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An Update on Allergic Rhinitis Mike Levin Division of Asthma and Allergy Department of Paediatrics University of Cape Town Red Cross Hospital
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An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Jun 22, 2020

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Page 1: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

An Update on Allergic Rhinitis

Mike Levin

Division of Asthma and Allergy

Department of Paediatrics

University of Cape Town

Red Cross Hospital

Page 2: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergic Rhinitis

Common condition with increasing prevalence

Affects 10-40% of the population

Significant reduction in quality of life

Decreased work & school attendance of 3 – 4%

Reduced work & school efficiency of 30 – 40 %

Page 3: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Core symptoms

Running nose

Itchy nose

Sneezing

Postnasal drip

Mannerisms

Allergic salute

Rabbit face

Noises

Tongue thrusting

Page 4: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Core symptoms

Running nose

Itchy nose

Sneezing

Nasal obstruction

Postnasal drip

Commonest problem

Nasal congestion

Affects sleep

Effects sleep 76.6%

Every night 37.2.%

Feel miserable 85.2%

Allergic Rhinitis Care

Programme in South Africa

Page 5: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

• Underestimated by patients and doctors

• Poor levels of satisfaction

• No single definition of disease control

Page 6: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Core symptoms

Nasal obstruction

Running nose

Itchy nose

Sneezing

Postnasal drip

Mannerisms

Mouth breathing

Allergic salute

Rabbit face

Noises

Tongue thrusting

Page 7: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergic Rhinitis

Intermittent

• 4 days per week

• or 4 weeks

Persistent

• > 4 days per week

• and > 4 weeks

Page 8: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergic Rhinitis

Mild

• Normal sleep and

• No impairment of daily

activities, sport, leisure and

• Normal work and school and

• No troublesome symptoms

Moderate - Severe

One or more items:

• Abnormal sleep

• Impairment of daily activities,

sport, leisure

• Abnormal work and school

• Troublesome symptoms

Page 9: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergic Rhinitis

Intermittent

• 4 days per week

• or 4 weeks

Mild

• Normal sleep and

• No impairment of daily

activities, sport, leisure and

• Normal work and school and

• No troublesome symptoms

Moderate - Severe

One or more items:

• Abnormal sleep

• Impairment of daily activities,

sport, leisure

• Abnormal work and school

• Troublesome symptoms

Page 10: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergic Rhinitis

Persistent

• > 4 days per week

• and > 4 weeks

Mild

• Normal sleep and

• No impairment of daily

activities, sport, leisure and

• Normal work and school and

• No troublesome symptoms

Moderate - Severe

One or more items:

• Abnormal sleep

• Impairment of daily activities,

sport, leisure

• Abnormal work and school

• Troublesome symptoms

Page 11: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Environmental

Control Measures Education

Pharmacotherapy Allergen

Immunotherapy

Management of allergic rhinitis

Page 12: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Environmental control

• All patients should have sensitisations tested

• Avoidance alone will not be successful

• Avoidance is challenging!

• Select patients for avoidance on basis of

disease severity and sensitisation patterns

Page 13: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Allergy testing

Page 14: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Education

• Patient expectations important

– Effects symptom reporting

– Effects adherence to treatment

– … need to teach patients to recognise symptoms

• Pathophysiology important to foster adherence

• Technique

Page 15: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Technique is critical

Page 16: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Step-wise therapy of rhinitis

Step 1

Step 2

Step 3

Oral/nasal

antihistamines

or nasal

cromones

Nasal steroids in

recommended

dose

Consider

immunotherapy

Page 17: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

mild intermittent

mild persistent

moderate severe

intermittent

moderate severe

persistent

avoidance of allergens, irritant and pollutants

immunotherapy

intranasal decongestant (<10 days) or oral decongestant

intranasal steroid

oral or local nonsedative H1-blocker

Modified from Bousquet J et al. J Allergy Clin Immunol. 2001;108:S147.

leukotriene receptor antagonists

Page 18: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Pharmacotherapy

• Intranasal corticosteroids

• Antihistamines

• Cromones

• Anticholinergics

• Decongestants

• Leukotriene antagonists

• Saline irrigation

• Do NOT use systemic esp depot steroids

Page 19: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Blockage Running Sneezing Itching

Intranasal

Corticosteroids

+++ +++ ++ +

Antihistamines

+ +++ +++ +++

Intranasal

cromones

+ + + +

Intranasal

decongestants

++++

Anticholinergics

++

Leukotriene

antagonists

++ ++

Page 20: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Intranasal corticosteroids

• Most effective therapy

• Effective against all symptoms

• Low adverse effects

• Impact on ocular symptoms

• Most cost effective

• First line therapy for moderate-severe or

persistent symptoms

• Regular “controller” therapy

Page 21: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Antihistamines

• Antihistamines relieve sneezing,

itching and rhinorrhoea

• Older antihistamines have sedative and

anticholinergic side effects

• Treatment with older antihistamines worsens

educational outcomes!

• Most new antihistamines are equally effective

in practice

• Best for intermittent rhinitis / acute symptoms

Page 22: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Others: Burst of therapy for a “flare”

• Nasal irrigation

– Simple and inexpensive

– Improves symptoms, QOL and reduces medication

• Intranasal decongestants

– Very effective for obstruction

– Use in older schoolgoing kids and adults

– Oral decongestants have additional side effects

• Other intranasal steroid formulations: drops

Page 23: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Immunotherapy

• Reduces symptoms

• Reduces medication use

• Only disease modifying therapy

– Alters course of disease

– Prevents new sensitisations

– Reduces development of asthma

Page 24: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Immunotherapy

• Indicated in subgroup of patients

– Moderate – severe persistent AR

– Proven IgE mediated allergy

– To single allergen

– Incompletely controlled with pharmacotherapy

– Do not wish long term therapy

– Side effects from pharmacotherapy

– Who are capable of adherence

Page 25: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment

Rhinitis-asthma link

• Rhinitis can exacerbate asthma

• Rhinitis can cause bronchial hypersensitivity

• Histamine challenge +ve in rhinitis without

asthma

• Most asthma exacerbations start in the upper

respiratory tract

• Treatment of rhinitis can improve asthma

symptoms

Page 26: An Update on Allergic Rhinitis - University of Cape Town · 2015-02-02 · Allergic Rhinitis Persistent •> 4 days per week •and > 4 weeks Mild •Normal sleep and •No impairment