powerpoint presentationentlectures.com/resources/powerpoint pr… · ppt file · web view ·...
TRANSCRIPT
Allergic Rhinitis
Dr. Dinesh Kumar, Assistant Professor, ENT, GMC Amritsar
DefinitionAllergic rhinitis is clinically defined as a symptomaticdisorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose
Natural History
Onset is common in childhood, adolescence and early childhood .
Symptoms often wane in older adults, but may develop or persist at any age
Natural HistoryNo apparent gender selectivity or predisposition to developing AR
May contribute to a number of other conditions
Allergic rhinitis Inflammatory disorder of nasal mucosa,
characterized by pruritus, sneezing, rhinorrhoea and nasal congestion.
Adversely affects social life, school performance, and work productivity; especially in patients with severe disease
Loss of productivity, missed school and work days, and direct costs associated with treatment create substantial costs to society.
Lancet 2011; 378: 2112–22
An Allergic Reaction
Inflammatory Cells
Dendritic Cells
T- Cells
B-Lymphocyt
es
Mast Cells
Eosinophils
Moncytes &
Macrophages
Histamine Chemokines
Cytokines
Chemical Mediator
s
Leukotrines Prostaglandins
The Allergic reactionSensitization
Ig E Production
Arming of mast cells
Release of mediators
Clinical effects
Inflammatory cascade in allergic rhinitis
Adapted from Indian J Chest Dis Allied Sci. 2003 Jul-Sep;45(3):179-89
How are the symptoms causedItchingSneezing
Increased mucus production Rhinorrhea
Vasodilation CongestionIncreased vascular permeability Oedema
Irritation of free nerve endingsnerve endings
Classical Symptoms
Repetitive
Sneezing
Nasal Congesti
on
Watery Rhinorrh
eaNasal
Pruritus
Other ManifestationsEye Symptoms
Ear Symptoms
Post nasal drip
AR
Intermittent
Persistent
Mild
Moderate to Severe
Classification
Intermittent
< 4 days/week< 4 weeks
Persistent
> 4 days /week> 4 weeks
Mild
Normal sleep
No impairment of daily activit
No troublesome Symptoms in untreated patients
Moderate to Severe
Abnormal Sleep
Impairement of daily activity
Abnormal work
Troublesome Symptoms
Risk Factors for Allergic Disease
Family History
Season of Birth
Male Gender during
ChildhoodIncrease in pollution
Dietary Changes Obesity
Allergic Shiners
Allergic Salute and Crease
Allergic Conjuctivitis
AR & Co-morbiditiesOtitis Media
URTI
Sinusitis
Nasal Polyps
Asthma
Allergic rhinitis and diseases of the upper airway
Key factors important to normal PNS function
Patency of ostia
Function of ciliary apparatusQuality of secretions
AR and AsthmaApprox. 80% of patientswith asthma haveaccompanying symptomsof rhinitis, and up to 60%of the patients with asthmahave sinusitis
Possible Mechanisms by which RhinitisCould Provoke a Worsening of Asthma
Possible mechanism AR could provoke worsening of Asthma
Nasobronchial refex
Nasal Obstruction
PND
Management of Allergic Rhinitis•Allergen Avoidance
•Pharmacotherapy
•Surgery• Immunotherapy
First Generation AntihistaminesRapid onset of actionShort half lifeSignificant relief from rhinorrhoea
Easily cross blood brain barrier
Side Effects
Second Generation AHImprove selectivityHepatic and Cardiovascular side effects of terfanadine and astemizole
Non sedatingDemonstrated efficacy for AR symptoms
Wide Therapeutic Window of Second Generation AntihistaminesThe second generation H1-antihistamines have a rapid onset of action with persistence of clinical effects for at least 24 hours, so these drugs can be administered once a day.
They do not lead to the development of tachyphylaxis and show a wide therapeutic window (e.g. fexofenadine)
Significance of wide therapeutic window (fexofenadine)
Low H1-antihistamine dose High
Ineffective Therapeutic Window Not tested for adverse effects
Maximum Studied dose
(Fexo 1380 mg)
Minimallyeffective dose(Fexo 60 mg)
Howarth PH. Advanced Studies in Medicine. 2004;4(7A):S508-512
Third Generation AHMinimal side effectsIncreased duration of action
Positive effect on nasal airflow
Reduction in nasal congestion
Effects of leukotrienes on airways Increased levels in nasal fluid after
allergen challenge Contribute to both early and late
phase Nasal congestion Sneezing, rhinorrhea Chemoattractant for eosinophils Promote eosinophil adhesion Decrease eosinophil apoptosis
Leukotrine Inhibitors: Competitively block binding of leukotrines
to end organs. Montelukast is only FDA approved
Leukotrine inhibitor Montelukast reduces exhaled Nitric oxide,
a marker for airway inflammation Montelukast works through LC C4 and D$
which are found in upper airway Because Montelukast acts throughout the
airway this agent is a good choice for those with concurrent Asthma and AR
Rationale for antihistamine-montelukast combination in AR Histamine
Responsible for rhinorrhea, nasal itching and sneezing
Less evident effect on nasal congestion
Leukotrienes Increase in nasal airway resistance
and vascular permeabilityBlockage or inhibition of these two mediators may provide additional benefits compared to single mediator inhibition
Intra-nasal SteroidsWork mostly locally, thus avoid unwanted side effects associated with their oral or I/V use
• Newer formulations show even lower systemic absorption
• Most effective against late-phase mediators with some effect on acute phase response.
Intra-nasal SteroidsShould be used in a chronic manner
Higher dose results in greater benefit
Judicious use in children and pregnant women recommended
Large paed studies have not shown significant adverse effects
Intra-nasal Steroids First line drug in seasonal AR However for perennial AR
management with I/N steroids alone has not proved to be as beneficial
Depending upon severity of disease short courses of oral steroids in addition to topical symptomatic relief more
Fewer side effects (IOP)
Drug and Symptom MatrixDrugs and Symptoms Sneezing Itching Rhinorrhea CongestionAntihistamines ***** **** ***Anticholinergics (Ipratropium bromide) *****Corticosteroids ***** ***** *** ***Decongestants *****Mast Cell Stabilisers ***** *** *Antileukotrines *** ** ****
Algorithm for management of ARAllergic Rhinitis
Intermittent Symptoms Persistent Symptoms
Mild Moderate/Severe
MildModerate/Severe
• Oral H1 Blocker• Intranasal H1
Blocker• Leukotrine
modifier
• Intranasal Steroid• Oral H1 Blocker• Intranasal H1
Blocker• Nasal Cromone• Leukotrine modifier
In PAR Pt. FU after 2-4 wks.
If failure step up, if improved continue for one month
Intranasal Steroid
Follow up after 2 wks.
Improved
Failed
Step down
Review DxCompliance
Intranasal Steroid
Itch/sneeze add H1 Blocker
Rhinorrhea add Ipratropium Blockage: add oral
decongestant/steroid short term
ImmunotherapyInvolves the sequential administration of antigen to patients with symptomatic, atopic conditions to induce tolerance to offending antigens
Effective in treatment of both AR & Asthma
Generally safe and well tolerated
ImmunotherapyInjectable: Popular in US
Sublingual: Popular in Europe
Intranasal: Under investigation
Selections of candidates for ITSymptoms induced by allergen exposure
Patients with rhinitis and symptoms from lower airway during peak allergen exposure
Insufficient control of symptoms with AH and/or topical steroids
Summary… Allergic rhinitis is associated with several
co-morbidities and affects quality of life and productivity
Second generation antihistamines are recommended for treatment of allergic rhinitis in adults and children; fexofenadine has proven efficacy, is devoid of sedation and has wide therapeutic window
Leukotrienes play key role in allergic rhinitis; montelukast is most throroughly tested leukotriene antagonist
Summary
Antihistamine-montelukast combination seems to be a more effective strategy than monotherapy in the treatment of allergic rhinitis in patients with moderate to severe symptoms
Fexofenadine-montelukast combination yields significant reduction in nasal congestion and nasal resistance in allergic rhinitis vs. fexofenadine
Drug and Symptom MatrixDrugs and Symptoms Sneezing Itching Rhinorrhea CongestionAntihistamines ***** **** ***Anticholinergics (Ipratropium bromide) *****Corticosteroids ***** ***** *** ***Decongestants *****Mast Cell Stabilisers ***** *** *Antileukotrines *** ** ****
Place in therapy for antihistamine-montelukast combination
Allergic rhinitis with nasal congestion
Allergic rhinitis with moderate-to-severe symptoms
Blessings from the Holy City…….
A very cordial invitation to all of you to the 5th
AOIPBCON being organized
at M K Hotel Amritsar
on 13th and 14th April 2013.
Guest Faculty
Dr. Renuka Bradoo
Dr. Ashok Gupta
Dr. Vikas Kakkar
Dr. Anil Monga
Dr. K K Handa
Thankyou !!!!!!