in serum allergen-specific IgG4 concentrations

• Only adult studies

Calderon M et al. Cochrane Database Syst Rev. 2007 (1): CD001936

Sublingual

Immunotherapy

for allergic rhinitis

(Review)

Radulovic S,

Calderon M, Wilson

D, Durham S

Comparison SLIT versus Placebo – Children: Outcome: Symptoms Score

Cochrane Database Syst Rev 2010, Dec 8(12): CD002893

15 Studies

Passalacqua G. Ann AllergyAsthma Immunol.2011;107:401– 406.

Ongoing Efficacy of Treatment

IT cost effective in asthmatic patients with pollen & HDM allergy

• Cost of Immunotherapy (IT) vs Conventional Therapy (CT) at 1, 7 &

10 years

time

CT

IT

CT IT

CT

IT

years1

7 years

10

Schadlich PK, Brecht JG. Economic evaluation of specific immunotherapy versus symptomatic treatment of allergic rhinitis in Germany. Pharmacoeconomics17(1),37-52 (2000).

Immunotherapy clinic

Case Studies

Case Study

• Yasmin age 4 year old

• 12 month history of bad smell from nose

and recurrent otitis media

• 1 appointments in ENT, 2 General

Paediatric appt

• 1 course of betnesol drops

• Several courses of oral antibiotic

• Regular nasal steroid

Case Study

• Diagnosis

Case Study

• Management

1. Removal by ENT Surgeon from nostril

2. Naseptin bd for 7 days to clear localised

infection

3. Discharged!

Case Study

• Mohammad age 12

• Referral for severe uncontrolled Asthma

Seretide 250mcg bd

Montelukast 5mg

8 courses of Prednisolone in 12months,

4 A&E admissions

Outpatient Appointment

• ? Compliance

• ? Intensive support

• ???

Investigations

• Spirometry

FVC 70%

FEV1 69%

39% reversability

FeNO Chest 20

Nasal NO Left 210 Rt 290

Investigations

• Skin Prick Testing

- House Dust Mite 18mm

- Grass Pollen 11mm

- Sliver Birch 6mm

- Cat 2mm

Investigations

• NIPF 70 / 60 / 60

• Examination

Nose

- swollen / pale turbinates

(complains has itchy nose and hayfever in the summer)

Treatment Given

• Asthma medication – same

• Flixonase Nasules (1 month)

• Followed by Avamys daily

• Daily antihistamine

Outpatient Review (6months later)

• No exacerbations of asthma

• Lung Function – normal

• FeNO Chest 8

Nasal NO Left 509 Rt 710

Subsequent Appointments

• Step down in Asthma medication

• Currently well controlled on:

- Regular rhinitis treatment

- Beclomethasone 100mcg bd

- Montelukast (when unwell)

- Infrequent salbutamol use.

Any Questions?

James Gardner

Children’s Allergy Nurse Consultant

jgardner@nhs.net

0191 282 1712

@allergynurseuk