Khaled R. Girgis, MD, PhD Allergist and Clinical Immunologist

1. Khaled R. Girgis, MD, PhDAllergist and Clinical Immunologist College Park Family Care Center 12208 W 87th Street Lenexa, KS 66215

2. Allergic Rhinitis Everything you need to know, almost

3. Allergic Rhinitis, Facts • More than 50 million Americans suffer from allergies • Sixth leading chronic disease in U.S. • 4.5 billion dollars in health care costs annually • 3.8 million days lost yearly (from work and school)

4. What is Rhinitis? • The nasal passages are lined with a membrane that produces mucus • Mucus is one of the body's defense systems: • Thin clear liquid, traps small particles and bacteria • The trapped bacteria usually remain harmless in healthy individuals • Even under normal circumstances, this produces a cycle of congestion and decongestion that occurs continuously throughout the day • When one side of the nose is congested, air passes through the open, or decongested, side. The sides alternate between being wide open and being narrowed

5. Allergic Rhinitis:Effect On Quality of Life • People with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. • Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms. • Patients with seasonal allergies experience hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, people are not aware that they wake up, but such events can cause fatigue the next day.

6. Allergic Rhinitis:Effect On Quality of Life • Children with severe allergies may have a higher risk for behavioral problems than those without allergies • There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media) • Chronic nasal obstruction can affect a child's appearance. If a child can only breathe through the mouth, this might lead to an elongated face and an overbite from teeth coming in at an abnormal angle • Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth

7. Allergic Rhinitis: Risk Factors • Increasing age, atopy, and high socioeconomic status • Parental history is also positively associated with development of allergic rhinitis. A maternal history of allergy was significantly associated with a diagnosis of rhinitis by age 6 years • Other risk factors include indoor and outdoor air pollution

8. Sagittal view of the inside of the nasal cavity

9. Allergic Rhinitis: Mechanism

10. Allergic Rhinitis: Symptoms • Rhinitis develops when congestion becomes severe or other changes occur that irritate the nasal passage • Patient must experience at least two of the following symptoms for an hour or more on most days: • Runny nose • Obstruction in the nasal passage • Nasal itching • Sneezing • These symptoms may occur as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors

11. The Allergic Appearance: Allergic shiners related to chronic nasal congestion Mouth breathing and a gaping mouth

12. The Allergic SaluteNasal itching causes repeated wiggling of the nose (bunny nose), or wiping and pushing of the nose

13. Chronic Rhinitis • When rhinitis lasts for a long period, it is most often caused by allergies but can also be caused by structural problems or chronic infections.

14. Chronic Rhinitis Not Related to Allergies • Aging Process • Mucous membranes become dry with age • Cartilage supporting the nasal passages weakens, causing changes in airflow • Therapy: Avoid possible allergens and airborne irritants and keep the nasal passages moist. Decongestants would not be appropriate

15. Vasomotor Rhinitis: Chronic Rhinitis Not Related to Allergies • Increased parasympathetic stimulation • Overreaction to irritants, cigarette smoke, air pollutants, strong odors, alcoholic beverages, stress, and exposure to cold • Gustatory rhinitis • Not the same as allergic reaction

16. Chronic Rhinitis Not Related to Allergies • Foreign Objects • Blockage in young children is very often caused by foreign objects • If left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling (very)

17. Chronic Rhinitis Not Related to Allergies • Polyps • soft, fluid-filled sacs • impede mucus drainage and restrict airflow • develop from sinus infections, do not regress on their own and may multiply and cause considerable obstruction • Deviated Septum • A common structural abnormality that causes rhinitis When deviated, it is not straight but shifted to one side, usually the left

18. Nasal Polyps • Protrude from the sinuses into the nasal cavities, usually from the middle meatus • Can be unilateral, or bilateral • Anosmia, most common presentation • Very common in CF • 50% of children (4-16 y/o) w/ nasal polyps have CF

19. Rhinitis of Pregnancy • One in five pregnant women will experience rhinitis symptoms (2nd or 3rd trimester) • Hormonally induced • Spontaneously resolves within few weeks after delivery • Limited therapeutic options

20. Drug-Induced RhinitisChronic Rhinitis Not Related to Allergies • Medications and Illegal Drugs • overuse of decongestant sprays can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis, Rhinitis Medicamentosa • Aspirin, Ibuprofen (Motrin, Advil), and Naproxen (Aleve) For minor pain, Acetaminophen (e.g., Tylenol), is usually recommended for patients with intolerance to NSAIDs. • Oral contraceptives, hormone replacement therapy, anti-anxiety agents, some antidepressants, and some blood pressure medications, including beta-blockers and vasodilators • Sniffing cocaine damages nasal passages and can cause chronic rhinitis

21. Local Allergic Rhinitis • Patients demonstrate Allergic Rhinitis symptoms but without other systemic manifestations • Negative SPT and negative RAST • Diagnosis: Nasal provocation and detection of specific IgE in nasal mucosa

22. Allergic Rhinitis: Diagnosis • Allergy Testing • Skin testing and in-vitro blood testing • Testing is important to institute specific avoidance measures • Skin testing is slightly more sensitive • Common allergens • Outdoors: tree, grass, weed pollens, and mold • Indoors: dust mites, pet dander, cockroaches and mold

23. Allergic Rhinitis: Diagnosis • Imaging studies • X-rays have a limited value • CT scans are preferred for evaluation of sinusitis • Endoscopy • Usually performed by an ENT physician, allows easy evaluation of the nose, and throat areas

24. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Pets: • If patient is allergic to pets, they should be given away or kept outside • If this isn't possible, they should at least be confined to carpet-free areas outside the bedroom • Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems • Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, are now available for pets that remove allergens from skin and fur and are easier to administer than wet shampoos.

25. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Dust Control • simply using a spray furniture polish is very effective for reducing both dust and allergens • Air cleaners, filters for air conditioners, and vacuum cleaners with HEPA filters can help remove particles and small allergens found indoors • Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens • Carpets and rugs should be avoided if possible

26. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Bedding and Curtains • Using semipermeable coverings to fully encase mattresses, box-springs and pillows is the most proven effective step in reducing dust mite levels • Curtains should be replaced with shades or blinds • Bedding should be washed using the highest temperature setting

27. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Reducing Humidity in the House • Dust mites thrive in humidity and damp houses increase the risk for mold • On-going humidifiers, then, can be counterproductive. If they are used, humidity levels should not exceed 40% and they should be cleaned daily with a vinegar solution

28. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Exterminating Pests • Cockroaches: eliminate by professional exterminators. (One study reported that ridding a home of cockroaches and cleaning the house using standard housecleaning techniques failed to eliminate the cockroach allergens themselves.) • Mice should be eliminated, attempts should be made to remove all dust, which might contain mouse urine and dander.

29. Allergic Rhinitis: TreatmentAvoidance/Outdoor Protection • Camping and hiking trips should not be scheduled during times of high pollen count (in the Northern states, May and June for grass pollen and mid-August to October for ragweed). • Patients who are allergic to mold should avoid barns, hay, raking leaves, and mowing grass. • Fungi in car air conditioners can also be a problem.

30. Allergic Rhinitis: Medical Treatment

31. Allergic Rhinitis:Second-Generation (Nonsedating) Antihistamines • The newer second-generation antihistamines do not usually cause drowsiness to the extent that the first generation antihistamines do. • Brand Names. • Loratadine (Claritin) is approved for children age two and over. OTC • Desloratadine (Clarinex) is similar to Claritin but significantly more potent and longer lasting. It is available only by prescription. • Cetirizine (Zyrtec) is approved for both indoor and outdoor allergies. It is the only antihistamine to date approved for infants as young as six months. OTC • Fexofenadine (Allegra) OTC • Levocetirizine (Xyzal) only by prescription • Studies suggest that cetirizine (Zyrtec) is more effective than either of these other agents in improving symptoms, including in children, although cetirizine causes more drowsiness at higher doses.

32. Allergic Rhinitis: Oral Decongestants • Oral decongestants come in many brands, which mainly differ in their ingredients. • The most common active ingredient is pseudoephedrine (Sudafed, Actifed, Drixoral). The alternative decongestant, phenylpropanolamine (PPA) was taken off the market.

33. Allergic Rhinitis: Oral Decongestants • Side Effects of Decongestants • Agitation and nervousness. • Drowsiness (particularly with oral decongestants and in combination with alcohol). • Changes in heart rate and blood pressure. • Avoid combinations of oral decongestants with alcohol or sedatives.

34. Allergic Rhinitis: Corticosteroid Nasal Sprays • Benefits: • The most effective agents currently available for treating allergic rhinitis. • Blocks the inflammatory response that triggers an allergic attack. They do not relieve symptoms immediately but may take several hours before their effects are felt. • They reduce inflammation and mucus production. • They improve night sleep and daytime alertness in patients with perennial allergic rhinitis. • Beneficial in treating polyps in the nasal passages.

35. Allergic Rhinitis: Corticosteroid Nasal Sprays • Corticosteroids available in nasal spray form include the following: • Triamcinolone (Nasacort). Approved for children over six, now OTC!!! • Mometasonefuroate (Nasonex). Approved for use in patients as young as three. • Fluticasone (Flonase). Approved for children over four. • Budesonide (Rhinocort). Approved for children over six.

36. Nasal Antihistamines • Efficacious and equal to or superior to oral antihistamines for treatment of SAR • Clinically significant effect on nasal congestion • Improved nasal symptoms in patients who failed oral antihistamines • Onset of action: 30 vs. 60-180 minutes for oral antihistamine • Side effects: Sedation, bitter taste

37. Nasal Antihistamines • Azelastine 0.1% and 0.15% (Astelin, Astepro) • Olopatadine (Patanase) • Azelastine/Fluticasone (Dymista)

38. Allergen Immunotherapy • Criteria for Allergen Immunotherapy • Severity of rhinitis symptoms • Duration of rhinitis symptoms • Progression of rhinitis • Failure to respond to medical treatment

39. Allergic Rhinitis: Allergen Immunotherapy • Administering Therapy • Immunotherapy requires a prolonged course of weekly injections ("allergy shots"). The process generally follows this course: • Injections of diluted extracts of the allergen are given on a regular schedule, usually weekly at first, then in increasing doses until a maintenance dose has been reached. It usually takes several months to reach a maintenance dose. • At that time, intervals between shots can be two to four weeks, and the treatment is continued for up to three to five years. • Patients can experience some relief within three to six months; if there is no benefit within 18-24 months, the shots should be discontinued.

40. Allergic Rhinitis:Conclusions • Allergic disorders are on the rise and have a significant impact on the quality of life • Allergic rhinitis can lead to other comorbidities such as asthma and sinusitis • Treatment should focus on trigger identification and avoidance, medications and allergen immunotherapy

41. References • Dykewicz MS, et al. Ann Allergy Asthma Immunol1998;81(5 Pt 2):478-518 • Rondon et al. J Investig Allergol Clin Immunol 2010; 20(5): 364-371 • Wallace et al. J Allergy Asthma ClinImmunol2008; 122: S1-84 • M. Varghese, M. C. Glaum and R. F. Lockey, Clinical & Experimental Allergy, 2010 (40) 381–384