- 1. Nathan Hare MD2/19/13Allergic Rhinitis
2. Outline Epidemiology Description Pathophysiology Triggers
Co-morbidities Local Allergic Rhinitis Treatment Environmental
Modifications Medications Subcutaneous Immunotherapy Sublingual
Immunotherapy 3. Allergic Rhinitis (AR) Affects 10-40% of children
world-wide 1 Affects up to 40% of children in the U.S. Affects
10-30% of adults in the U.S.21. Jamal J Al Sayyad1,*, Zbys
Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Editorial Group:
Topical nasal steroids forintermittent and persistent allergic
rhinitis in children Cochrane Ear, Nose and Throat Disorders Group,
Published Online:21 JAN 20092.
http://www.aaaai.org/conditions-and-treatments/library/allergy-library/rhinitis.aspx
4. Symptoms of Allergic Rhinitis Nasal Congestion Nasal Pruritus
Sneezing Rhinorrhea Post Nasal Drainage Daytime inattention
Irritability Hyperactivity 5. Bischoff Nature Reviews Immunology 7,
93104 (February 2007) | doi:10.1038/nri2018Pathophysiology 6.
Common Triggers for Allergic RhinitisSeasonal Perennial Tree Pollen
Grass Pollen Weed Pollen Mold Spores Dust Mites Cockroaches Cat Dog
Mouse (inner cityschools) *Permaul P, Hoffman E, Fu C, Sheehan W,
Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D,
Phipatanakul W.Allergens in urban schools and homes of children
with asthma.Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi:
10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.Exposure is to
airborne allergensHave to think of indoor exposure beyond the home
7. Inner City School Allergen Exposures Settled dust and airborne
allergen levels 12 schools, vs homes Mouse levels were substantial
Cat and Dog levels low, but were higher at school Dust mite and
cockroach levels were lowPermaul P, Hoffman E, Fu C, Sheehan W,
Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D,
Phipatanakul W.Allergens in urban schools and homes of children
with asthma.Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi:
10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6. 8. Allergic
Rhinitis: Comorbidities Important to remember impacts on
childrenbeyond the nose Asthma , eczema, food allergy(28%, 50%, 38%
of 108 4 yo pts w AR1) Oral Allergy Syndrome (25% of 8 year olds 1)
Sleep Disordered Breathing ADHD (?) Daytime inattention
Irritability Hyperactivity1. Westman M, Stjrne P, Asarnoj A, Kull
I, van Hage M, Wickman M, Toskala E.Natural course and
comorbidities of allergic and nonallergic rhinitis in children.J
Allergy Clin Immunol. 2012 Feb;129(2):403-8. doi:
10.1016/j.jaci.2011.09.036. Epub 2011 Nov 5. 9. AR & Sleep
Disordered Breathing inChildren Jan 2013 Review, covered last 25
years Ages 7-17 Case-series or Case-Control articles 10 articles
studied habitual snoring 6 articles studied OSA 12/18 articles:
statistically significant associationbetween AR and SDB Evidence
grade BLin SY, Melvin TA, Boss EF, Ishman SL.The association
between allergic rhinitis and sleep-disordered breathing in
children: a systematic review.Int Forum Allergy Rhinol. 2013 Jan
10. doi: 10.1002/alr.21123. [Epub ahead of print] 10. ADHD &
Allergic Rhinitis Taiwan Cross-sectional study: increased
prevalence of AR inADHD pts 1 Second study: Significant association
among ADHD, ticdisorder, and AR 2 Third study: increased prevalence
of ADHD in ARpatients (226,000 pediatric patients) 31. Chou PH, Lin
CC, Lin CH, Loh EW, Chan CH, Lan TH.Prevalence of allergic rhinitis
in patients with attention-deficit/hyperactivity disorder: a
population-based study.Eur Child Adolesc Psychiatry. 2012 Dec 30.
[Epub ahead of print]2. Chen MH, Su TP, Chen YS, Hsu JW, Huang KL,
Chang WH, Bai YM.Attention deficit hyperactivity disorder, tic
disorder, and allergy: Is there a link? A nationwide
population-based study.J Child Psychol Psychiatry. 2012 Nov 12.
doi: 10.1111/jcpp.12018. [Epub ahead of print]3.. Tsai MC, Lin HK,
Lin CH, Fu LS.Prevalence of attention deficit/hyperactivity
disorder in pediatric allergic rhinitis: a nationwide
population-based study.Allergy Asthma Proc. 2011
Nov-Dec;32(6):41-6. doi: 10.2500/aap.2011.32.3489 11. Local
Allergic Rhinitis Negative prick skin tests, negative
intradermalskin tests, negative allergen-specific serum IgE
Symptoms after nasal challenge with allergen Local
allergen-specific IgE produced afterchallenge with allergen
47-62.5% prevalence in European studiesRondn C, Campo P, Togias A,
Fokkens WJ, Durham SR, Powe DG, Mullol J, Blanca M.Local allergic
rhinitis: concept, pathophysiology, and management.J Allergy Clin
Immunol. 2012 Jun;129(6):1460-7. doi: 10.1016/j.jaci.2012.02.032.
Epub 2012 Apr 18. Review. 12. Allergic Rhinitis: Treatment Can we
change the environment to reduce thepatients exposure to triggers?
Can we modify the patients symptoms? Can we modify the patients
immune system? 13. Environmental Modifications Does pet ownership
make a difference in thedevelopment of AR? Dust Mite Avoidance
Measures Getting Rid of Pets if the patient is allergic Washing the
pet Keep windows closed and run the AC duringpollen and mold
seasons Clean any visible mold 14. Does Pet Ownership in
ChildrenChange Anything? 2012 International Survey Early-life
exposure to cats is a risk factor for rhinoconjunctivitis in 6- to
7-year-oldchildren, especially in less-affluent countries.
Brunekreef B, Von Mutius E, Wong G, Odhiambo J, Garca-Marcos L,
Foliaki S; ISAAC Phase Three Study Group.Exposure to cats and dogs,
and symptoms of asthma, rhinoconjunctivitis, and
eczema.Epidemiology. 2012 Sep;23(5):742-50. 15. Does Pet Ownership
in ChildrenChange Anything? Australian Birth Cohort Followed 620
infants for first 12 yrs of life Pets at birth either decreased or
had no effect onallergic disease up to age 12. We found no evidence
that exposure to cats ordogs at birth increases the risk of
allergic diseasein high-risk children.Lodge CJ, Lowe AJ, Gurrin LC,
Matheson MC, Balloch A, Axelrad C, Hill DJ, Hosking CS, Rodrigues
S, Svanes C, Abramson MJ, Allen KJ, Dharmage SPets at birth do not
increase allergic disease in at-risk children.Clin Exp Allergy.
2012 Sep;42(9):1377-85. doi: 10.1111/j.1365-2222.2012.04032.x. 16.
Does Pet Ownership in ChildrenChange Anything? 2012 Meta-analysis
Children ages 6-10 22,000 children from 11 European Birth
Cohortsfrom 1990s Owning a furry pet or bird during the first 2
yearsof life did not affect the risk of developing
allergicrhinitis.Ldrup Carlsen KC, Roll S, Carlsen KH, Mowinckel P,
Wijga AH, Brunekreef B, Torrent M, Roberts G, Arshad SH, Kull I,
Krmer U, von Berg A, Eller E, HKuehni C, Spycher B, Sunyer J, Chen
CM, Reich A, Asarnoj A, Puig C, Herbarth O, Mahachie John JM, Van
Steen K, Willich SN, Wahn U, Lau S, Keil T;GALEN WP 1.5 Birth
Cohorts working group.Does pet ownership in infancy lead to asthma
or allergy at school age? Pooled analysis of Individual participant
data from 11 European birth coPLoS One. 2012;7(8):e43214. doi:
10.1371/journal.pone.0043214. Epub 2012 Aug 29. 17. House dust mite
avoidancemeasures for perennial AllergicRhinitis 2010 Cochrane
Review, assessed as up to date endof 2009.1 9 trials (501
participants satisfied criteria) Mite-impermeable bedding covers (2
studies weregood quality) Acaricides (2 studies) HEPA filters (2
studies) Acaricides +/- covers (1 study)1. Aziz Sheikh1,*, Brian
Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial
Group:House dust mite avoidance measures for perennial allergic
rhinitisCochrane Ear, Nose and Throat Disorders Group Published
Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009 18. House
dust mite avoidancemeasures for perennial AllergicRhinitis
Conclusions: Trials to date small and of poor methodological
qualitydifficultto offer any definitive recommendations on the role
of housedust mite avoidance measures in the management of house
dustmite sensitive perennial allergic rhinitis. Use of acaricides
and extensive bedroom-based environmentalcontrol programmes may be
of some benefit in reducing rhinitissymptoms and, if considered
appropriate, these should be theinterventions of choice. Isolated
use of house dust mite impermeable bedding is unlikely toprove
effective.1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3,
Constant Paul van Schayck4 Editorial Group:House dust mite
avoidance measures for perennial allergic rhinitisCochrane Ear,
Nose and Throat Disorders Group Published Online: 7 JUL 2010
Assessed as up-to-date: 30 DEC 2009 19. Washing the PetDogs:Hodson
T, Custovic A, Simpson A, Chapman M, Woodcock A, Green R.Washing
the dog reduces dog allergen levels, but the dog needs to be washed
twice a weekJ Allergy Clin Immunol. 1999
Apr;103(4):581-5.Cats:Nageotte C, Park M, Havstad S, Zoratti E,
Ownby D.Duration of airborne Fel d 1 reduction after cat washing.J
Allergy Clin Immunol. 2006 Aug;118(2):521-2. Epub 2006 Jun 27.Drop
in Cat allergen levels lasted only 1 day after washing. But, it was
pointed out thatGoetz DW.Washing the cat requires shampoo.J Allergy
Clin Immunol. 2007 Mar;119(3):758; author reply 758-9. Epub 2007
Jan 19. 20. What about HypoallergenicDogs? Hypoallergenic Breeds do
not exist. In this study, dogs from hypoallergenic breedshad higher
allergen levels in hair and coatsamples than control dogs.
Differences between breeds were small.Vredegoor DW, Willemse T,
Chapman MD, Heederik DJ, Krop EJ.Can f 1 levels in hair and homes
of different dog breeds: lack of evidence to describe any dog breed
as hypoallergenJ Allergy Clin Immunol. 2012 Oct;130(4):904-9.e7.
doi: 10.1016/j.jaci.2012.05.013. Epub 2012 Jun 22. 21. Treating
Symptoms Nasal Saline Irrigation Medications 22. Nasal Saline
Irrigation (SNI) Meta-analysis: 50 trials, >400 participants
Performed regularly up to 7 weeks 27.66% improvement in nasal
symptoms 62.1% reduction in medicine consumption 31.19%
acceleration of mucociliary clearancetime 27.88% improvement in
quality of life. no evidence showing that regular, daily
SNIadversely affects the patients health or causesunexpected side
effects.Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Msges
R.Nasal irrigation as an adjunctive treatment in allergic rhinitis:
a systematic review and meta-analysis.Am J Rhinol Allergy. 2012
Sep-Oct;26(5):e119-25. doi: 10.2500/ajra.2012.26.3787. 23. Nasal
Saline Irrigation in Children 4 week RCT, investigator blinded 220
children aged 5-9 yrs with seasonal AR 80 used hypertonic saline
(2.7%), 80 used normalsaline, 60 control subjects (no treatment)
Evaluated effect on Nasal symptoms(rhinorrhea, itching, sneezing,
nasalobstruction), swelling of turbinates, adenoidhypertrophy or
middle ear effusionMarchisio P, Varricchio A, Baggi E, Bianchini S,
Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito
S, Principi NHypertonic saline is more effective than normal saline
in seasonal allergic rhinitis in children.Int J Immunopathol
Pharmacol. 2012 Jul-Sep;25(3):721-30. 24. Nasal Saline Irrigation
in Children Hypertonic Saline: significant reduction in allareas
Normal Saline: significant reduction inrhinorrhea and sneezing
Control: no significant changeMarchisio P, Varricchio A, Baggi E,
Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C,
Patria F, Esposito S, Principi NHypertonic saline is more effective
than normal saline in seasonal allergic rhinitis in children.Int J
Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30. 25. Medications
Anti-histamines Oral, Intranasal Leukotriene-modifyingagents Oral
Steroids Oral, Intranasal Mast-cell stabilizers Intranasal 26.
Bischoff Nature Reviews Immunology 7, 93104 (February 2007) |
doi:10.1038/nri2018Pathophysiology 27. Antihistamines1st Generation
2nd Generation Diphenhydramine Hydroxyzine Chlorpheniramine
Brompheniramine Loratadine, Desloratadine Cetirizine,
Levocetirizine Fexofenadine Azelastine (Astelin, 5yrs, Astepro,
12yrs, intranasal) Olopatadine(Patanase, 6*Also thought to work as
a mast cell
stabilizer(http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021545s013lbl.pdf)
28. Leukotriene-Modifiers Montelukast (Singulair, 6 mo) Zafirlukast
(Accolate, 5 yrs) Zileuton (Zyflo, 12 yrs) 29. Intranasal
SteroidsLiquid Dry Powder Fluticasone(Flonase, 4 yrs)
Mometasone(Nasonex, 2yrs) Ciclesonide(Omnaris, 6 yrs)
Triamcinolone(Nasacort AQ, 2 yrs) Beclomethasone(Qnasl, 12 yrs old)
Ciclesonide(Zetonna, 12 yrs old) 30. Intranasal Steroids 6 week
study of beclomethasone, placebo, andplacebo/prednisone:
beclomethasone NOT INFERIOR to placebo inregards to suppression of
hypothalamic-pituitary-adrenal axis functionRatner PH, Miller SD,
Hampel FC Jr, Melchior A, Dunbar SA, Tantry SK.Once-daily treatment
with beclomethasone dipropionate nasal aerosol does not affect
hypothalamic-pituitary-adrenal axisAnn Allergy Asthma Immunol. 2012
Nov;109(5):336-41. doi: 10.1016/j.anai.2012.08.005. 31. Intranasal
Steroids in Children Cochrane Review published online 2009,
assessedas up to date 2006 3 trials, total 79 children
Beclomethasone or flunisolide vs. placebo Weak or unreliable
evidence for effectiveness.11. Jamal J Al Sayyad1,*, Zbys
Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Topical nasal steroids
for intermittent andpersistent allergic rhinitis in children
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group,
Published Online:21 JAN 2009 32. Intranasal Steroids with add-on
oralAntihistamine therapy in children 2010 Cochrane Review found
only 1 RCT with 24children (defined as under age 18).1 Sufficient
data not provided to answer question Conclusion: no evidence
available for benefit of add-onantihistamine treatment to
intranasal steroids for children withintermittent or persistent
allergic rhinitis. Take-away message: dont forget potential side
effects ofantihistamines, and keep in mind costs of adding a
secondmedication.1. Mona Nasser1,*, Zbys Fedorowicz2, Hamad
Aljufairi3, William McKerrow4Antihistamines used in addition to
topical nasal steroids for intermittent and persistent allergic
rhinitis in childrenEditorial Group: Cochrane Ear, Nose and Throat
Disorders GroupPublished Online: 7 JUL 2010 Assessed as up-to-date:
20 SEP 2009 33. Total Nasal Symptom Score Intensity of nasal
symptoms Rhinorrhea, Nasal itching, NasalObstruction, Sneezing0 =
No symptoms1 = Mild2= Moderate3= Severe Total Possible Score ranges
from 0 (no symptoms) to12 (maximum symptom intensity)Valero A,
Izquierdo I, Giralt J, Bartra J, del Cuvillo A, Mullol J.Rupatadine
improves nasal symptoms, quality of life (ESPRINT-15) and severity
in a subanalysis of a cohort of Spanishallergic rhinitis patients.J
Investig Allergol Clin Immunol. 2011;21(3):229-35. 34. Combination
Therapy: Intranasalsteroid & Intranasal antihistamine TNSS:
Total Nasal Symptom Score The TNSS improved 27.1% with fluticasone
nasalspray, 24.8% with azelastine nasal spray, and37.9% with the 2
agents in combinationRatner PH, Hampel F, Van Bavel J, Amar NJ,
Daftary P, Wheeler W, Sacks H.Combination therapy with azelastine
hydrochloride nasal spray and fluticasone propionate nasal sprayin
the treatment of patients with seasonal allergic rhinitis.Ann
Allergy Asthma Immunol. 2008 Jan;100(1):74-81. doi:
10.1016/S1081-1206(10)60408-5. 35. Combination Intranasal steroid
andAntihistamine Fluticasone and azelastine in the samedelivery
device Meta-analysis of 3 separatemulticenter, randomized,
double-blind, placebo- and active-controlled, parallel-group trials
Each trial conducted for 14 days duringdifferent allergy seasons
3398 patients (>11 yrs old) Moderate to severe seasonal
allergicrhinitisCarr W, Bernstein J, Lieberman P, Meltzer E,
Bachert C, Price D, Munzel U, Bousquet J.A novel intranasal therapy
of azelastine with fluticasone for the treatment of allergic
rhinitis.J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10.
doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13. 36. Combination
Intranasal steroid andAntihistamine Combination reduced mean
reflectivetotal nasal symptom score from baseline(-5.7 [SD, 5.3])
Fluticasone (-5.1 [SD, 4.9], P < .001) Azelastine (-4.4 [SD,
4.8], P < .001) Placebo (-3.0 [SD, 4.2], P < .001). Available
now as Dymista (12 yrs)Carr W, Bernstein J, Lieberman P, Meltzer E,
Bachert C, Price D, Munzel U, Bousquet J.A novel intranasal therapy
of azelastine with fluticasone for the treatment of allergic
rhinitis.J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10.
doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13. 37. Fig
E1Source: Journal of Allergy and Clinical Immunology 2012;
129:1282-1289.e10 (DOI:10.1016/j.jaci.2012.01.077 )Copyright 2012
American Academy of Allergy, Asthma & Immunology Terms and
Conditions 38. Inferior Turbinate Surgery after failedMedical
Treatment of Allergic Rhinitis 2010 Cochrane review was unable to
find anyrandomized controlled trials comparing this surgery
tocontinued medical treatment.11. Jemy Jose1,*, Andrew P
Coatesworth2, Inferior turbinate surgery for nasal obstruction in
allergic rhinitis after failedmedical treatment Editorial Group:
Cochrane Ear, Nose and Throat Disorders Group Published Online: 8
DEC 2010Assessed as up-to-date: 5 JUL 2010 39. Altering the Immune
Response Helminths (Worms) Subcutaneous Immunotherapy (Allergy
Shots) Sublingual Immunotherapy 40. Worms Why look? Helminths
modulate the naturalimmune responses of their human hosts, andmay
prevent or cure immune-mediated or allergicdiseases (e.g. allergic
rhinitis) in the host. Non-randomized studies support this
hypothesis.1 Trials using helminths like hookworm
(Necatoramericanus) or porcine whipworm (Trichuris suis)show that
they are safe and may be effectivetherapies for the control of the
aberrant intestinalinflammation seen in Crohns disease
andulcerative colitis.21. Ashley M Croft1,*, Peter Bager2, Sushil
Kumar3 Helminth therapy (worms) for allergic rhinitisEditorial
Group: Cochrane Ear, Nose and Throat Disorders Group Published
Online: 18 APR 2012 Assessed as up-to-date: 24 JUN 20112. Elliott
DE, Weinstock JV. Where are we on worms? Curr Opin Gastroenterol.
2012 Nov;28(6):551-6. doi: 10.1097/MOG.0b013e3283572f73. 41.
Helminth therapy (worms) forAllergic Rhinitis 2012 Cochrane Review,
assessed as up to date2011.1 They found 130 people 1.8 to 7.7x
increase in GI side effects vs placebo Insufficient evidence,
appears to be safe1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3
Helminth therapy (worms) for allergic rhinitisEditorial Group:
Cochrane Ear, Nose and Throat Disorders Group Published Online: 18
APR 2012 Assessed as up-to-date:24 JUN 2011 42. Allergy Injection
Immunotherapy (IT)for Seasonal Allergic Rhinitis 2009 Cochrane
Review1, assessed as up to date2006 51 of 1111 publications met
criteria 2871 participants (1645 active, 1226 placebo) Averaged 18
injections per participant Duration of IT 3 days to 3 years1.
Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian
Hurwitz4, Aziz Sheikh5, Stephen Durham6Allergen injection
immunotherapy for seasonal allergic rhinitisEditorial Group:
Cochrane Ear, Nose and Throat Disorders Group Published Online: 21
JAN 2009 Assessed as up-to-date: 13NOV 2006 43. Allergy Injection
Immunotherapy (IT)for Seasonal Allergic Rhinitis Symptom Scores
from 15 trials an overall reduction in the immunotherapy group(SMD
-0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication score
data from 13 trials an overall reduction in the immunotherapy
group(SMD of -0.57 (95% CI -0.82 to -0.33, p
