1. A Quick Tour Of ALLERGIC RHINITIS Manjul Dixit, M.D.

2. Allergic Rhinits: 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

3. Interesting Facts • 10% to 20% of population have intermittent rhinitis • 30% to 50% of patients have persistent rhinitis • Up to 15% of patients are children 6 to 7 years of age • Up to 40% of patients are adolescents 13 to 14 years of age • 18% to 21% of patients are young adults 15 to 24 years of age • less than 8% of patients are adults over 65 years of age • Allergic rhinitis is one of the major 10 conditions that lead to medical consultation in U.S. managed-case populations

4. Clinical Manifestations • Repetitive sneezing • Eye symptoms • Watery rhinorrhea • Ear symptoms • Nasal pruritus • Postnasal drainage • Nasal congestion

5. Quality Of Life • Fatigue • Sleep Disorders • Learning Problems • Chronic Rhinosinusitis • Dental Abnormalities • Speech Disorders • Emotional problems • Impaired activity and social functioning • Poor perception of general health • > 800,000 missed days of work, school, and decreased productivity days • $5.4 to $7.7 billion dollars lost

6. Types of Rhinitis

7. Conditions that mimic rhinitis

8. The Allergic Reaction

9. ARIA Classification Moderate-severe one or more items • abnormal sleep • impairment of daily activities, sport, leisure • abnormal work and school • troublesome symptoms • Intermittent • < 4 days per week • or < 4 weeks • Persistent • ≥ 4 days per week • and ≥ 4 weeks Mild normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms ARIA Report 2001

10. Diagnosis of AR • History • Physical / Nasal Examination • Laboratory Testing - Skin Prick Test - Peak Nasal Inspiratory Flow Rate - Rhinomanometry

11. PHYSICAL EXAMINATION • Allergic shiner • Dennie Morgan line • Allergic crease • Allergic salute • Nasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic • Exclude structural problems (polyps, deflected nasal septum) Others: nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability

12. Why? -Trees: Spring and Fall Oak, Maple, Cedar, Olive and Elm - Grasses: Early Summer and Fall Kentucky Blue Grass, Orchard, Redtop, Timothy, and Bermuda -Weed: Late Summer and Fall Pigweed, Sage, Mugwort, lamb’s quarters -Outdoor Molds: Summer and Early Fall Alternaria and Cladosporium Dry and Windy days -Indoor Molds: Aspergillus and Penicillium -Pets -Cockroaches

13. Management of AR • Allergen Avoidance • Pharmacotherapy • Immunotherapy - Subcutaneous - Sublingual

14. Pharmacotherapy

15. Actions of Various Nasal Preparations in the Treatment of Rhinitis Antileukotrienes +++ ++ 0 ++++

16. The “Ideal” Drug For Allergic Rhinitis Should Have The Following Features: • Inhibit both early and late phases • Be an H1 blocker • Counter effects of other mediators • Fast-acting, to control the early phase • Dosing-od or bd for compliance • No side effects • Manage all symptoms • Intranasal administration

17. The “Ideal” Drugs Are…… “Corticosteroids are undoubtedly the pharmacotherapeutic agents with the broadest application for the treatment of many types of rhinitis”

18. Intranasal corticosteroid therapy • Potent topical activity • Administration of low doses directly at site of action • Considerable efficacy at low doses • High topical: systemic activity ratios • Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity • Markedly greater inhibition of EAR than with oral steroids

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