ALLERGIC RHINITIS WHEN ALL FAILS

1. ALLERGIC RHINITIS WHEN ALL FAILS ADIL WARIS

2. SPONSOR MESSAGE • BAYER SPONSORED SESSION

3. Diagnosis • Usually not difficult • Symptoms can be seasonal or perineal • Allergic salute • Allergic crease • Look up nostrils at the inferior turbinates

4. Investigations • Usually not needed • Eosinophilia • Serum IgE • Skin prick allergy test

5. Real six pack

6. TREATMENT 1 Antihistamines • For how long • Value of changing molecules • 6 percent alcohol • Systemic delivery or local • For mild disease • For rhinorrhea • For sneezers

7. TREATMENT 2 Nasal steroids • Treatment of choice for blockers especially • Little side effects • Local application • Changing molecules • Different preservatives and propellents • Some with antihistamines • Onset of action 7 days and wears off in 7 days • BanovC, LaForce C, Lieberman P. Double blind trial of Astelin nasal spray in the treatment of vasomotor rhinitis. Ann Allergy Asthma Immunol 2000; 84:138.

8. TREATMENT 3 Saline douches • Washes out the cytokines • Do it before the steroid spray • Sea sprays • Saline sprays

9. TREATMENT 4 Montelukast • Systemic • Quick onset • Not all benefit • Useful is asthma is onboard

10. Cromolyn sodium nasal spray • 1-2 sprays 3-4 times daily • No adverse effects • Cromolyn is less effective than glucocorticoid nasal sprays • Controlling mild symptoms.

12. Ipratropium bromide • 0.03 percent nasal spray • Decreasing rhinorrhea • Decreasing the release of substance P. • less effective than glucocorticoid nasal sprays • Useful in children or adults who have profuse rhinorrhea not otherwise controlled with topical nasal corticosteroids • Adult patients with concomitant allergic and nonallergic (or vasomotor) rhinitis. 

13. TREATMENT 5 Prevention • Allergy testing • House dust mite • Grass pollens especially Bermuda grass • Mould spores • Milk • Animal dander … remove pet all or nothing /hypoallergic animals • Other foods very unlikely

14. RESULTS • Children aged 1 to 18 years • 2005 to date • 1150 patients results • Atopic asthmatics • Allergic rhinitis • Combinations of above

15. POLLENS Mould Mix445- 38.7% Bermuda Grass251- 21.8% Grass Pollen Mix193- 16.8% Tree Pollens Mix149 - 12.9% Weed Pollen Mix38- 0.03% Pyrethrum4- 0.003% Aspergillus2- 0.001%

16. LIVING CREATURES House dust mite 704 - 61.2% Cat405- 35.2% Cockroach372- 32.3% Dog335 - 29.1% Feathers320- 27.8% Horse5- 0.004% Rabbit5- 0.004%

17. FOODS Egg White160- 13.9% Milk155- 13.4% Soya140- 12.1% Citrus Mix68- 5.9% Egg Yolk44- 3.8% Cereal mix26- 2.2%

18. NON ATOPIC STATE DEFINED All negative 83 - 7.2%

20. Nasal decongestant sprays • Phenylephrine,oxymetazoline, xylometazoline, and naphazoline. • Downregulation of the alpha-adrenergic receptor develops after three to seven days, • Rebound nasal congestion may result. • Then viscious cycle --eventual dependency -- rhinitis medicamentosa. 

21. Chronic nonallergic rhinitis • 50 percent of patients with chronic rhinitis have a component of nonallergic rhinitis • Perennial symptoms and mild or absent nasal itching and sneezing. • Chronic nasal congestion and/or rhinorrhea changes in temperature and relative humidity, odors, or alcohol. • They have little nasal itching or sneezing. • Headaches, anosmia, and sinusitis are common. • Negative skin tests to inhalant allergens. • Include vasomotor rhinitis, gustatory rhinitis, and nonallergic rhinitis with nasal eosinophilia syndrome. 

22. Nasal hyperreactivity • Non IgE mediated • Biomass fuels • Oudh and incense • Smokers • Mossi chips and coils • Painting /varnishing • Scented candles

23. Nasal hyperreactivity • Karvol/ vicks /Echinacea • Humidifiers …mould counts • Vaporisers

24. Chronic rhinosinusitis  • Inflammatory condition involving the paranasal sinuses and linings of the nasal passages • CRS can coexist with allergic rhinitis • Requires anytwo of the following symptoms, present for at least 12 weeks: • •Anterior and/or posterior mucopurulent drainage • •Nasal obstruction • •Facial pain, pressure, and/or fullness • •Decreased sense of smell

25. Rhinitis due to systemic medications • Birth control pills, antihypertensive drugs (alpha-adrenergic blockers, beta-adrenergic blockers, angiotensin-converting enzyme [ACE] inhibitors), erectile dysfunction drugs, and NSAIDs. • Psychiatric medications chlorpromazine, thioridazine, perphenazine, chlordiazepoxide, amitriptyline, and alprazolam. • cyclosporine and mycophenolic acid

26. Alternative therapies • Traditional Chinese medicine (TCM) includes herbal therapy, acupuncture, massage, and dietary therapy. • Studies of acupuncture for the treatment of allergic rhinitis have shown modest benefit • There are several herbal therapies that have demonstrated efficacy, including Ayurvedic mixes, butterbur, and Tinosporacordifolia. • Nasal sprays consisting of dilute solutions of capsaicin have shown efficacy for allergic rhinitis in randomized trials when administered several times daily. • National Center for Complementary and Alternative Medicine. Expanding Horizons of Health Care: Strategic Plan 2005-2009. NIH publication no. 04-5568, National Center for Complementary and Alternative Medicine; NIH, Bethesda, MD 2005.

27. Allergic rhinitis under in infancy • Does it exist • Airway sensitization • Role of milk allergy via breast milk • Ng ML, Warlow RS, Chrishanthan N, et al. Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (I). ClinExp Allergy 2000; 30:1314.

28. NEVER FORGET • Are the patients adherent • Is the inhaler technique for the nose spray correct • Douche first then steroid spray • Have you treated asthma?

29. Kenya future • Allergen immunotherapy … takes long and do you have the correct ingredients