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 OSAS

Atopic Otitis Laryngitis

Dermatitis
Media
 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
70 65.7%

60
% patients

50.0%
50
23.0%
40
30
20
10
0
Asthma Chronic Otitis media Recurrent
sinusitis with effusion 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;20:305–17.
 Impact of allergic rhinitis on patients’ daily life

SLEEP AND TIREDNESS

• 46% of patients feel tired1
• 77% of patients have trouble falling asleep1

DAILY ACTIVITIES LEARNING AND COGNITIVE

IMPAIRED2,3 FUNCTIONS DISTURBED6
Impact of
allergic
rhinitis
WORK AND SCHOOL PRODUCTIVITY
EMBARRASSMENT
• ≤90% effectiveness at work4
• ≤93% impaired classroom performance3,5 • Adolescents embarrassed to use
inhalers6

1. Scadding G et al. EAACI 2007, Abstract 1408. 2. Reilly MC et al. Clin Drug Invest 1996;11:278–88. 3. Tanner LA et al. Am J Manag Care 1999;5(Suppl 4):S235–S247. 4. Blanc PD et al. J Clin
Epidemiol 2001;54:610–18. 5. Juniper EF et al. J Allergy Clin Immunol 1994;93:413–23. 6. Marshall PS, Colon EA. Ann Allergy 1993;71:251–8.
 Nasal Inflammation: An Underlying Mechanism
in Allergic Rhinitis
Early-Phase Response Late-Phase Response
Mast Cell Cellular Infiltration/Inflammation
Allergen

Other Inflammatory Mediators

Histamine Eosinophil
Proteases

Basophil
Chemotactic
factors

Monocyte
Mast cell
Other
Inflam.
mediators Lymphocyte
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 days per week and
 <4 weeks  >4 weeks

MILD MODERATE–SEVERE
 Normal sleep and One or more items
 No impairment of daily activities, sport,  Abnormal sleep
leisure and  Impairment of daily activities, sport,
 Normal work and school and leisure
 No troublesome symptoms  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):S147–336; ARIA: at a glance pocket reference 2007.
 Symptoms suggestive Symptoms usually NOT assurlated
of allergic rhinitis With allergic rhinitis

- unilateral symptoms
- nasal obstruction without other
2 or more of the following symptoms for
symptoms
> 1 hr on most day :
- mucopurulent rhinorrhea
- watery anterior rhinorrhea
- posterior rhinorrhea (post nasal drip)
- sneezing, especially paroxysmal
- with thick mocous
- nasal obstruction
- and / or no anterior rhinorhea
- nasal pruritis
- pain
± conjunctivitis
- 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)

16
Management – Therapeutic Considerations
Allergen
avoidance
indicated when
possible

Immunotherapy
Pharmacotherapy effectiveness
safety specialist prescription
effectiveness may alter the natural
course of the disease
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
Short course of
corticosteroids added
to INS,
INS added to non-sedating AH
non-sedating AH  decongestant
 decongestant
Inadequate response to
Non-sedating AH
therapy, symptoms
 decongestant
Moderate severe impact of HRQoL,
persistent symptoms, comorbidities
bothersome
Mild intermittent
symptoms
Step-down
as symptoms improve:
Immunotherapy if symptoms:  Reduce number of drugs
 Show inadequate response to therapy  Reduce dose
 Prolonged  Change therapy
 Impact upon HRQoL
 Lead to co-morbid conditions

AH, antihistamine; HRQoL, health-related quality of

life; INS, intranasal corticosteroids Adapted from Bousquet J et al. J Allergy Clin Immunol 2001;108:S147–S334.
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
28
 Drugs Efficacy to AR Symptoms

Agent Sneezing Rhinorrhea Nasal Itchy nose Level of

obstruction evidence

Oral H1-antihistamine ++ ++ + +++ A

Intranasal ++ ++ + ++ A
H1-antihistamine

Intranasal CS +++ +++ +++ ++ A

Oral decongestant 0 0 + 0 A

Intranasal decogestant 0 0 ++++ 0 C

Intranasal chomones + + + + A

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  Quality of life
(50-70%)
 IDEAL ORAL ANTIHISTAMINE
EAACI/ARIA Requirements for Oral
Antihistamines1

• Potent & selection • Effective • No • Rapid onset

• Anti allergic/inflammatory • IAR / PER • Sedation/cognitive • Long duration of
• No interference: food • Nasal symptom psychomotor action (once daily
medication • Asthma symptom impairment preferred)
• CyP3A no interaction • Preventive • Anticholinergic • No tachyphylaxis
• No interactions with the • Cardiac side effects
disease to avoid toxic • Weight gain
reactions • Safety in young/
elderly
• Safety in pregnant
& breast feeding
• Post marketing
safety analysis

EAACI = European Academy of Allergy and Clinical Immunology; ARIA = Allergic Rhinitis and its Impact on Asthma. 30
1. Bousquet J et al. Allergy. 2004;59(suppl 77):4–16.
 ANTI
HISTAMINE

Oral Local
Antihistamine Antihistamine

FIRST GENERATION SECOND New/Next - Effective < 30’

- H1 receptor GENERATION Generation - Controlling Sneezing
antagonist - H1 receptor - Non sedating Rhinorea Nasal
- Sedation/ antagonist - Eliminating / Itching
drowsiness - Less Sedation limiting cardiac risk - Blocking H1 receptor
- Anti Cholinergic - Once daily - Anti Inflamatory - More Effective than
- Cross blood brain - Rapid onset Activity oral AH
barrier - Do not cross blood - Reducing nasal - Less Effective than
- CTM, Diphen brain barrier congestion INS
Hydramine - Terfenadine - Desloratadine - Minor Local side
astemizole cetirizine effect
- Levocetirizine
loratadine,Fexo - Rupatadine - Azelastine / Levo -
Fenadine 31
Cabastine
 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 H1-
antihistamines (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 H1-
antihistamines in adults with seasonal AR (conditional recommendation/moderate-
quality evidence) and in adults with persistent AR (conditional
recommendation/very-low-quality evidence)
 New-generation oral H1-antihistamines are suggested rather than intranasal H1-
antihistamines 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;126:466–476.
 Guideline Perspectives on Oral Antihistamine and
Oral Decongestant Therapy in Allergic Rhinitis

EAACI
Joint Task Force Consensus on Allergic ARIA
Agent Practice Parameters1 Rhinitis2 2001 Guidelines3
Oral antihistamines Effective for Effective on rhinorrhea, Effective in reducing itching,
reducing symptoms of itching, sneezing, and itch, but sneezing, and watery
sneezing, and rhinorrhea, but have limited effects on rhinorrhea; however, they are
have little objective effect on nasal congestion less effective on nasal
nasal congestion obstruction

Oral decongestants Effectively reduce Effective on nasal Effective for nasal obstruction
nasal congestion produced congestion but do not improve other
by rhinitis 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;81:474–477.
2. van Cauwenberge P et al. Allergy. 2000;55:116–134.
3. Bousquet J et al. J Allergy Clin Immunol. 2001;108(suppl):S147–334.
Nasal Corticosteroid
Systemic VS Topical Corticosteroid
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
Intranasal
 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

 adults and pediatric patients > 2 years of age

 Nasal Polyps
 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.