Treatment and Management

of Allergic Rhinitis that is

appropriate for Children,
Adults and the Elderly
Prof., Dr., dr. Teti H. Madiadipoera, SpTHT-KL(K).,FAAAAI
2-54%

THT RSHS 20%

ISAAC 4.8%
 LEARNING OBJECTIVES

SELECTION OF PHARMACOTHERAPY
for patients with Allergic Rhinitis
TO CONTROL
 OUTLINE

• WHAT MATTERS TO THE ALLERGIC PATIENT

• HOW ALLERGIC DISEASES AFFECTS OUR PATIENTS
• TO DISCUSS NON SEDATIVE ANTIHISTMINE
• APPLICATION IN ALLERGIC RHINITIS FOR CHILDREN,ADULT
AND ELDERLY
 What Is
Allergic Rhinitis?
• Allergic Rhinitis (AR) is a symptomatic IgE-driven inflammation
of nasal mucosa
• Nasal congestion/obstruction
• Rhinorrhea, itchy nose and, and/r sneezing are the symptoms
of AR
• Symptom of conjunctivitis (tearing and itching) occurs
frequenly
• The presence of 2 or more nasal symptoms for more than 1 h
per day suggestive of AR

Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in
collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008;63:Suppl 86:8-160.
 CONTROLLED
Controlled is a defined as a disease state in
which the patients do not have symptoms
anymore

Or

The remaining symptoms are not regarded as

bothersome.
 ALLERGIC RHINITIS

Nasal Obstruction

Nasal Discharge

Nasal Sneezing

Nasal Itching

Sleep disturbance
Juniper ‘s Quality of Life

Dramatic Economic Effect

JUNIPER, JACI, 1997

 Pathophysiology of Allergic Rhinitis
and Impact on Sleep
Early-Phase Response Late-Phase Response
Mast Cell Cellular Infiltration/Inflammation
Histamine Eosinophil
Proteases CysLTs, GM-CSF,
TNF-, IL-1, IL-3,
Allergen PAF, ECP, MBP
Basophil
Chemotactic factors Histamine, CysLTs,
(CysLTs, PAF, IL-5) TNF-, IL-4, IL-5, IL-6
Mast cell CysLTs Monocyte
Prostaglandins CysLTs, TNF-,
Neosynthesis PAF, IL-1, IL-10
PAF
Bradykinin
ILs Lymphocyte
TNF- IL-4, IL-13, IL-5,
GM-CSF IL-3, GM-CSF, IL-6

Bascom et al. Am Rev Respir Dis. 1988;138:406. Bascom et al. J Allergy Clin Immunol.
1988;81:580. Pearlman. J Allergy Clin Immunol 1999;104:S132. Quraishi et al. J Am
Osteopath Assoc. 2004;104(suppl 5):S7.
 THE UNIFIED AIRWAY
CONCEPTUAL FRAMEWORK

OTITIS
MEDIA

SLEEP
ASTHMA ALLERGIC DISORDER
BREATHING
RHINITIS

DENTO
RHINOSI FACIAL
NUSITIS ABNORMAL
ITIS

KROUSE, INTERRELATIONSHIP OF AIRWAY DISEASE WITH ALLERGIC

RHINITIS 2008
 DIAGNOSIS
DIAGNOSIS IN VIVO
ANAMNESIS
1. PHYSICAL EXAMINATION
2. NASAL & OCULAR SYMPTOM
3. NASOENDOSCOPY
4. SKIN PRICK TEST
 UPPER RESPIRATORY DISEASE
(ALLERGIC RHINITIS, RHINOSINUSITIS, NASAL POLYPOSIS)

Inflammation
CO-MORBIDITIES
Adenoid hypertrophy (AH) Symptoms
Rhinosinusitis
Respiratory infections
Asthma
CONSEQUENCES
Symptom bother
Mood changes
Impaired work/school productivity
Sleep disturbances
Impaired quality of life
 Allergic Rhinitis

ARIA Classification Intermittent Persistent

symptoms symptoms
Time of exposure • <4 days per week • >4 days/week
• or <4 weeks • and >4 weeks
• Seasonal
Moderate-Severe
• Perennial Mild one or more items
all of the following • abnormal sleep
• Occupational • normal sleep
• impairment of
AR • no impairment of daily
daily activities,
activities,
sport, leisure sport, leisure
• no impairment of work • impaired work
and school and school
• no troublesome • troublesome
symptoms symptoms
Bousquet J, et al. ARIA update 2008. Allergy2008: 63 (Suppl. 86): 8–160
 nasal symptom, extremely
not at all bothersome bothersome

VAS < 5 Controlled AR

VAS > 5 Uncontrolled AR

Bousquet PJ, Bachert C, Canonica GW, Casale TB, Mullol J, Klossek JM et al. Uncontrolled
allergic rhinitis during treatment and its impact on quality of life: a cluster randomized trial. J
Allergy Clin Immunol 2010;126:666–668 e661–665
 RHINITIS MANAGEMENT

Severe disease
Intranasal steroids
Mild disease H1 Blocker
H1- antihistamine
LRTA

Uncontroled disease
Immunotherapy
 TREATMENT
• Nasal lrrigation
• Antihistamines
• Chromones
• Vasoconstrictors
• Intranasal steroid
• Anti-leukotriene
• Immunotherapy
• Surgical reduction of inferior turbinate
 H1 ANTIHISTAMINES : CHEMICAL AND
FUNCTIONAL CLASSIFICATION
Functional class
Chemical class First (old) generation Second (new) generation

Brompheramine, chlorpheniramine,
Alkylamines dexchlorpheniramine, dimethindene, pheniramine, Acrivastine
tripolidine

Piperazines Buclinize, cyclizine, hydroxizine, meclizine, oxatomide Cetirizine, levocetirizine

Astemizole, bepostatine, bilastine, desloratadine,

Piperidines Azatadine, cyproheptadine, diphenylpyraline, ketotifen ebastine, fexofenadine, levocabastine, loratadine,
mizolastine, rupatadine, terfenadine, alcaftadine

Carbinoxamine, clemastine, dimenhydrate,

Ethanolamines
diphenhydramine, doxylamine, phenyltoloxamine

Ethylenediamines Antazoline, pyralamine, tripelennamine

Phenothiazines Methidilazine, promethazine

Other Doxepin Azelastine, emedastine, epinastine, olopatadine

Estelle F, Simons R, Simons KJ. JACI 2011

 Recommended algorithm for primary care practitioners
in the selection of antihistamines

Abdullah Baharudin, Therapeutics and Clinical Risk Management 2019:15 1267–1275

THE QUESTIONS

What are ideal

criteria for
antihistamine ?

What are
guidelines said ?
PROPERTIES OF A NEW GENERATION OF
ANTIHISTAMINES

1. Potent H1 receptor blockage

2. Additive anti-allergic activities
3. Rapid onset of action
4. 24 h duration of action
5. No interference with drug or
food
6. No sedation, no psychomotor
impairment
7. No anticholinergic effects, no
weight gain
8. No cardiac effect, no toxicity

BOUSQUET ET AL ALLERGY.2003;28;192-97
Licensing Age And Children’s Doses Of Commonly
Prescribed Antihistamines
 LORATADINE
EARLY SYMPTOM CONTROL IN SAR

Harold B Kaiser. Loratadine provides early symptoms control in seasonal allergic rhinitis.2008
 THE RESULT
• Indicated that loratadine and fexofenadine
significantly reduced Allergic Rhinitis after 7 days
of treatment compared with placebo
• Early sustained symptom relief was seen With
LORATADINE
• Suggesting that it may be more effective for
treating Seasonal Allergic rhinitis

Kaiser HB, Banov CH. American Journal of Theurapeutic 1998;5:245-51

 Patient Profile children
• Avoid the use of sedating or psychomotor-impairing
antihistamines in children due to their sedating effect
• Dose non –sedating second generation antihistamines
according to bodyweight rather than age
• Use adjuct therapies such as topical saline or nasal aspirator
• Appropriate formulation and taste of medication can improve
patiets compliance
• Be mindfull of food – drug intrraction

Abdullah Baharudin, Therapeutics and Clinical Risk Management, 2019

 Working Adult
• Avoid the use of sedating or psychomotor-impairing
antihistamines in working adults, especially in pilots and
individuals who operate vehicles or machinery.
• In the treatment of AR, enhanced relief of symptoms can be
achieved with a combination of antihistamines and
decongestants; however, long-term use of decongestants is
discouraged because of the risk of rebound congestion.
• Primary care providers are recommended to refer patients to
a specialist if symptoms cannot be controlled by indicated
doses.

Abdullah Baharudin, Therapeutics and Clinical Risk Management, 2019

 Patient Profiles : Woman
• Choose non-sedating antihistamines for pregnant or breastfeeding
women. Choose an antihistamine that is minimally excreted into
breast milk.
• Choose antihistamines according to their safety profile during
pregnancy.
• Counsel pregnant and breastfeeding patients on the benefits and
risks of available treatment options.
• Antihistamines should be avoided in the first trimester of
pregnancy due to the risk of teratogenicity.
• Refer to a specialist when in doubt or if symptoms persist or
worsen.

Abdullah Baharudin, Therapeutics and Clinical Risk Management, 2019

 ANTIHISTAMINE IN PREGNANCY

An observational cohort study

There is no risk above the baseline for major
malformation when cetirizine is taken during
pregnancy.
Meta-analyses.
Cetirizine does not appear to be associated with a
major increase risk for malformations

Etwel F, Djikanovic N. Journal of Obstetrics and Gynaecology 2014;34: 392-9

 First generation
antihistamines
Avoid
Highly anticholinergic;
reduced clearance, develop
tolerance, risk of confusion,
dry mouth, constipation.
May use diphenhydramine for
acute treatment of severe
allergic reaction

ANTIHISTAMINES
FOR OLDER ADULTS
AMERICAN GERIATRICS SOCIETY 2015 UPDATE BEERS CRITERIA
POTENTIALLY INAPPROPRIATE MEDICATION USE
 Second generation
antihistamines
Minimal sedation and little if any
impairment in cognitive and
psychomotor activity in healthy
nonelderly patients.
Less likely to induce the adverse
central nervous system effects in
older patients that are
ANTIHISTAMINES characteristic of the first-
FOR OLDER ADULTS generation antihistamines.

AMERICAN GERIATRICS SOCIETY 2015 UPDATE BEERS CRITERIA

POTENTIALLY INAPPROPRIATE MEDICATION USE
 ARIA GUIDELINES FOR ALLERGIC
RHINITIS BASED ON GRADING OF
RECOMMENDATIONS ASSESSMENT,
DEVELOPMENT AND EVALUATION

(GRADE)
BOSQUET ET AL, JACI JANUARY 2020
Assesment of control in UNTREATED
symptomatic patient

BOSQUET ET AL, JACI JANUARY 2020

Assesment of control in TREATED
symptomatic patient

BOSQUET ET AL, JACI JANUARY 2020

CONCLUSION
 THE GOAL

SELECTION OF PHARMACOTHERAPY
for patients with Allergic Rhinitis
TO CONTROL
 ADULT AND ELDERLY
THE SEVERITY OF THE DISEASE
BASED ON VISUAL ANALOG SCALE

JACI 2020
 AR reduces QoL and learning
ability in children
Second generation
antihistamines
Loratadine, cetirizine,
fexofenadine well-documented
clinical efficacy in AR
Well tolerated over a long
periode, have fewer side effects
on cognition

ANTIHISTAMINES
FOR CHILDREN
FITZSIMONS R.ARCH.DID. CHILD.EDUC PRAC ED 2013:304
THANK YOU