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Alfred Tam
MBBS(HK), FRCP(Edin., London, Glasg.) FHKCPaed, FHKAM(Paediatrics)
IgE mediated
Ever rhinitis Current rhinitis Current rhinoconjunctivitis Ever eczema 1995 (3618) 2001(4448)
HK
3110
BJ
4227
GZ
3565
Wheeze
Rhinoconjunctivitis
5.8(5.0-6.7)
15.0(13.9-16.4)
3.8(3.3-4.4)
6.7(5.9-7.5)
3.4(2.8-4.1)
7.4(6.6-8.3)
Flexural eczema
3.8(3.1-4.5)
2.2(1.8-2.7)
1.8(1.4-2.3)
%(95%CI) Numbers
HK 1341
BJ 1044
GZ 1098
Atopic
D. pter D. far Cat Cockroach
41.2(38.5-43.8)
34.1(31.5-36.6) 25.9(23.5-28.2) 3.7(2.7-4.7) 11.5(9.8-13.2)
23.9(21.3-26.4)
7.5(5.9-9.1) 5.7(4.3-7.1) 5.6(4.2-6.9) 13.3(11.3-15.4)
30.8(28.1-33.5)
20.0(17.6-22.4) 17.9(15.6-20.2) 4.3(3.1-5.5) 17.8(14.8-19.2)
Symptoms
Ever allergic rhinitis Allergic rhinitis in past 12 months Allergic rhinoconjunctivitis in past 12 months AR limiting activities Ever hay fever Doctor diagnosed hay fever
%
34.9 27.6 10.7 17 7.8 11.2
n
338 267 104 165 76 109
Skin test
Higher sensitivity Immediate results Requires expertise Cheaper
Foreign body in the nose Rhinitis associated with physical or chemical factors Drug, food induced rhinitis NARES, aspirin sensitivity Vasomotor rhinitis
Short Form Health Survey (SF-36) Profiles of Patients with Allergic Rhinitis
90 85 80 controls (n=139) allergic rhinitis (n=312)
* *
scale: 0 to 100
75
70 65 60 55 50
Physical Functioning
* * *
*
Role Physical Bodily Pain General Health Vitality Social Functioning Role Emotional Mental Health Change in Health
20
OR=11
15
Asthma (%)
10
OR=17
5 0
Atopic
Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; 104:301
Non atopic
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
Moderatesevere
one or more items . abnormal sleep . impairment of daily activities, sport, leisure . abnormal work and school . troublesome symptoms
in untreated patients
nasal obstruction
nasal itch
0 to + + 0 ++
+++ ++ 0 ++
++ 0
+
0 0 0
+
0 0 0
+
0 ++ +
+
0 0 0
0
++ 0 0
Anti-cholinergics Anti-leukotrienes
0 0
+++ +
0 ++
0 0
0 ++
Oral Antihistamines
First generation agents
Chlorpheniramine
Brompheniramine Diphenydramine Promethazine Tripolidine Hydroxyzine Azatadine
Newer agents
Acrivastine Azelastine Cetirizine Desloratadine Fexofenadine Levocetirizine Loratadine
Mizolastine
Nasal Antihistamines
Azelastine Levocabastine Olopatadine
* * * * *
*
* *
* * *
0.6
0.4
0.2
* P<0.05
1 wk 4 wk
6 mo
1 wk 4 wk
6 mo
1 wk 4 wk
6 mo
1 wk 4 wk
6 mo
1 wk 4 wk
6 mo
13.7%
6.3%
www.PDR.net
2.1%
1.8%
www.PDR.net
Fexofenadine 60 mg bid
Levocetirizine 5 mg qd Loratadine 10 mg qd
1.3%
0.9%
www.PDR.net
6.8%
1.8%
8%
6%
Minimal or no sedative effects Once daily administration Rapid onset and 24 hour duration of action
Pseudoephedrine
Phenylephrine
Oxymetazoline Xylometazoline
nasal turbinates
vasoconstriction
Decongestants
EFFICACY: Oral decongestants: moderate Nasal decongestants: high
ADVERSE EFFECTS: Oral decongestants: insomnia, tachycardia, hyperkinesia tremor, increased blood pressure, stroke (?) Nasal decongestants: tachyphylaxis, rebound congestion, nasal hyperresponsiveness, rhinitis medicamentosa
cytosolic phospholipase A2
leukotriene C4 arachidonic nucleus acid + 5-lipoxygenase activating protein 5-lipoxygenase leukotriene A4
leukotriene C4
leukotriene D4 leukotriene E4
leukotriene C4 synthase
-0.4
-0.6
*
placebo, N=149 montelukast, N=155
mean baseline=2.0 *p<0.01 vs placebo Adapted from Nayak, et al. Ann Allergy Asthma Immunol. 2002;88: 592
loratadine, N=301
Safety
Dyspepsia (approx. 2%)
Nasal Corticosteroids
Beclomethasone dipropionate
Budesonide Ciclesonide*
Flunisolide
Fluticasone propionate Mometasone furoate Triamcinolone acetonide
Nasal Corticosteroids
1 2 3
suppression of
Efficacy of Nasal Corticosteroid Sprays in Children with Allergic Rhinitis and Seasonal Symptoms
Nasal Corticosteroids
Most potent anti-inflammatory agents
Effective in treatment of all nasal symptoms including obstruction Superior to anti-histamines and anti-leukotienes First line pharmacotherapy for persistent allergic rhinitis
Nasal Corticosteroids
Overall safe to use Adverse Effects Nasal irritation Epistaxis Septal perforation (extremely rare) HPA axis suppression (inconsistent and not clinically significant) Suppressed growth (only in one study with beclomethasone)
Nasal Corticosteroid vs Placebo: Effects on 12-Hour Urinary Free Cortisol in 2-3 Year-Old Children
6-week treatment
Value of 1 indicates no change from baseline
1.0 0.8
0.98
SE=1.14 N=31
0.94
SE=1.15 N=29
Placebo
Environmental manipulations:
allergen avoidance Pollution treatment
Environmental Control
1. Allergens
Allergen Avoidance
Pets Remove pets from bedrooms and, even better, from the entire home Vacuum carpets, mattresses and upholstery regularly
To Conclude
Allergic rhinitis is very common and causes considerable morbidity Adequate and appropriate treatment leads to significant improvement in quality of life Co-morbid conditions are common and warrants special attention and treatment for optimal results Environmental manipulations is also important in the control of disease