Allergic Rhinitis

OTC 2015

 Practice guideline for the treatment of allergic rhinitis. American

Academy of Otolaryngology–Head and Neck Surgery Feb.2015,
Vol. 152(1S) S1–S43
 Treatment of Allergic Rhinitis. Am Fam Physician.
 Allergic rhinitis management pocket reference 2008. Allergy 2008:

63: 990–996.
 Pharmacotherapy: A pathophysiologic Approach. 7 th Edition 2008.
 Safety of Antihistamines in Children. Drug Safety 2001; 24 (2): 119-

 Second-Generation Antihistamines Actions and Efficacy in the

Management of Allergic Disorders. Drugs 2005; 65 (3): 341-384

Allergic RhinitisOverview
The most common atopic disease
The hallmark of ~: a temporal relationship

between the exposure to allergens & the
development of nasal symptoms
It takes at least 2 years of exposure to
allergens) to develop AR (thus, very rare in
children <1 year)
The prevalence of AR: lowest in children < 5

 highest 2nd---- 4th decades
Genetic predisposition (60%)

In a sensitized individual, allergic
rhinitis occurs when mucous
inhaled allergenic materials that
elicit a specific response mediated
by immunoglobulin E (IgE).


Allergic Rhinitis (AR) is an inflammatory. stuffy nose. such as animal dander or pollen. IgEmediated disease characterized by nasal congestion. sneezing. rhinorrhea (nasal drainage). examples of the symptoms of AR are sneezing. . and itchy nose. It can also be defined as inflammation of the inside lining of the nose that occurs when a person inhales something he or she is allergic to.Definitions. runny nose. and/or nasal itching. post nasal drip.

perennial/ year-round (eg. or episodic (environmental from exposures not normally encountered in the patient’s environment. and (3) severity of symptoms. . visiting a home with pets). pollens). eg. such as seasonal (eg. (2) frequency of symptoms.AR may be classified by: (1) the temporal pattern of exposure to a triggering allergen. Classifying AR in this manner may assist in choosing the most appropriate treatment strategies for an individual patient. dust mites).


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Subsequent exposure to the same antigen produces an allergic reaction when mast cell mediators are released. Exposure to antigen stimulates IgE production and sensitization of mast cells with antigen specific IgE antibodies.Allergen sensitization and the allergic response. B. 9 . A.

Mast cells degranulating and releasing vasoactive amines. .

Mast Cell Mediators 11 .

Allergic Rhinitis Most patients develop symptoms before age 30 Asthma develops in about 19% of children with rhinitis (more likely with perrenial allergic rhinitis) The term “rhinitis” refers to the inflammation of the nasal mucous membranes. Whenever a a causative allergen can be identified allergic rhinitis It is difficult sometimes to distinguish between different types of rhinitis Comparison between different types of .

pruritis. congestion Congestion Pattern Perennial or seasonal Any time Any time Temporal relationship with use of topical decongestant Associated Factors Concurrent None atopic disease.Features of Common Rhinitis Symptoms Allergic rhinitis Infectious rhinitis Vasomotor rhinitis Rhinitis Medicamentosa Etiology Allergen Viral or bacterial Unknown Tachyphylaxis to topical decongestants Symptoms Rhinorrhea. cough Rhinorrhea. congestion. mucupurulent rhinorrhea. cough with postnasal drip ocular itching etc Fever (more common in children). concurrent use of antihypertensive therapy . scratchy throat. strong odours. family history Affects women primarily. alcohol. change in humidity and temperature Overuse of topical decongestants. congestion. stress. sneezing.

molds.Perennial Allergic Rhinitis Caused by continuous exposure to many different types of allergens Dust Mite the most common cause of perennial allergic rhinitis Commonly: household dust mites. cockroaches. house pets Less commonly: cottonseed & flaxseed (found in fertilizers. hair setting preparations and foods). some vegetable gums (found in hair setting prep & foods) .

Caused by: Dust mites .

. May remain airborne for up to 6 hrs. moist environment Cat-derived allergens: light small proteins secreted through the sebaceous glands in the skin. the main allergen is the glycoprotein that coats their faeces. Can be detected at home even 6 months after removal of the cat. Dust mite remain airborne for about 30 minutes after being disturbed Molds: grow best in warm. beddings & reproduce best in warm (18-21ºC) humid (>50%) environment found in most homes Mites feed on human skin scales and their own faeces.Perennial Allergic Rhinitis Dust mite: thrive in carpets. Mite itself is not allergen.

g. tree.Seasonal Allergic Rhinitis Caused by wind-borne plant pollens (e. grass. etc) “hay fever”. and “rose fever” are terms related to seasons associated grass pollinosis and NOT associated with FEVER! .


and treatment earache . for evaluation frequent HA. .Complications 1. 2. 3. refer to Dr. purulent nasal discharge. Sinusitis Recurrent otitis media & hearing loss Patients who develop: fever. . . .

sneezing. puffiness & conjuctival erythema Nasal: congestion. itching of the palate and throat Systemic: malaise & fatigue: . mild sore throat due to postnasal drip. itching. sinus HA. mild soreness. earache. lacrimation. postnasal drip and nasal pruritus Head & Neck: loss of taste and smell.Symptoms of Allergic Rhinitis Ocular: itching. watery rhinorrhea.

Physical Assessment “allergic shiners”  venous/lymphatic congestion Chronic mouth breathing highly arched palate A horizontal crease across the lower third of the nose (in patients repeatedly rub their noses upward) called “nasal salute” Nasal mucosa: pale & swollen Nasal secretions: clear & watery Eyes: watery with scleral & conjuctival erythema and periorbital edema .

Allergic shiners Arched palate because of mouth breathing Periorbital edema .


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"making it an attractive treatment option" for allergy sufferers who do not respond to second-generation antihistamines and are not satisfied with dosing schedules associated with the first-generation antihistamines. It is dosed once every 12 hours. However. most of these older drugs had not gone through the FDA's approval process. . Carbinoxamine is a mildly sedating antihistamine. sustained-release histamine-H1 receptor blocker indicated for the treatment of seasonal and perennial allergic rhinitis in children aged 2 years and older. it was widely used in carbinoxamine-containing combination products. Tris Pharma). Before 2006.Update: April 2013 The US Food and Drug Administration (FDA) has approved carbinoxamine maleate extended-release (Karbinal ER. the first liquid. The drug will be available in a 4 mg/5 mL oral suspension.