Allergic Rhinitis

Dr. Dinesh Kumar, Assistant Professor, ENT, GMC Amritsar

Definition

Allergic rhinitis is clinically

defined as a symptomatic
disorder of the nose induced by
an IgE-mediated inflammation
after allergen exposure of the
membranes lining the nose
Natural History

Onset is common in childhood,

adolescence and early
childhood .
 Symptoms often wane in older
adults, but may develop or
persist at any age
Natural History
No apparent gender
selectivity or predisposition
to developing AR
 May contribute to a number
of other conditions
Allergic rhinitis
 Inflammatory disorder of nasal mucosa,
characterized by pruritus, sneezing,
rhinorrhoea and nasal congestion.
 Adversely affects social life, school
performance, and work productivity; especially
in patients with severe disease
 Loss of productivity, missed school and work
days, and direct costs associated with treatment
create substantial costs to society.

Lancet 2011; 378: 2112–22

An Allergic Reaction
 Dendritic
Cells

Moncytes &
Macrophages T- Cells

Inflammatory Cells

B-
Eosinophils Lymphocytes

Mast Cells
 Histamine Chemokines

Chemical Cytokines
Mediators

Leukotrines Prostaglandins
The Allergic reaction
Sensitization
Ig E Production

Arming of mast cells

Release of mediators
Clinical effects
Inflammatory cascade in allergic rhinitis

Adapted from Indian J Chest Dis Allied Sci. 2003 Jul-Sep;45(3):179-89

How are the symptoms caused

Irritation of free nerve endings Itching

nerve endings Sneezing
Increased mucus production Rhinorrhea
Vasodilation Congestion
Increased vascular permeability Oedema
Classical Symptoms

Repetitive Nasal Watery Nasal

Sneezing Congestion Rhinorrhea Pruritus
Other Manifestations

Eye Symptoms

Ear Symptoms

Post nasal drip

AR

Intermittent Persistent

Classificatio
n

Moderate to
Mild Severe
Intermittent

<4
days/week < 4 weeks
Persistent

>4
days /week > 4 weeks
Mild

Normal sleep

No impairment of daily activit

No troublesome Symptoms in
untreated patients
Moderate to Severe

Abnormal Sleep

Impairement of daily activity

Abnormal work

Troublesome Symptoms
Risk Factors for Allergic Disease

Male Gender
Family Season of
during
History Birth
Childhood

Increase in Dietary
Obesity
pollution Changes
Allergic Shiners
Allergic Salute and Crease
Allergic Conjuctivitis
AR & Co-morbidities

Otitis
Media

Asthma URTI

Nasal Sinusiti
Polyps s
Allergic rhinitis and diseases of the upper airway
Key factors important to normal PNS
function

Patency of ostia

Function of ciliary
apparatus

Quality of secretions
AR and Asthma

Approx. 80% of patients

with asthma have
accompanying symptoms
of rhinitis, and up to 60%
of the patients with asthma
have sinusitis
Possible Mechanisms by which Rhinitis
Could Provoke a Worsening of Asthma

Possible mechanism AR could provoke worsening of Asthma

PND

Nasal
Obstruction

Nasobronchial
refex
Management of Allergic Rhinitis

• Allergen Avoidance

• Pharmacotherapy

• Surgery
• Immunotherapy
First Generation Antihistamines
Rapid onset of action
Short half life
Significant relief from
rhinorrhoea
Easily cross blood brain
barrier
Side Effects
Second Generation AH
Improve selectivity
Hepatic and Cardiovascular side
effects of terfanadine and
astemizole
Non sedating
Demonstrated efficacy for AR
symptoms
Wide Therapeutic Window of Second
Generation Antihistamines
 The second generation H1-antihistamines
have a rapid onset of action with
persistence of clinical effects for at least 24
hours, so these drugs can be administered
once a day.
 They do not lead to the development of
tachyphylaxis and show a wide therapeutic
window (e.g. fexofenadine)
 Significance of wide therapeutic window
(fexofenadine)

Maximum
Studied dose
(Fexo 1380 mg)

Not tested for

Ineffective Therapeutic Window adverse effects

Low H1-antihistamine dose High

Minimally
effective dose
(Fexo 60 mg)

Howarth PH. Advanced Studies in Medicine. 2004;4(7A):S508-512

Third Generation AH
Minimal side effects
Increased duration of action
Positive effect on nasal airflow
Reduction in nasal congestion
Effects of leukotrienes on airways
 Increased levels in nasal fluid after allergen
challenge
 Contribute to both early and late phase
 Nasal congestion
 Sneezing, rhinorrhea
 Chemoattractant for eosinophils
 Promote eosinophil adhesion
 Decrease eosinophil apoptosis
Leukotrine Inhibitors:
 Competitively block binding of leukotrines to end
organs.
 Montelukast is only FDA approved Leukotrine
inhibitor
 Montelukast reduces exhaled Nitric oxide, a marker
for airway inflammation
 Montelukast works through LC C4 and D$ which are
found in upper airway
 Because Montelukast acts throughout the airway this
agent is a good choice for those with concurrent
Asthma and AR
Rationale for antihistamine-montelukast
combination in AR
 Histamine
 Responsible for rhinorrhea, nasal itching and
sneezing
 Less evident effect on nasal congestion
 Leukotrienes
 Increase in nasal airway resistance and
vascular permeability
Blockage or inhibition of these two mediators
may provide additional benefits compared to
single mediator inhibition
Intra-nasal Steroids
 Work mostly locally, thus avoid
unwanted side effects associated with
their oral or I/V use
 • Newer formulations show even
lower systemic absorption
 • Most effective against late-phase
mediators with some effect on acute
phase response.
Intra-nasal Steroids
 Should be used in a chronic manner
 Higher dose results in greater benefit
 Judicious use in children and
pregnant women recommended
 Large paed studies have not shown
significant adverse effects
Intra-nasal Steroids
 Firstline drug in seasonal AR
 However for perennial AR management with
I/N steroids alone has not proved to be as
beneficial
 Depending upon severity of disease short
courses of oral steroids in addition to topical
symptomatic relief more
 Fewer side effects (IOP)
Drug and Symptom Matrix
Drugs and Symptoms Sneezing Itching Rhinorrhea Congestion
Antihistamines
***** **** ***
Anticholinergics
(Ipratropium bromide)
*****
Corticosteroids
***** ***** *** ***
Decongestants
*****
Mast Cell Stabilisers
***** *** *
Antileukotrines
*** ** ****
 Algorithm for management of AR
Allergic Rhinitis

Intermittent Symptoms Persistent Symptoms

Mild Moderate/Severe Mild Moderate/Severe

Intranasal Steroid
• Oral H1 Blocker • Intranasal Steroid
• Intranasal H1 • Oral H1 Blocker
Blocker • Intranasal H1 Blocker Follow up after 2 wks.
• Leukotrine • Nasal Cromone
modifier • Leukotrine modifier
Improved Failed
In PAR Pt. FU after 2-4 wks.
Review Dx
Step down
If failure step up, if improved continue for one month Compliance

Intranasal Itch/sneeze add H1 Rhinorrhea add Blockage: add oral decongestant/steroid

Steroid Blocker Ipratropium short term
Immunotherapy
 Involves the sequential administration
of antigen to patients with
symptomatic, atopic conditions to
induce tolerance to offending
antigens
 Effective in treatment of both AR &
Asthma
 Generally safe and well tolerated
Immunotherapy
Injectable: Popular in US
Sublingual: Popular in
Europe
Intranasal: Under
investigation
Selections of candidates for IT
 Symptoms induced by allergen
exposure
 Patients with rhinitis and symptoms
from lower airway during peak
allergen exposure
 Insufficient control of symptoms with
AH and/or topical steroids
Summary…
 Allergic rhinitis is associated with several co-
morbidities and affects quality of life and productivity
 Second generation antihistamines are recommended
for treatment of allergic rhinitis in adults and children;
fexofenadine has proven efficacy, is devoid of
sedation and has wide therapeutic window
 Leukotrienes play key role in allergic rhinitis;
montelukast is most throroughly tested leukotriene
antagonist
Summary

 Antihistamine-montelukast combination seems

to be a more effective strategy than
monotherapy in the treatment of allergic
rhinitis in patients with moderate to severe
symptoms
 Fexofenadine-montelukast combination yields
significant reduction in nasal congestion and
nasal resistance in allergic rhinitis vs.
fexofenadine
Drug and Symptom Matrix
Drugs and Symptoms Sneezing Itching Rhinorrhea Congestion
Antihistamines
***** **** ***
Anticholinergics
(Ipratropium bromide)
*****
Corticosteroids
***** ***** *** ***
Decongestants
*****
Mast Cell Stabilisers
***** *** *
Antileukotrines
*** ** ****
Place in therapy for antihistamine-montelukast
combination

Allergic rhinitis with nasal

congestion
Allergic rhinitis with moderate-
to-severe symptoms
Blessings from the Holy City…….
Thankyou !!!!!!