OTC 2015

References  Practice guideline for the treatment of allergic rhinitis. American Academy of Otolaryngology–Head and Neck Surgery Feb.2015, Vol. 152(1S) S1–S43  Treatment of Allergic Rhinitis. Am Fam Physician. 2010;81(12):  Allergic rhinitis management pocket reference Allergy 2008: 63: 990–996.  Pharmacotherapy: A pathophysiologic Approach. 7 th Edition  Safety of Antihistamines in Children. Drug Safety 2001; 24 (2):  Second-Generation Antihistamines Actions and Efficacy in the Management of Allergic Disorders. Drugs 2005; 65 (3):

Allergic Rhinitis-Overview  The most common atopic disease  The hallmark of ~: a temporal relationship between the exposure to allergens & the development of nasal symptoms  It takes at least 2 years of exposure to aeroallergens (airborne environmental allergens) to develop AR (thus, very rare in children <1 year)  The prevalence of AR: lowest in children < 5 yrs  highest 2 nd th decades  Genetic predisposition (60%)

In a sensitized individual, allergic rhinitis occurs when mucous membranes are exposed to inhaled allergenic materials that elicit a specific response mediated by immunoglobulin E (IgE). 4

Definitions. Allergic Rhinitis (AR) is an inflammatory, IgE-mediated disease characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, and/or nasal itching. It can also be defined as inflammation of the inside lining of the nose that occurs when a person inhales something he or she is allergic to, such as animal dander or pollen; examples of the symptoms of AR are sneezing, stuffy nose, runny nose, post nasal drip, and itchy nose.

AR may be classified by: (1) the temporal pattern of exposure to a triggering allergen, such as seasonal (eg, pollens), perennial/ year-round (eg, dust mites), or episodic (environmental from exposures not normally encountered in the patient’s environment, eg, visiting a home with pets); (2) frequency of symptoms; and (3) severity of symptoms. Classifying AR in this manner may assist in choosing the most appropriate treatment strategies for an individual patient.

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9 Allergen sensitization and the allergic response. A. Exposure to antigen stimulates IgE production and sensitization of mast cells with antigen specific IgE antibodies. B. Subsequent exposure to the same antigen produces an allergic reaction when mast cell mediators are released.

Mast cells degranulating and releasing vasoactive amines.

Mast Cell Mediators 11

Allergic Rhinitis Most patients develop symptoms before age 30 Asthma develops in about 19% of children with rhinitis (more likely with perrenial allergic rhinitis) The term “rhinitis” refers to the inflammation of the nasal mucous membranes. Whenever a a causative allergen can be identified  allergic rhinitis It is difficult sometimes to distinguish between different types of rhinitis Comparison between different types of rhinitis

Features of Common Rhinitis Symptoms Allergic rhinitis Infectious rhinitis Vasomotor rhinitisRhinitis Medicamentosa Etiology AllergenViral or bacterial UnknownTachyphylaxis to topical decongestants Symptoms Rhinorrhea, congestion, sneezing, pruritis, cough with postnasal drip ocular itching etc Fever (more common in children), mucupurulent rhinorrhea, scratchy throat, congestion, cough Rhinorrhea, congestion Congestion Pattern Perennial or seasonal Any time Temporal relationship with use of topical decongestant Associated Factors Concurrent atopic disease, family history NoneAffects women primarily, strong odours, alcohol, stress, change in humidity and temperature Overuse of topical decongestants, concurrent use of antihypertensive therapy

Perennial Allergic Rhinitis Caused by continuous exposure to many different types of allergens Dust Mite  the most common cause of perennial allergic rhinitis Commonly: household dust mites, molds, cockroaches, house pets Less commonly: cottonseed & flaxseed (found in fertilizers, hair setting preparations and foods); some vegetable gums (found in hair setting prep & foods)

Caused by: Dust mites

Perennial Allergic Rhinitis Dust mite: thrive in carpets, beddings & reproduce best in warm (18-21ºC) humid (>50%) environment found in most homes Mites feed on human skin scales and their own faeces. Mite itself is not allergen, the main allergen is the glycoprotein that coats their faeces. Dust mite remain airborne for about 30 minutes after being disturbed Molds: grow best in warm, moist environment Cat-derived allergens: light small proteins secreted through the sebaceous glands in the skin. May remain airborne for up to 6 hrs. Can be detected at home even 6 months after removal of the cat.

Seasonal Allergic Rhinitis Caused by wind-borne plant pollens (e.g. tree, grass. etc) “hay fever”, and “rose fever” are terms related to seasons associated grass pollinosis and NOT associated with FEVER!

Complications 1. Sinusitis 2. Recurrent otitis media & hearing loss 3. Patients who develop: fever, purulent nasal discharge, frequent HA, earache refer to Dr. for evaluation and treatment

Symptoms of Allergic Rhinitis Ocular: itching, lacrimation, mild soreness, puffiness & conjuctival erythema Nasal: congestion, watery rhinorrhea, itching, sneezing, postnasal drip and nasal pruritus Head & Neck: loss of taste and smell, mild sore throat due to postnasal drip, earache, sinus HA, itching of the palate and throat Systemic: malaise & fatigue:

Physical Assessment “allergic shiners”  venous/lymphatic congestion Chronic mouth breathing  highly arched palate A horizontal crease across the lower third of the nose (in patients repeatedly rub their noses upward) called “nasal salute” Nasal mucosa: pale & swollen Nasal secretions: clear & watery Eyes: watery with scleral & conjuctival erythema and periorbital edema

Allergic shiners Arched palate because of mouth breathing Periorbital edema

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Update: April 2013 The US Food and Drug Administration (FDA) has approved carbinoxamine maleate extended-release (Karbinal ER, Tris Pharma), the first liquid, sustained-release histamine-H1 receptor blocker indicated for the treatment of seasonal and perennial allergic rhinitis in children aged 2 years and older. The drug will be available in a 4 mg/5 mL oral suspension. It is dosed once every 12 hours, "making it an attractive treatment option" for allergy sufferers who do not respond to second-generation antihistamines and are not satisfied with dosing schedules associated with the first-generation antihistamines. Carbinoxamine is a mildly sedating antihistamine. Before 2006, it was widely used in carbinoxamine-containing combination products. However, most of these older drugs had not gone through the FDA's approval process.