CURRICULUM VITAE

EDUCATION
Faculty of Medicine University of Indonesia 2003 - 2009
ENT Specialist Faculty of Medicine University of Indonesia 2013-2017

WORKING EXPERIENCE
Pasar Rebo General Hospital 2017 – now
Hermina Depok Hospital 2017 – now
Sejahtera Ciracas Clinic 2019 – now
Bhayangkara Brimob 2017 - 2018
MANAGEMENT ALLERGIC
RHINITIS IN ADULT
dr. Indah Trisnawaty, Sp. T.H.T.K.L
Definition
based on ARIA guideline

Allergic rhinitis (AR) is a symptomatic disorder of the

nose induced after exposure to allergens via IgE-
mediated hypersensitivity reactions, which are
characterized by 4 cardinal symptoms of watery
rhinorrhea, nasal obstruction, nasal itching and
sneezing.
 The nose and the lung: United Airway
Disease?
Anatomical & Upper and the lower respiratory tracts have anatomical and histological similarities,
Histological Evidence including the basement membrane, lamina propria, ciliary epithelium, glands, and goblet
cells.

Licari A, Castagnoli R, Denicolo CF, Rossini L, Marseglia A, Marseglia GL. The nose and the lung: United Airway Disease? Frontiers in Pediatric. 2017
 The nose and the lung: United Airway
Disease?
Epidemiologic
Evidence

19–38% of patients with AR have concomitant asthma and 30–80% of

asthmatics have AR Early allergic response Late allergic response
(maximal at 10–20 min) (within 2–6 h)
Pathophysiologic
Evidence Upper airways
edema, itching in the skin, Upper and lower
rhinorrhea, sneezing, and airways eosinophil
Release of granule- activation and CD4 T
erythema cell tissue infiltrate,
associated
allergen-specific IgE mediators (i.e., essential to maintain
hypersensitivity or the chronic
molecules bound to histamine, tryptase), Lower respiratory tract
IgE-mediated cells by allergen inflammatory process
reactions membrane lipid-
particles derived mediators bronchospasm, edema, and tissue damage
(i.e., leukotrienes), mucous secretion, and
and cytokines cough

Licari A, Castagnoli R, Denicolo CF, Rossini L, Marseglia A, Marseglia GL. The nose and the lung: United Airway Disease? Frontiers in Pediatric. 2017
 Pathophysiology
Sensitization
Early and late reactions

Min YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis. Allergy Asthma Immunol Res. 2010;2(2):65-76.
Risk Factor Genetics
and familial
history

Early-life risk
Social class
factors

Outdoor

Indoor
Allergen Inhalant
Pollutans Allergens
Tobacco exposure
smoke
Food
Climate Allergens
change Ethnic group Occupational
Agents
ARIA 2008
Classification and treatment option
Based on ARIA Guideline

Intermittent Persistent
• <4 days per week • ≥4 days per week
• Or <4 weeks • And ≥4 weeks

Mild
• Normal sleep
• Normal daily activities, sport,
leisure
• Normal work and school
• No troublesome symptoms
Moderate/Severe
One or more items
• Abnormal sleep
• Impairment of daily activities
• Problems caused at work/school
•Troublesome symptoms
 Diagnosis of Allergic Rhinitis

Allergic symptoms Physical Examination Diagnostic tests

• watery rhinorrhea • Allergic Sign • Skin testing

• sneezing • Anterior Rhinoscopy • Serum specific IgE level
• nasal obstruction • Nasoendoscopy
• nasal pruritus

Visual Analogue
Score (VAS)

CHANG SB. Newly Allergic rhinitis classification by Innovative Endoscopic Diagnostic Method - Danyoung Classification. HEAD MIRROR JOURNAL 2015 Vol 1
SKIN TESTING (IgE-mediated allergic reaction)

ATOPY PATCH INTRADERMAL

SKIN PRICK TEST
TEST SKIN TEST

INTERPRETATION FACTORS AFFECTING SKIN TESTING

0 : control site is completely negative The quality of the allergen extract
+1 : wheals > control (-) Age
+2 : wheals 1 – 3 mm > control (-) Seasonal variations
+3 : wheals 3 – 5 mm > control (-) Drugs
+4 : wheals > 5 mm > control (-) Skin Disease
Differential Diagnosis

• reserpine
Infectious rhinitis Occupational Drug-induced • Guanethidine
(rhinosinusitis) rhinitis rhinitis • phentolamine
• methyldopa
• ACE inhibitors
Nasal symptoms • a-adrenoceptor antagonists
related to Food-induced • intraocular or oral ophthalmic
Hormonal rhinitis physical and rhinitis.
chemical factors preparations of b-blockers
• chlorpromazine
• oral contraceptives
Rhinitis of the
elderly. Atrophic rhinitis
OTHER COMPLICATIONS AND COMORBID
DISEASES

Allergic
Rhinosinusitis Nasal polyposis
conjunctivitis

Eustachian tube
Adenoid dysfunction and
hypertrophy otitis media
with effusion
 Management

ALLERGEN
AVOIDANCE !!
NEW PARADIGM OF ALLERGIC RHINITIS
TREATMENT

Hellings PW,Fokkens WJ,Bachert C,Akdis CA, Bieber T, Agache I et all. Positioning

the Principles of precision medicine in care pathways for AR and CRS. A EUFOREA-
ARIA-EPOS-AIRWAYS ICP statement. Allergy 2017;72:1297-1305
 Pharmacotherapy - efficacy to AR symptoms

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

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

Supression of mediator release from mast cells,eosinophil & Second and new generation
basophil. ( antiallergy & antiinflammatory ), effective for all
▪No/little sedation effect, lipophobic
nasal symptoms including nasal obstruction
▪Selective ! no anticholinergic effect
Most AH : onset of action 1 – 2 hours & 24 hours duration of
▪No cardiotoxicity (except aztemizole &
action
terfenadine cause ventricular
tachycardia)
Ideal antihistamine
▪Loratadine, cetirizine, fexophenadine,
• higher potency, longer duration of action, faster onset of
action, bepotastine besilate, levocetirizine,
• minimal / non sedative effect & psychomotor impairment desloratadine, rupatadine
• no cardiac side efects ▪First line therapy
• no anti cholinergic effects
• no weight gain
DECONGESTANT

• Decongestant = vasoconstrictor
• Sympathomimetic agent
• Phenylephrine, oxymetazoline, pseudoephedrine, phenylpropanolamine
• Pseudoephedrine : well-established sympathomimetic agent
- Pseudoephedrine Retard-Pellets (PER) : slow release formulation,
plasma half life of 12 hr
• Achieved dose → disturbing side effects : cardiac & CNS
• Used with caution :
• hypertension, coronary artery disease, hyperthyroidism, DM, narrow angle
glaucoma, prostate hypertrophy
ANTIHISTAMINES-DECONGESTANT COMBINATIONS

• Nasal congestion as prominent symptom •

• Pseudoephedrine : 180-240mg daily
• Phenylpropanolamin : max. 150mg
• Phenylephrine /topical : 40 mg
• Pseudoephedrine : the only available drug used in combination with oral
antihistamines, better reduction of global nasal symptoms compared with
antihistamines alone.
• Non sedative antihistamin
Cetirizine + pseudoephedrine
Desloratadine + pseudoephedrine
Fexophenadine + pseudoephedrine
INTRANASAL CORTICOSTEROID

• Budesonide, triamcinolone acetonide, fluticasone propionate, mometasone furoate and

fluticasone furoate
• Not absorbed systemically → induce few systemic side effects.
• Steroid particles penetrate the cellular membrane and bind to cytoplasmic steroid
receptors.
• The steroid-receptor complex is transferred to the nucleus and binds to the specific DNA
site. The anti-inflammatory effect is induced by alteration in protein synthesis after binding
of the steroid-receptor complex to DNA or by affecting other transcription factors.
• INHIBIT both early and late reactions and reduce IgE production and eosinophilia by
inhibiting the secretion of cytokines including IL-4, 1L-5 and IL-13.
• DECREASE eosinophils and basophils in 1 week
• Effective in all AR symptoms, especially nasal obstruction and eye symptoms
• The therapeutic effect of intranasal corticosteroids is encountered 7 hours after adminis-
tration47 and reaches the maximal level after 2 weeks.
INTRANASAL CORTICOSTEROID
IS IT SAFE?
• The systemic absorption rates
• Flunisolide, triamcinolone acetonide and
beclomethasone dipropionate are 20-50%
• Mometasone furoate and fluticasone propionate
are very low (≤0.1% and ≤2%, respectively)
• Most of the intranasal corticosteroids are eliminated by
first-pass hepatic metabolism.
• Children aged 7-12 years use mometasone 200 μg or
budesonide 400 μg for 2 weeks → growth rates of the
lower extremities are not significantly affected
• Twelve- month use of beclomethasone dipropionate
may cause growth retardation in children
• 1-year mometasone or fluticasone therapy in children
do not cause growth retardation
• Intranasal corticosteroids usually improve the symptoms of patients
with asthma.
• Watson et al intranasal beclomethasone therapy reduces bronchial
hyperresponsiveness and asthmatic symptoms in patient with AR
and asthma.
• Foresi et al fluticasone propionate suppresses bronchial
hyperresponsiveness in patients with seasonal AR.
The ideal for a INCS
• Treats bothersome nasal and ocular symptoms
• Strong affinity for the GR
• Provides 24-hour efficacy
• Highly selective for the glucocorticoid receptor (GR)
• Good safety and tolerability profile
• Fast onset of action , once daily
• Comfortable and easy to use device, good patient’s
• acceptability
• Odorless
Glucocorticoid Receptor Binding Affinity

• Meltzer et al Immunol Allergy Clin N Am 31 (2011) 545–560

Bioavailability

• Meltzer et al Immunol Allergy Clin N Am 31 (2011) 545–560

 FFNS provides relief from nasal symptoms

In elderly adults (≥ 65 years) with PAR Mean Change from Baseline in RQLQ

N=44

Lee et al. ACAAI 2010

 FFNS improves nasal symptoms
In children with SAR

Mean change from baseline in mean daily rTNSS over 2-weeks in patients aged 6–11 yr
Global Paediatric PAR US Paediatric SAR
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 EP
US Paediatric SAR
0
Treatment Day FFNS 110
-0.5 µg
FFNS 55 µg Placebo
Mean change from baseline

-1
Baseline
-1.5 mean daily 8.5 8.6 8.4
-2 rTNSS
-2.5 LS mean
-3 change from
baseline
-3.5 over 2-week –3.16 –2.71 –2.54
-4 treatment
period (*P=0.025) (*P=0.553)
-4.5
(* difference
-5 FFNS vs
-5.5 placebo)

FFNS 110 µg FFNS 55 µg Placebo Patient (n) 146 152 150

Consistent improvement of nasal symptoms

Meltzer EO et al. Pediatr Allergy Immunol 2009;20:279-86

 FFNS improves nasal symptoms
In children with PAR

Treatment Day
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 E
FFNS 110 µg FFNS 55 µg Placebo
0
Mean change from baseline

-0.5

Global Paediatric PAR

-1
FFNS 110 µg FFNS 55 µg Placebo
-1.5
Baseline mean
-2 8.6 8.5 8.5
daily rTNSS
-2.5
LS mean change
-3 from baseline
over 4-week –3.6 –3.8 –3.0
-3.5 treatment period
(* difference (*P=0.073) (*P=0.003)
-4
FFNS vs
-4.5 placebo)
-5 Patient (n) 185 185 188
-5.5

Consistent improvement of nasal symptoms

Masperó J et al. Otolaryngol Head Neck Surg 2008;138:30–7

 NASAL LAVAGE

• Reduce inflammatory mediators ( histamine, PGD2, LTC4) , decrease nasal

symptoms ( nasal congestion )
• Cleaning nasal secretion, allergens, mucus, and irritants
• Antiinflammatory effects, improve mucociliary clearance
• Increase nasal patency with few associated side effects
• Complimentary/adjunctive treatment for INCS
• Well tolerated, effective, inexpensive, decrease medication requirements
• Isotonic or hypertonic

Lohia S, Schlosser RJ, Soler Z. Nasal Saline for Allergic Rhinitis. Cochrane Database of Systematic Reviews. 2013; 9 International Forum of Allergy and Rhinology: Allergic Rhnitis. 2018