Allergic rhinitis lecture 100829
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The document outlines essential information regarding allergic rhinitis, its prevalence, diagnosis, and treatment strategies. It highlights the importance of accurate diagnosis, patient education, and the association between allergic rhinitis and comorbid disorders like asthma. It also discusses various treatment options, including avoidance strategies and medications, as well as the economic burden of allergic rhinitis on healthcare.
![Additional medications Decongestants: oral (-D, OTC e.g. Sudafed) are somewhat helpful Do NOT use topical OTC sprays – potent BUT addicting (e.g. Afrin, Vicks 4-way) Leukotriene receptor antagonist (Montelukast [Singulair]): not as effect as antihistamines or intranasal steroid sprays, so not first line therapy Saline nasal rinses to cleanse the nasal and sinus cavities. Use volume, several times per day Gargle to reduce post-nasal drip with dilute mouthwash](https://image.slidesharecdn.com/allergicrhinitislecture100829-100828193955-phpapp01/85/Allergic-rhinitis-lecture-100829-34-320.jpg)
Allergic rhinitis lecture 100829
- 2. Neil L. Kao, M.D. Board Certified Allergist President of Board of Directors Upstate Region of South Carolina American Lung Association 2008-11
- 3. What do practitioners need to know? Necessity of making an accurate diagnosis Association with comorbid disorders Need for patient and family education Routine followup is required Safe, effective, well tolerated therapy Role of active management in allergic rhinitis
- 4. The Burden of Allergic Rhinitis 50% patients symptomatic > 4 months/year 20% patients symptomatic > 9 months/year 10,000 children out of school daily 10,000,000 office visits annually 2,000,000 days of missed school $5.3 billion for direct and indirect costs in year 1996 And this accounts only for allergic rhinitis, nonallergic rhinitis is another issue Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis
- 7. Definition of Allergic Rhinitis Rhinitis is an inflammation (type 1) of the mucous membranes of the nose. Allergic rhinitis involves reactions in the nasal mucosa from repeated allergen exposures that causes immediate hypersensitivity. These reactions may be seasonal or perennial.
- 9. Allergic Rhinitis and Other Comorbid Disorders Sinusitis Otitis media, serous otitis, dizzyness Allergic conjunctivitis Swollen adenoid, tonsils, lymph nodes Dentofacial abnormalities Sleep disorders with snoring Asthma
- 10. One Airway Hypothesis PREVALENCE of asthma is 4x more common patients with allergic rhinitis Allergic rhinitis is present in 85% of patients with asthma IMMUNE PATHWAYS are shared between the upper and lower airways Investigate: patients with persistent rhinitis for asthma and patients with persistent asthma for rhinitis Treatment strategies should combine the treatments of upper and lower airways in terms of safety and efficacy Optimal treatment of allergic rhinitis results in reduced bronchial hyperresponsiveness, fewer emergency visits for asthma, frequency of asthma exacerbations, and the need for inhaled corticosteroids.
- 11. Epidemiology Of Allergic Rhinitis Allergic rhinitis was reported the second most prevalent chronic condition in the United States in 1994 Affects 40 to 50 million people Incidence highest in people ages 15-25 years Affects 20% to 30% of adults, 40% of children In one study, 57% of patients with chronic rhinitis had nonallergic or mixed rhinitis
- 12. Natural History of Allergic Rhinitis Onset common in childhood, adolescence & early adulthood Symptoms often wane in older adults, but may develop at any age or persist at any age No gender selectivity May contribute to: sleep disorders, fatigue, learning problems
- 14. Allergy History Screen
- 15. What Medications are Your Patients Taking? Patients will self-medicate because they are consumers Over-the-counter medications Under-medicate or over-medicate or both Beware rhinitis medicamentosa Were they compliant and properly instructed? Did they use a friend’s or family member’s medications for relief? Ask the questions to get the true history
- 19. Physical Examination Allergic shiner Dennie Morgan line Allergic crease, congested nasal breathing, sniffling Allergic salute, mouth breathing Nasal mucosa: may appear normal or pale bluish, swollen, with watery secretions Exclude structural problems (polyps, deviated nasal septum) Others: nasal voice, frequent snoring, coughing, repetitive sneezing, malaise, irritability
- 20. Diagnosis of Allergic Rhinitis History Physical / Nasal Examination Nasal smear for eosinophils, WBC, bacteria Skin Prick Test (in vivo) > serum RAST, as in more accurate, quicker. Recommended by A.C.P. unless Skin Tests can not be done Blood: CBC/diff, IgE levels (poor screening tests)
- 21. Allergy Prick Skin Tests
- 22. Causes of Rhinitis Allergy NARES syndrome Occupational, hobbies Hormonal Drug induced Anatomic defects Infections, viral Irritants Adverse food reaction Emotional Atrophic Ciliary dyskinesia Immunodeficiency diseases
- 24. Allergic Rhinitis Therapy Empathy, compassion, hope Education Avoidance of triggers Medications Allergy Immunotherapy (shots) Followup Allergy action plan
- 25. Educational Resources American Academy of Allergy, Asthma, and Immunology -- http://www.aaaai.org American College of Allergy, Asthma, and Immunology – http://www.acaai.org Asthma & Allergy Foundation of America - http://www.aafa.org Allergy & Asthma Network/Mothers of Asthmatics, Inc. -- http://www.aanma.org Our website has pollen counts -- http://www.allergicdisease.com
- 26. Pollens Keep windows closed Change clothes & remove shoes when coming inside after being outdoors Use air conditioning Monitor pollen counts at National Allergy Bureau (www.aaaai.org/nab) We are the only certified site in SC
- 27. Weed pollen count Mold spore count Tree pollen count Grass pollen count
- 28. Mold Reduce humidity in the home below 40% Clean surfaces with bleach solution If flooding occurs, discard affected belongings with mold growth
- 29. Cats, dogs, mammal pets, birds Find a new home for pets Keep pets outdoors (94, 78, 15, 16) Keep pets of beds, furniture, carpets Consider removing carpeting and upholstered furniture Use a HEPA-filtered vacuum cleaner Use HEPA air filtration
- 30. Dust mites Reduce humidity below 40% with a dehumidifier or air conditioner Consider removing upholstered furniture and carpet from bedroom and rooms Encase pillows and mattresses with allergen covers Wash bedding weekly in hot water
- 31. Avoid irritants Smoke or exhaust from any source Paints, glues, cleaning products, aerosols, perfumes Photocopier exhaust Paper dust Dry wall board dust
- 32. Anti-Histamine medications Act by preventing histamine from binding to its receptors Primarily helpful in controlling sneezing, itching, runny nose; ineffective in relieving nasal congestion 1 st generation anti-histamines (short half-life, sedating, older): chlorpheniramine (OTC), diphenhydramine (OTC) (Benedryl) 2 nd generation anti-histamines (long half-life, no or lower sedating, newer, preferred): cetirizine (OTC) (Zyrtec), loratadine (OTC) (Alavert, Claritin); prescription azelastine (Astepro nose spray), fexofenadine (Allegra), desloratadine (Clarinex) , olopatadine (Patanase nose spray) , levocetirizine (Xyzal)
- 33. Intranasal corticosteroid sprays Potent topical activity: all have equal efficacy Administration of low doses directly at site of action High topical:systemic activity ratios Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity Markedly greater inhibition of immediate allergic reaction due to histamine than with oral steroids No effect on growth or eyes
- 34. Additional medications Decongestants: oral (-D, OTC e.g. Sudafed) are somewhat helpful Do NOT use topical OTC sprays – potent BUT addicting (e.g. Afrin, Vicks 4-way) Leukotriene receptor antagonist (Montelukast [Singulair]): not as effect as antihistamines or intranasal steroid sprays, so not first line therapy Saline nasal rinses to cleanse the nasal and sinus cavities. Use volume, several times per day Gargle to reduce post-nasal drip with dilute mouthwash
- 35. Allergy Immunotherapy (Injections) Only therapy that can raise T-cell tolerance back to normal levels to allergens so there is no allergic immune response Indications: 1) when medications and avoidance don’t work; 2) can’t tolerate adverse effects from medications; 3) severe $ burden from cost of meds; 4) many comorbid disorders; 5) complications and getting worse, developing asthma Best practices: from a board certified allergist
- 36. Concept of "minimal persistent inflammation“ causing chronic disease Threshold level for symptoms Symptoms inflammation Ciprandi et al, J Allergy Clin Immunol 1996 An inflammatory process which is actually present even in asymptomatic subjects who are exposed to allergens 0 , 1 1 1 0 1 0 0 0 2 4 6 8 1 0 1 2 M o n t h s mite allergen (µg/g of dust) Minimal persistent inflammation
- 38. What do practitioners need to know? Necessity of making an accurate diagnosis Association with comorbid disorders Need for patient and family education Routine followup is required Safe, effective, well tolerated therapy Role of active management in allergic rhinitis
- 40. Let us,then, be up and doing, With a heart for any fate; Still achieving, still pursuing, Learn to labor and to wait. Henry Wadsworth Longfellow
Editor's Notes
- #2: When was it built? By whom? Why? Art appreciation like in JAMA. The Taj Mahal is a mausoleum located in Agra , India , that was built under Mughal Emperor Shah Jahan in memory of his favorite wife, Mumtaz Mahal . The Taj Mahal is considered the finest example of Mughal architecture , a style that combines elements from Persian , Turkish , Indian , and Islamic architectural styles. Taj Mahal is an integrated symmetric complex of structures that was completed around 1648.
- #8: In people with allergies, the immune system is overly sensitive to substances such as animal dander, molds, pollen, etc. With repeated exposure they build up a sensitivity to these allergens. This sensitivity then causes allergic reactions.
- #14: The Eiffel Tower was named after it’s designer, Gustav Eiffel. It is located along the Seine River in Paris. When it was completed in 1889, it was the tallest structure in the world.
- #24: The Pietà ( 1498 – 1499 ) by Michelangelo is a marble sculpture in St. Peter's Basilica in Vatican City , the first of a number of works of the same theme by the artist. The statue was commissioned for the French cardinal Jean de Billheres , who was a representative in Rome. The statue was made for the cardinal's funeral monument, but was moved to its current location, the first chapel on the right as one enters the basilica, in the 18th century . This famous work of art depicts the body of Jesus on the lap of his mother Mary after the Crucifixion .
- #25: Avoidance of allergens when possible is the most important aspect of allergy treatment. Decreasing exposure to allergens results in improvement in symptoms and less need for medications. Total avoidance of allergens is usually not possible, so medications are usually necessary. Fortunately we have many safe and effective medications for allergies. Allergy injections are usually reserved for those patients whose symptoms are not controlled by avoidance and medications. Allergy injections can be very effective in certain patients with certain allergies, but should be prescribed and administered by physicians with training or experience in this kind of therapy.
- #36: For allergy shots to be effective, they have to be used in the proper dose, for the proper allergens, and only when the patients allergies fit the pattern of symptoms. In other words, a patient should not be on allergy shots to grass, when their symptoms only occur in the winter.
- #40: Mona Lisa , or (La Joconde) is a 16th-century portrait painted in oil on a poplar panel by Leonardo Da Vinci during the Italian Renaissance . It is arguably the most famous painting in the world, and few other works of art have been subject to as much scrutiny, study, mythologizing and parody. The work is owned by the French government and hangs in the Musée du Louvre in Paris , France with the title Portrait of Lisa Gherardini, wife of Francesco del Giocondo . The painting is a half-length portrait and depicts a woman whose expression is often described as enigmatic. The ambiguity of the sitter's expression, the monumentality of the half-figure composition, and the subtle modeling of forms and atmospheric illusionism were novel qualities that have contributed to the painting's continuing fascination.