Allergic Rhinits

Oleh:
Rudy Salam, S.Farm., M.Biomed., Apt

Dept. Farmasi Klinis Program Studi Farmasi FKUB

 Introduction

Rhinitis • inflamasi membran mukosa hidung

• rhinitis alergi  alergen yang terhirup oleh

hidung
• rhinitis non-alergi faktor-faktor pemicu
tertentu
Penyebab: • rhinitis vasomotor idiopatik; sensitif
terhadap fumes, odors, temperature &
atmospheric changes, irritant
• rhinitis medicamentosa
• rhinitis struktural abnormalitas struktural
Definition
Hypersensitivity
Tipe I immediate
hypersensitivity disebut alergi
Tipe II antibody mediated
Tipe III  immune complex
mediated
Tipe IV T-cell mediated
 Epidemiology
Prevalensi rhinitis alergi berkisar 4 – 40% dan cenderung meningkat
prevalensinya

USA : 9% dewasa dan 10 % anak-anak (2002) Berdasarkan pada

penelitian

Jakarta (2006), didapatkan 9% menjadi 12,3%

Penyebab belum bisa dipastikan  peningkatan polusi udara, populasi

dust mite, kurangnya ventilasi di rumah atau kantor, dll.

Biaya yang dikeluarkan secara langsung (mis: pengobatan, periksa ke dokter)

dan tidak langsung (mis: tidak masuk sekolah/kerja) diperkirakan 2-5 US$
Etiology
Pathophysiology
Sensitization phase

Early phase

Antigen presenting cell

Intracellular Adhesion
Molecul
Late phase

Cellular recruitment
phase
Signs and Symptomps
Bersin berulangkali
• Hidung berair
(rhinorrhea)
•Tenggorokan, hidung,
kerongkongan gatal
•Mata merah, gatal,
berair
•Post-nasal drip
 Diagnosis
Pemeriksaan fisik, riwayat pengobatan,
dan riwayat keluarga

Skin test/skin prick test atau RAST

(Radioallergosorbent test)

Menyuntikkan ekstrak alergen (senyawa

test) secara S.C  tunggu reaksinya

Skin prick test : kulit digores dengan

jarum steril, ditetesi senyawa alergen 
tunggu reaksinya
Skin Prick Test
Classification
Classification
Complications

Allergic rhinitis menunjukkan adanya

kaitan dengan perkembangan
terjadinya asma pada anak-anak dan
dewasa

Depression, anxiety, delayed speech

development & dental abnormalities
General Treatment Approach
Note:
• Klinisi (dokter/apoteker)
harus memaksimalkan
setiap langkah
pengobatan sebelum
melangkah ke tahap
pengobatan selanjutnya
• Edukasi pasien menjadi
bagian penting dalam
keberhasilan terapi
(khususnya
berhubungan dengan
obat AR bebas)
 Goals of Treatment

Obat alergi yang dijual bebas digunakan untuk meringankan dan mengontrol
gelaja dari SAR & PAR
Treatment algorithm for allergic rhinitis
Nonpharmacologic Therapy
 Pharmacotherapy
Antihistamine

Decongestant

Leukotriene antagonis

Ipratropium bromida

Cromolyn Sodium

Corticosteroid nasal
Note: Immunoterapi dilakukan jika langkah farmakoterapi tidak
menunjukkan hasil yang optimal
A pharmacy protocol for treating
allergic rhinitis
Treatment options for allergic rhinitis adapted from ARIA, 2001
ARIA Guidelines: Recommendations
for Management of Allergic Rhinitis
Agent for Allergis Rhinitis:
Antihistamines
Antihistamine Development
Antihistamine agents
 Agent for Allergis Rhinitis:
Decongestan

MoA • alpha-adrenergic agonist

• vasoconstriction restricts blood flow to

Effects nasal mucosa decreasing nasal obstruction

(no influence on pruritis, sneezing or nasal
secretion)

• Oral: HA, nervousness, irritability, tachycardia,

SE palpitations, insomnia.
• Topical(nasal): prolonged use (>5-7 days) leads to
rhinitis medicamentosa
 Decongestant agent
Oral decongestant Onset lambat,
tapi efek lebih lama & kurang

menyebabkan iritasi lokal tidak

menimbulkan resiko rhinitis
medikamentosa

Fenilefrin Fenil Pseudo (Schwinghammer, 2001)

propanilamin efedriin
 Agent for Allergis Rhinitis:
Intranasal Corticosteroids (INS)
Research of INS
Agent for Allergis Rhinitis:
Cromolyn Intranasal

Agent:
Cromolyn 5.2 mg/spray
Do: 1 spray tid-qid; max 6x/day
 Agent for Allergis Rhinitis:
Ipratropium Intranasal
MoA inhibits muscarinic cholinergic receptors
SAR (2 sprays/nostril 0.03% bid-tid) PAR (2 sprays/nostril 0.06% qid)

reduces watery rhinorrhea (no effect on nasal itching, sneezing or nasal

congestion)

SE: irritation, crusting, epistaxis

Note:
effective at reducing both “cold-air” and
limited to control of watery secretions.
“gustatory”rhinitis

Note: 0.03%= 21 mcg/spray; 0.06%= 42 mcg/spray

 Agent for Allergis Rhinitis:
Leukotriene Receptor Antagonist
 Alternative Agent
Chinese herbal
Lactobacillus
Omalizumab medicine and
rhamnosus
acupuncture
• a recombinant • microbial exposure • Epedhra (Ma-
humanized anti-IgE in the early years Huang)
monoclonal of life could help decongestant
antibody  Anti- prevent allergic
IgE antibodies bind evidence
to the site on the (prenatally to
IgE molecule that mothers) shows
recognizes the IgE little benefit in
receptor, thereby allergic airway
preventing the IgE diseases (limited
molecule from research)
binding to mast
cells or basophils
inhibit release
mediators
Comparison of standard drug used in AR
 Therapeutic options for AR:
efficacy in nasal & ocular symptoms
 Immunotherapy
MoA If… Contraindication

• induction of IgG • When medications & • age < 5-6 yrs.

blocking antibodies avoidance don’t work • use of beta-blockers.
• reduction in specific IgE • positive skin tests • contraindication to
(long-term), correlate with rhinitis sx epinephrine.
• reduced recruitment of • Usually prescribe by a • pt non-compliance.
effector cells specialist • autoimmune dz.
• altered T-cellcytokine • Most effective for dust • induction during
balance (a shift from T- mites, pollen, cat pregnancy
helper type 1 to T- allergy (maintenance OK).
helper type 2), T-cell • May also be effective • uncontrolled asthma,
anergy, for dog, mold allergy FEV1<70%
• induction of regulatory • Cost, discomfort, time,
T cells normal course 3-5 years
 Route of Administration

Subcutaneous Sublingual

a weekly subcutaneous injection of

an extract of the allergen, in keep the extract under the tongue
solution, in increasing doses until a for a couple of minutes and then
standard maintenance dose is swallow it
reached

intervals of approximately 20 days dose of allergen is greater than

for not less than 3 years for subcutaneous immunotherapy
perennial allergens (about 3-300 times higher)
Starting Immunotherapy
Vial #5 Vial #4 Vial #3 Vial #2 Vial #1

0.05 mL 0.05 mL 0.05 mL 0.05 mL 0.05 mL

0.10 mL 0.10 mL 0.10 mL 0.07 mL 0.07 mL

0.20 mL 0.20 mL 0.20 mL 0.10 mL 0.10 mL

0.40 mL 0.40 mL 0.40 mL 0.15 mL 0.15 mL

0.25 mL 0.20 mL

0.35 mL 0.30 mL

0.50 mL 0.40 mL

0.50 mL
Parameter efektifitas
Evidence based medicine of AR:
Effectiveness of twice daily azelastine nasal spray in patients
with seasonal allergic rhinitis
2 sprays per nostril of
azelastine nasal spray (137
μg/spray
mometasone nasal spray (50
μg/spray
15 min post administration
29.5% compared with 12.3%
with placebo
8 h post administration
33.9% from baseline versus
18.6% with placebo
azelastine nasal spray was
significantly more effective
than mometasone at each
time point during the 8-hour
study period

Horak F. Ther Clin Risk Manag. 2008 October; 4(5): 1009–1022

Evidence based medicine of AR:
Effectiveness of twice daily azelastine nasal spray in patients with
seasonal allergic rhinitis
azelastine nasal spray (2
sprays per nostril twice daily;
1,1mg)
fluticasone propionate nasal
spray 2 sprays per nostril
daily; 200 μg)

Horak F. Ther Clin Risk Manag. 2008 October; 4(5): 1009–1022

Evidence based medicine of AR:
Effectiveness of twice daily azelastine nasal spray in patients with
seasonal allergic rhinitis
azelastine nasal spray (2
sprays/nostril twice daily)
with oral cetirizine (10 mg
daily) in the treatment of
patients with moderate to
severe SAR
azelastine nasal spray
significantly improved the
TNSS (p < 0.001) and each of
the four individual symptoms
of the TNSS (p < 0.01)
compared with cetirizine

Horak F. Ther Clin Risk Manag. 2008 October; 4(5): 1009–1022

Intranasal irradiation with
the xenon chloride ultraviolet
B laser improves allergic
rhinitis
308 nm xenon chloride (XeCl)
ultraviolet B (UVB) laser is highly
effective for the treatment of
inflammatory skin diseases
2 groups 0.25 × the individual
minimal erythema dose (MED)
twice , medium-dose group
treated four times weekly,
starting with 0.4 × MED each
group, the dosage was gradually
increased
medium-dose group
significantly inhibited the
rhinorrhoea, the sneezing, the
nasal obstruction and the total
nasal score
a new therapeutic tool in the
treatment of allergic rhinitis

Csoma Z, Ignacz F, Bor Z, Szabo G, Bodai L, Dobozy A, Kemeny L. J Photochem Photobiol B. 2004 Sep 8;75(3):137-44.
Ultraviolet light
phototherapy for allergic
rhinitis
Phototherapy
immunosuppressive effect
for immune mediated skin
diseases
double-blind study combined
low dose UVB, low dose UVA
and visible light proved to be
effective in reducing symptom
scores
intranasal phototherapy 
alternative treatment of
allergic rhinitis and other
inflammatory and immune
mediated mucosal diseases

L. Keme´ny, A. Koreck / Journal of Photochemistry and Photobiology B: Biology 87 (2007) 58–65

Patient Counseling
Evaluation of Therapeutic Outcames