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ALLERGIC RHINITIS

BEST PRACTICE OF PRIMARY CARE


FROM GUIDELINE INTO CLINICAL PRACTICE

ARIF DERMAWAN

ALLERGIC RHINITIS
A symptomatic disorder of the nose, induced after
allergen exposure, by an IgE-mediated
inflammation of the nasal membranes
It was defined in 1929.1:
The three cardinal symptoms in nasal reactions occurring
in allergy are :

a. sneezing,
b. nasal obstruction, and
c. mucous discharge

ARIA 2008 Update (in collaboration with the World Health Organization, GA2LEN* and Allergen

ALLERGIC RHINITIS
Represent a Global Health Problem
10 - 25% world population
The prevalence is increasing (into 40%)
Alter the social life of patients:
school performance/work productivity
The costs of incurred by rhinitis are substantial
Asthma and rhinitis are common co-morbidities
one airway one disease
Maxillary sinusitis is the common complication

Triggers
Allergens
Aeroallergens
mites, pollens, animal
danders, insects, plant origin,
moulds

Food allergens
Occupational rhinitis
Latex allergy
Pollutants
Indoor air pollution
domestic allergens,
indoor gas pollutants
(tobacco smoke)

Outdoors air pollution


Automobile pollution

ALLERGIC MANIFESTATION
Allergy = Systemic Disease

Asthma

Allergic
Rhinitis

Urticaria

Conjunctivitis

Allergy

Atopic
Dermatitis

Otitis

Media

OSAS

Laryngitis

Symptoms of Allergic Rhinitis

Sneezing
Anterior rhinorrhea
Nasal itch
Posterior rhinorrhea
Congestion

Patients may not present with all symptoms


Symptoms from other organs: Eye itchy, Palatal Itchy, Urtica, Derm. Atopic,
Asthma
Majority of patients experience worst symptoms in the morning

Signs Allergic Salute

Signs Allergic Shiner

Signs Nasal Crease

Nasal Cavity:
Normal vs Allergic Rhinitis

NASOENDOSKOPI

Common allergic rhinitis comorbidities


Patients (%) with selected conditions + co-morbid allergic rhinitis
90

85.7%

80
65.7%

% patients

70
60

50.0%

50
23.0%

40
30
20
10
0
Asthma

Chronic
sinusitis

Otitis media
with effusion

Recurrent
nasal polyposis

Allergic rhinitis is a common co-morbidity in patients with


other upper respiratory tract conditions
Schoenwetter WF et al. Curr Med Res Opin 2004;20:30517.

Impact of allergic rhinitis on patients daily life


SLEEP AND TIREDNESS
46% of patients feel tired1

77% of patients have trouble falling asleep1

LEARNING AND COGNITIVE


FUNCTIONS DISTURBED6

DAILY ACTIVITIES
IMPAIRED2,3

Impact of
allergic
rhinitis
WORK AND SCHOOL PRODUCTIVITY
90% effectiveness at work4
93% impaired classroom performance3,5

EMBARRASSMENT
Adolescents embarrassed to use
inhalers6

1. Scadding G et al. EAACI 2007, Abstract 1408. 2. Reilly MC et al. Clin Drug Invest 1996;11:27888. 3. Tanner LA et al. Am J Manag Care 1999;5(Suppl 4):S235S247. 4. Blanc PD et al. J Clin
Epidemiol 2001;54:61018. 5. Juniper EF et al. J Allergy Clin Immunol 1994;93:41323. 6. Marshall PS, Colon EA. Ann Allergy 1993;71:2518.

Nasal Inflammation: An Underlying Mechanism


in Allergic Rhinitis

Histamine
Proteases

Late-Phase Response
Cellular Infiltration/Inflammation
Eosinophil

Basophil
Chemotactic
factors

Monocyte

Mast cell
Other
Inflam.
mediators

Lymphocyte

Other Inflammatory Mediators

Early-Phase Response
Mast Cell
Allergen

Nasal Mucosa in Patients with


PAR

Pearlman. J Allergy Clin Immunol. 1999;104:S132. Bascom et al. Am Rev Respir Dis. 1988;138:406. Bascom et al. J Allergy
Clin Immunol. 1988;81:580. Quraishi et al. J Am Osteopath Assoc. 2004;104(suppl 5):S7. Minshall et al. Otolaryngol Head
Neck Surg. 1998;118:648.

Allergic Rhinitis:
Classification and
Management
Guideline

ARIA classification of allergic rhinitis


Based on the severity of AR symptoms and quality of life

INTERMITTENT

PERSISTENT

<4 days per week or


<4 weeks

>4 days per week and


>4 weeks

MILD

MODERATESEVERE

Normal sleep and


No impairment of daily activities, sport,
leisure and
Normal work and school and
No troublesome symptoms

One or more items


Abnormal sleep
Impairment of daily activities, sport,
leisure
Impaired work and school
Troublesome symptoms

In untreated patients
ARIA, Allergic Rhinitis and its Impact on Asthma
Bousquet J et al. J Allergy Clin Immunol 2001;108(Suppl 5):S147336; ARIA: at a glance pocket reference 2007.

Symptoms suggestive
of allergic rhinitis

Symptoms usually NOT assurlated


With allergic rhinitis

2 or more of the following symptoms for


> 1 hr on most day :
- watery anterior rhinorrhea
- sneezing, especially paroxysmal
- nasal obstruction
- nasal pruritis
conjunctivitis

- unilateral symptoms
- nasal obstruction without other
symptoms
- mucopurulent rhinorrhea
- posterior rhinorrhea (post nasal drip)
- with thick mocous
- and / or no anterior rhinorhea
- pain
- recurrent epistaxis
- anosmia

Classify and assess severity


(see section 4)

Bousquet et all. ARIA 2008 Update. Allergy 2008:63(S86):8-160

Diagnosis
Typical History
General ENT examination
Diagnostic Test
Skin tests
Allergen-specific IgE
Endoscopy
Cytology
Nasal challenge test
Imaging
(ARIA WHO Consensus 2001)
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Management Therapeutic Considerations


Allergen
avoidance
indicated when
possible

Immunotherapy

Pharmacotherapy

effectiveness
specialist prescription
may alter the natural
course of the disease

safety
effectiveness
easy administration

Patient
education
always indicated
18

Principles of Clinical Management


of Congestion
23

Establish diagnosis
Define goals, consider quality of life
Educate and counsel
Treat appropriately
Follow-up and adherence
Evaluate further options

Stepwise approach to management of


allergic rhinitis

INS added to
non-sedating AH
decongestant
Non-sedating AH
decongestant

Mild intermittent
symptoms

Moderate severe
persistent symptoms,
bothersome

Immunotherapy if symptoms:
Show inadequate response to therapy
Prolonged
Impact upon HRQoL
Lead to co-morbid conditions
AH, antihistamine; HRQoL, health-related quality of
life; INS, intranasal corticosteroids

Short course of
corticosteroids added
to INS,
non-sedating AH
decongestant
Inadequate response to
therapy, symptoms
impact of HRQoL,
comorbidities

Step-down
as symptoms improve:
Reduce number of drugs
Reduce dose
Change therapy

Adapted from Bousquet J et al. J Allergy Clin Immunol 2001;108:S147S334.

Stepwise Treatment Proposed


Mild intermittent: oral H1-antihistamines

Moderate severe Intermittent:


intra nasal topical steroid (high dose) +
if needed: oral H-1 antihistamine and/or oral steroid (short
term course)
Mild persistent:
oral H-1 Antihistamine, or
low dose intra nasal topical steroid
Moderate-severe persistent:
High dose intra nasal topical steroid
If symptoms are severe : add oral H-1 Antihistamine,
and or short course of oral corticosteroid at beginning of
the treatment
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Drugs Efficacy to AR Symptoms


Agent

Sneezing

Rhinorrhea

Nasal
obstruction

Itchy nose

Level of
evidence

Oral H1-antihistamine

++

++

+++

Intranasal
H1-antihistamine

++

++

++

+++

+++

+++

++

Oral decongestant

Intranasal decogestant

++++

Intranasal chomones

Intranasal CS

Bousquet J, et al. Allergy 2002;57:841


Bousquet J, et al. Allergy 2008;63 (Suppl.86); 8-160

Oral H1-Antihistamine

Reduced
Symptoms Alergic
Rhinitis
(50-70%)

Quality of life

IDEAL ORAL ANTIHISTAMINE


EAACI/ARIA Requirements for Oral
Antihistamines1

Potent & selection


Anti allergic/inflammatory
No interference: food
medication
CyP3A no interaction
No interactions with the
disease to avoid toxic
reactions

Effective
IAR / PER
Nasal symptom
Asthma symptom
Preventive

No
Sedation/cognitive
psychomotor
impairment
Anticholinergic
Cardiac side effects
Weight gain
Safety in young/
elderly
Safety in pregnant
& breast feeding
Post marketing
safety analysis

Rapid onset
Long duration of
action (once daily
preferred)
No tachyphylaxis

EAACI = European Academy of Allergy and Clinical Immunology; ARIA = Allergic Rhinitis and its Impact on Asthma.
1. Bousquet J et al. Allergy. 2004;59(suppl 77):416.

30

ANTI
HISTAMINE

Oral
Antihistamine

FIRST GENERATION
- H1 receptor
antagonist
- Sedation/

drowsiness
- Anti Cholinergic
- Cross blood brain
barrier

- CTM, Diphen
Hydramine

SECOND
GENERATION
- H1 receptor
antagonist

Local
Antihistamine

New/Next
Generation
- Non sedating
- Eliminating /

- Less Sedation

limiting cardiac risk

- Once daily

- Anti Inflamatory

- Rapid onset
- Do not cross blood

Activity
- Reducing nasal

brain barrier
- Terfenadine
astemizole cetirizine
loratadine,Fexo
Fenadine

congestion
-

Desloratadine

- Levocetirizine
- Rupatadine

- Effective < 30
- Controlling Sneezing
Rhinorea Nasal
Itching

- Blocking H1 receptor
- More Effective than
oral AH
- Less Effective than

INS
- Minor Local side
effect
- Azelastine / Levo Cabastine

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ARIA 2010 Guideline Update1

In 2010, ARIA published an update to their 2008 guidelines, which


reconfirmed that new-generation oral H1-antihistamines are
recommended and preferred over the old-generation oral H1antihistamines (strong recommendation, low-quality evidence)
With respect to the use of oral vs intranasal antihistamines, ARIA makes the
following recommendations:

New-generation oral H1-antihistamines are suggested rather than intranasal H1antihistamines in adults with seasonal AR (conditional recommendation/moderatequality evidence) and in adults with persistent AR (conditional
recommendation/very-low-quality evidence)
New-generation oral H1-antihistamines are suggested rather than intranasal H1antihistamines in children with intermittent or persistent AR (conditional
recommendation/very-low-quality evidence)
In many patients with different values and preferences or those who experience
adverse effects, an alternative choice may be equally reasonable

ARIA = Allergic Rhinitis and its Impact on Asthma; AR = allergic rhinitis.


1. Brozek JL et al. J Allergy Clin Immunol. 2010;126:466476.

Guideline Perspectives on Oral Antihistamine and


Oral Decongestant Therapy in Allergic Rhinitis

Agent

Joint Task Force


Practice Parameters1

EAACI
Consensus on Allergic
Rhinitis2

ARIA
2001 Guidelines3

Oral antihistamines

Effective for
reducing symptoms of itching,
sneezing, and rhinorrhea, but
have little objective effect on
nasal congestion

Effective on rhinorrhea,
sneezing, and itch, but
have limited effects on
nasal congestion

Effective in reducing itching,


sneezing, and watery
rhinorrhea; however, they are
less effective on nasal
obstruction

Oral decongestants

Effectively reduce
nasal congestion produced
by rhinitis

Effective on nasal
congestion

Effective for nasal obstruction


but do not improve other
symptoms of rhinitis

EAACI = European Academy of Allergology and Clinical Immunology; ARIA = Allergic Rhinitis and its Impact on Asthma.
1. Dykewicz MS et al. Ann Allergy Asthma Immunol. 1998;81:474477.
2. van Cauwenberge P et al. Allergy. 2000;55:116134.
3. Bousquet J et al. J Allergy Clin Immunol. 2001;108(suppl):S147334.

Nasal Corticosteroid
Systemic VS Topical Corticosteroid
Intranasal

Systemic

Increased potential for


systemic side effects
Significant contraindications

Reserved for patients who fail


other therapies, and severe
cases
Long-term use (>3 weeks) is
not recommended, except in
autoimmune disease

Decrease potential of
systemic side effect
High concentration can be
achieved at receptor sites
Limited contraindications

Preferred therapy for


relief of nasal congestion in
all form of rhinitis
Well-tolerated and can be
used long-term without
atrophy
Prophylactic use is effective in
reducing congestion,
rhinorrhea, sneezing, and
itching

Treatment Indication Intranasal


Mometasone Furoate

Seasonal and Perennial Allergic Rhinitis

Nasal Polyps

adults and pediatric patients > 2 years of age

Treatment of nasal polyps in patients > 18 years of age

Mild to moderate uncomplicated acute rhinosinusitis

Treatment of symptoms in patients >12 years without signs


and symptoms of severe bacterial infection

Ref : PI BPOM

Conclusion

Allergic rhinitis is the most common allergy


manifestation.

Based on ARIA guideline : Intranasal corticosteroids


and new generation of non-sedating antihistamine
are first-line therapy for allergic rhinitis.
Desloratadine level of evidence for IAR and PAR is
Level A.
Based on pharmacodynamic and pharmacokinetic
profile , Mometasone Furoate INS is the most potent
and safe INS.