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Treatments of chronic rhinitis in children

APAPARI Workshop ‐ Cambodia, September 12, 2015

Jiu‐Yao Wang, MD, DPhilDistinguished Professor of PediatricsDirector , Allergy and Clinical Immunology Research (ACIR) CenterNational Cheng Kung University Tainan, TAIWAN

Quality of Life

• Patients’ quality of life can be profoundly affected by Allergic Rhinitis.

• Typical Effects:

– Loss of QoL

– Fatigue

– Low energy

– Decrease in social functioning

– Learning impairment

– Anxiety

– Inability to integrate

Allergies in Asia‐Pacific: A Survey of Diagnosed Patients with Allergic Rhinitis

3

Population Sampling Frame Interview lengthAdults or children and adolescents diagnosed with nasal allergies or allergic rhinitis, symptomatic or being treated for nasal allergies in the past 12 months

Telephone* and in-person#

screening of national or major city sample of households

Range:10 - 90 min.Mean: 34.9 min.

CountryNumber of Households

Screened

Completed Sample

Philippines 1,285# 100

Australia

China

Korea

Hong Kong

Malaysia

Singapore

Taiwan

Vietnam

3,534*

19,580*

608&

2,118*

491#

2,002#

1,780*

2,588#

303

325

300

100

100

100

100

107

TOTAL: 33,986 1,535

&Korea used a different methodology – physician referral.

Comparison of three published allergic rhinitis control 

questionnairesCARAT (33-35) RCAT (36,37) ARCT (38)

Administration mode Self-questionnaire Self-questionnaire Self-questionnaire

Diseases considered Allergic rhinitis and asthma Allergic rhinitis Allergic rhinitis

Period of evaluation The previous 4 weeks The previous week The previous 2 weeks

Number of final items/questions

17 in development, 10 in the final tool

26 in development 6 in the final tool

5 in the final tool

Response type 4-point frequency scale and some yes/no items

5-point Likert scale 5-point frequency scale

Validation status Tested in 141 non-treated adult patients (CARAT 1/)

and then 193 adults (CARAT 10). Internal consistency over 0.70. Longitudinal

validation in 51 patients at 4 outpatient clinics. Test-

retest reliability (intra-class correlation coefficient) =

0.82

Psychometric validation by 410 patients consulting allergy specialists. God psychometric properties

and reliable internal consistency (Cronbach alpha coefficient: 0.70)

Tested in 902 patients selected by 411 primary

care physicians and allergists. Internal consistency: 0.77

Other comments Tested in patients consulting an allergist

Significant correlations with physician-rated disease

severity, total nasal symptom score and

physician-recommended change in therapy

Based on the Asthma Control Questionnaire.

Significant correlations with the clinical picture and the

impact of allergic rhinitis on social and sports activities.

Demoly et al. Clinical & Translational Allergy 2013

Mean Work or School Productivity

Q26. Thinking about (your/your child’s) ability to do the things (you want/ he/she wants) to on a scale from 0 to 100, where 100 means 100% able, where would you rank (your/his/her) ability on days when (you don’t have/he/she doesn’t have) nasal allergy symptoms? N = 300

Q27. Where would you rank (your/your child’s) ability to the things (you want/he/she wants) to do on the same scale of 0 to 100, where 100 means 100% able, when (your/his/her nasal) allergies are at their worst? N = 100

Impact of Nasal Allergies on Daily Life

Q30. During the worst one month period, would you say the condition impacted (your/his/her) daily life a lot, a moderate amount, some, a little or did not really impact daily life? N = 99

Most Bothersome Symptom of Nasal Allergy: Allergies in Asia‐Pacific Survey

Q19. Which of these symptoms was the MOST bothersome to (you/your child)?Base: Had at least one extremely or moderately bothersome symptom, N = 89

How Bothersome are Symptoms:All AIAP Countries

Q18. When (you have/your child has) nasal allergy attacks, how bothersome are the following symptoms usually: extremely bothersome, moderately bothersome, slightly bothersome, or not bothersome?Base: Had symptom at least a few days a month

Worst Months for Nasal Allergies

Q15b. During what particular months of the year are (your/his/her) nasal allergies the worst? Base: Reported seasonal allergies N = 82

Allergic Rhinitis

Recurrent Rhinitis due to an IgE –mediated reaction of the nasal mucosa to allergens.

Characterize by  sneezing, 

itching,congestion, rhinorrhea 

and ocular symptoms

Source: Bousquet et al. J Allergy Clin Immunol. 2001; 108 (5 suppl):S147; Bauchau and Durham. Eur Respir J.2004; 24:758; Linneberg. BMJ 2005:331.352; Wjst et al. PLoS Med. 2005; 2:e294; Jarvis et al. J Allergy Clin Immunol. 2005; 116:675.

Prevalence of Allergic Rhinitis (AR)

• AR is one of the most common chronic conditions, particularly in subjects under 18

– 500 million sufferers worldwide, 250 million in China

– Up to 40% of children

• Impact

– Impacts on quality of life, work/school 

performance and productivity

Allergic Rhinitis

Provoked by exposure to allergens in the environment. 

A. Pollens – birch grass, weed

B. House dust mites

C. Animal danders

D. Cockroaches and certain mold species

How does one develop Allergic Rhinitis

Diagnosis

1.History

a. Exposure to specific allergen

b. Nasal congestion, rhinorrhea, itching, and sneezing

c. Family history of allergy

2. Skin testing

ARIA classification of allergic rhinitis

Moderate‐severe

one or more items 

• abnormal sleep

• Impairment of daily 

activities, sport, leisure

• abnormal work and school

• troublesome symptoms

Intermittent symptoms• 4 days per week• or 4 weeks

Persistent symptoms• 4 days per weeks• and 4 weeks

Mild all of the following• Normal sleep• No impairment of daily

activities, sport, leisure• Normal work and school• No troublesome symptoms

Scadding, G. Prim Care Respir J. 2010

MildIntermittent

Moderate/Severe

Intermittent

MildPersistent

Moderate/Severe

Persistent

Local Cromone (Mast Cell Stabilizer)

Oral or Local Non-Sedating Antihistamine

Intranasal Decongestant (<10 days) or Oral DecongestantAllergen and Irritant Avoidance

Immunotherapy

Intranasal Corticosteroid

Anti-leukotrienes

Treatment of Allergic Rhinitis

Pharmacologic Options for Allergic Rhinitis

Agent Sneezing Itching Congestion Rhinorrhea Ocular

Oral Antihistamine ++ ++ +/- ++ ++

Nasal Antihistamine + + +/- + –

IntranasalCorticosteroid ++ ++ ++ ++ +OralDecongestant – – + – –

IntranasalDecongestant – – ++ – –

Intranasal Mast Cell Stabilizer + + + + –

Topical Anticholinergic – – – ++ –

Adapted with permission from The AAAAI Allergy Report. 

http:// www.aaaai.org/ar/working_vol2/001.asp.  Accessed April 8, 2008.

– provides no benefit +    provides modest benefit

+/‐ provides minimal benefit   ++  provides substantial benefit

"The International Primary Care Respiratory Group, British Society for Allergy and Clinical Immunology, and American Academy of Allergy Asthma and Immunology

recommend initiating therapy with an intranasal corticosteroid alone for mild to moderate disease and using second‐line 

therapies for moderate to severe disease”

Am Fam Physician. 2010;81:1440-1446.

1. Shake bottle

2. Lock down

3. Using RIGHT hand for LEFT

nostril put nozzle just inside 

nose aiming towards outside wall

4. Squirt once or twice (2 different directions 

5. Change hands and repeat for other side

6. DO NOT SNIFF HARDAdapted scadding OK, Durham SR, Mirakian R. et al. BSACI 

guidelines for the management of allergic and non‐allergic rhinitis. Clin Exp Allergy 2008; 38:19‐42

Correct procedure for using a nasal spray

Scadding, G. Prim Care Respir J 2012, 21;122

Allergic Rhinitis

Asthma

Asthma + AR

Approximately 80%of asthmatics have allergic rhinitis

Approximately 40%of allergic rhinitis patients have asthma

Epidemiologic studies have consistently shown that asthma and allergic rhinitis co‐exist in the same patient.

Allergic Rhinitis and Asthma

Summary of the features suggesting a bidirectional link between the upper 

and lower airways

Expert Rev . Clin. Immunoll. 6(3), 413-423 (2010)

Physiopathological hypotheses explaining the concept of ‘one airway disease’

Expert Rev . Clin. Immunoll. 6(3), 413-423 (2010)

Reasons for continuing symptoms and poor asthma control

Category

Patient behavioural-related factors

Low/non adherence with therapyIncorrect use of inhaler leading to ineffective/reduceddrug deliverySmoking interfering with steroid treatmentLow patient expectations/aspirations/goals of therapyUnwillingness to use therapy and/or attend medicalconsultationsReliance on complimentary/alternative therapies

Scadding, G. Prim Care Respir J. 2010

Algorithm for the treatment of rhinitis

• Add intranasal  corticosteroid  (INS)

• Few side effects with good technique – see box

• Onset of action is 6‐8 hours after first dose but maximal effect may not be apparent until after 2 weeks

• Similar efficacy  for all INS, systemic absorption negligible with 

• mometasone and fluticasone, modest for remainder and high for betamethasone and dexamethasone

• Raised intra‐ocular pressure has been described and patients with 

• glaucoma should be monitored more closely

• Fluticasone has UK license for >4 years of age for short term use

Diagnosis by history skin prick test/specific IgEAllergen/irritant avoidance nasal douching

Symptoms

1. Oral/topical non-sedating antihistamines

2. Regular use better than as required use

3. First generation e.g. chlorphenamine cause sedation which can reduce academic and/or non-academic performance and should be avoided.

4. Non-Sedating antihistamines licensed from age 1 year in UK

Treatment failure

Scadding, G. Prim Care Respir J 2010, 21;122

Treatment failure

Waterly rhinorrhoea-add topicalipratropium

1. Check use/compliance, increase dosage where appropriate2. Consider short course oral corticosteroids to gain control for severe nasal blockage or

important events e.g. exams. 3. Always use in conjunction with INS: suggested regime for adults is 0.5mg/kg orally in

the morning with food for 5-10days

Itch/sneeze – addnon-sedating antihistamine

Catarrh – addLeukotriene receptor

Antagonist if asthmatic

Blockage

? Infection/structural problem

Treatment failure

Surgical referralConsider immunotheraphy if symptoms

Predominantly due to one allergen

Add (briefly)• Decongestant• Or oral corticosteroids• Or longer term- long-acting

non-sedating antihistamines tropical azelastine/leukotriene receptor antagonist

Scadding, G. Prim Care Respir J 2010, 21;122

Algorithm for the treatment of rhinitis