Allergic Rhinitis - NPRANG...• In 2012, 9.0% or 6.6 million children reported hay fever in the...
Transcript of Allergic Rhinitis - NPRANG...• In 2012, 9.0% or 6.6 million children reported hay fever in the...
Allergic Rhinitis
James Gardner
Children’s Allergy Nurse Consultant
Great North Children’s Hospital, Newcastle
Associate Clinical Lecturer, Newcastle University
Allergic Rhinitis
• Prevalance / Impact
• Diagnosis
• Treatment
• When treatment fails..
Prevelence of AR
• Roughly 7.8% of people 18 and over in the U.S. have hay fever.1
• Worldwide, allergic rhinitis affects between 10% and 30 % of the
population.2
• Worldwide, sensitization (IgE antibodies) to foreign proteins in the
environment is present in up to 40% of the population.2
• In 2012, 7.5% or 17.6 million adults were diagnosed with hay fever
in the past 12 months.3
• In 2012, 9.0% or 6.6 million children reported hay fever in the past
12 months.4
• In 2010, 11.1 million visits to physician offices resulted with a
primary diagnosis of allergic rhinitis.5
1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2010. By Jeannine S. Schiller, M.P.H., Jacqueline W. Lucas, M.P.H., Brian W. Ward,
PhD and Jennifer A. Peregory, M.P.H., Division of Health Interview Statistics.
2. World Health Organization. White Book on Allergy 2011-2012 Executive Summary. By Prof. Ruby Pawankar, MD, PhD, Prof. Giorgio Walkter Canonica, MD, Prof.
Stephen T. Holgate, BSc, MD, DSc, FMed Sci and Prof. Richard F. Lockey, MD.
3. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012, table 3, 4.
4. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012, table 2.
5. National Ambulatory Medical Care Survey: 2010 Summary Tables, table 13.
Allergic Rhinitis and Impact on
Quality of Life and Work• In USA
2 million school days lost per year
4 million work days lost per year
28 million impaired work days
• In UK
Performance in school exams in 15-16 yr
olds worsened
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Po
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Apri
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5th
May
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May -
12th
May
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May -
19th
May
20th
May -
26th
May
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May -
2nd J
une
3rd
June -
9th
June
10th
June -
16th
June
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June -
23rd
June
24th
June -
30th
June
1st
July
- 7
th J
uly
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July
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July
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July
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22nd J
uly
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July
S1
English
Maths
Science
Grass pollen counts 2003
Walker et al: JACI 2007;120:(2) 381-7
Most Patients with Asthma Have Allergic Rhinitis
• Approximately 80% of asthmatics have
allergic rhinitis
Adapted from The Workshop Expert Panel. Management of Allergic Rhinitis and its Impact on Asthma (ARIA) Pocket
Guide. A Pocket Guide for Physicians and Nurses. 2001; Bousquet J and the ARIA Workshop Group J Allergy Clin
Immunol 2001;108(5):S147-S334; Sibbald B, Rink E Thorax 1991;46:895-901; Leynaert B et al Am J Respir Crit
Care Med 2000;162:1391-1396.
Asthmaalone
Allergic rhinitisalone
Allergicrhinitis
+ asthma
Childhood allergic rhinitis increases the risk of developing asthma
Burgess JA et al. J ACI 2007;120:863-9
0
1
2
3
4
5
6
7
Adult lifeAdolescencePreadolescence
Hazard
Rati
o
Incre
ased
asth
ma r
isk
2.19
4.34
7.12All p< 0.001 vs. no
childhood AR
Childhood allergic rhinitis has been associated with a significant 2-7
fold increase in the incidence of asthma in later life
Asthma
OME
Rhinosinusitis
The United Airway
Allergic signs
Denny Morgan lines
Allergic shiner
Nasal crease
Allergic
salute
Allergic
crease
Defining Allergic Rhinitis
Moderate-severe one or more items
Abnormal sleep.
Impairment of daily activities, sport, leisure.
Problems caused at school or work.
Troublesome symptoms.
Intermittent symptoms
< 4 days per week
Or < 4 weeks
Intermittent symptoms
< 4 days per week
Or < 4 weeks
Mild
Normal sleep.
Normal daily activities.
Normal work and school.
No troublesome symptoms.
Persistent symptoms
> 4 days per week and > 4 weeks
Persistent symptoms
> 4 days per week and > 4 weeks
History
Examination
Skin-prick tests/RAST +/-Others
Allergy(seasonal, perennial,
or occupational)
Infection(acute or
chronic)
Structural(polyps, septum,
turbinates, etc)
Other(idiopathic, NARES,
hormonal, drugs, etc)
Allergic Rhinitis Differential
DiagnosisRhinitis
Immunodeficiency
PCD
Cystic fibrosis
Choanal atresia
Foreign body
Hypothyroidism
Menstrual cycle
Oral contraceptive
Courtesy of S.Durham
Differential Diagnosis
Guidelines
Treatment Approach
0
1
2
3
4
5
6
7
8
9
10Guidelines group
Free-choice treatment group
Days 1-7 Days 8-14 Days 15-21 Days 1-21
Modified from Bousquet et al Allergy 2003: 58:733-741
P=0.0001
P=0.0001P=0.0001
P=0.0001
SAR control in relation to therapeutic scheme based on International Guidelines
HCPs Awareness of
Guidelines
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ENT Allergist Paediatrician GP NP
74%
88%
44%
53%60%
Modified from Meltzer E et al: JACI 2009; 124:S43-70
HCPs awareness of professional guidelines for the management of AR
- Bousquet J et al JACI 2001 Nov;108(5 Suppl):S147-334. - Bousquet J et al Allergy 2008: 63 (Suppl. 86): 8–160- Brozek JL et al JACI 2010 Sep;126(3):466-76.
- Scadding G et al CEA, 2008 38, 19–42
bsaciImproving allergy care
Guidelines for Allergic Rhinitis
Roberts G et al Allergy. 2013 Sep;68(9):1102-16
mildintermittent
mildpersistentmoderate
severeintermittent
moderatesevere
persistent
allergen and irritant avoidance
immunotherapy
intra-nasal decongestant (<10 days) or oral decongestant
local cromone
intra-nasal steroid
oral or local non-sedative H1-blocker
Treatment of allergic rhinitis (ARIA)
Allergic rhinitis and its impact on asthma
www.whiar.org
2001
Paediatric Rhinitis Proposed Therapeutic Approach
Roberts G et al Allergy. 2013 Sep;68(9):1102-16
H1Oral or topical NON SED Regular oral NON SED
Intermittent symptoms Persistent symptoms
Rx failure Rx failure
Diagnosis by history ± SPT/RAST
Allergen + irritant avoidance ± douching
Still symptomatic
Check use / concordance
increase dose +/or OC
INTRANASAL STEROIDS (INS)
Surgical referral
Review dose/ compliance
Consider allergy referral -
IMMUNOTHERAPY for SAR
? Infection / structural problem
Rx failure
Rx failure
Rx failure
Add (briefly)
decongestant / OC or (longer
term) LTRA / desloratadine /
levocetirizine
Rx failure
Itch/sneeze
+non sed α H1Rhinorrhoea
+Ipratropium / LTRACatarrh +LTRA Blockage
H1
Treatment of Allergic RhinitisBSACI Guidelines
Treatment-Level of Evidence
Seasonal
Rhinitis
Perennial
Rhinitis
Adult Children Adult Children Persistent
Rhinitis
Oral anti-H1 A A A A A
Intranasal anti-H1 A A A A B*
Intranasal
corticosteroids
A A A A B*
Intranasal cromones A*** A*** A*** A***
Anti-leukotrienes A A B**
Anti-IgE mab A A A A B*
Bousquet et al Allergy 2006 :61:1086-96
*** study conducted with small number of patients
Treatment Satisfaction in
Children
A: Reasons for requesting a
Change in PrescriptionB: Reason for dissatisfaction
with prescription
Meltzer E et al: JACI 2009; 124:S43-70
(4-17 years)
Compliance and Education
• Easy to use device
• Minimal Sensory
Disturbance
• Once daily dosing
• Education
- Device Technique
- Safety of Drug
- Warning of Possible Side
Effect
Newer INS: Low bioavailability
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
11%
% B
ioavaila
bili
ty
44%
0.5%0.1% 0.5%
Nasonex: Summary of Product Characteristics. Data Accessed April 2011
Kariyawasm H and Scadding GK Journal of Asthma and Allergy 2010:3 19-28
Rhinocort: Summary of Product Characteristics. Data Accessed April 2011
Beconase: Summary of Product Characteristics. Data Accessed April 2011
Mometasone
Fluorate
Fluticasone
Fluorate
Fluticasone
Proprionate
Budesonide Beclometasone
Diproprionate
Combination therapy
• A new formulation (Azelastine/FP) has shown superiority when compared to each single drug and placebo.
• These findings have been consistent in:
- 3 separate trials in patients with SAR
- 1 trial in patients with PAR
• These studies have included children ≥12
• Studies in younger children need to be performed with one on-going in 4-11 year old.
Carr W et al; JACI 2012:129(5)
Anti-LRAs Receptor for the treatment of AR
with Co-morbid asthma in Grass Pollen allergic
children.N: 32 SAR (Grass pollen) (age 8-12)
Individual and median decrease in FEF 25-75
measures during the grass pollen season
compared with pre-season in
loratadine/montelukast and loratadine only
groups
Individual and median asthma symptom scores
in loratadine/montelukast and loratadine only
groups
Keskin O et al; PAI 2006 :17
The addition of A-LTRA provided benefit in controlling lower airway symptoms
preventing the seasonal decrease in LF parameters
Nasal Irrigation as adjuvant
treatment in AR
Garavello W et al; PAI 2003:14
Hermelingmeier K et al; Am J Rhinol Allergy 2012:26(5)
Three-times daily nasal irrigation with hypertonic saline in
children (aged 6-12) with seasonal allergic rhinitis
significantly reduces Total Rhinitis Symptoms Score and a
reduction the amount of rescue anti-H1 in the treatment
group.
Nasal Irrigation improves: Symptoms, RQLQ & MCT
Paediatric Rhinitis Proposed Therapeutic Approach
Roberts G et al Allergy. 2013 Sep;68(9):1102-16
Indication for Immunotherapy
• At least 1 year history of AR +/- Asthma
• Evidence of sensitisation
• Evidence for clinical relevance of disease related allergen
• Availability of standardised allergen extract
Bufe A and Roberts G CEA 2011;41:1256-62
Benefits of Immunotherapy
• Able to induced Immune-tolerance
• Sustained prevention of symptoms
• Able to modify disease progression
- Prevention of new sensitization
- Asthma prevention
What’s Available?
Two Routes of Administration
- Used in 75% of children - Potential Severe Side effects- Administration by Specialist- Contraindicated in Asthmatic
- Used in 25% of children- Home Therapy (only 1st Dose Supervised)- Can be used in asthmatic
SCITSLIT
• 51 DB PC RC studies were included (1950-2006)
• Patients with SAR due to grass, tree or weed pollen
• Participants: n=2,871 (1,645 active; 1,226 placebo)
• Adults
Calderon M et al. Cochrane Database Syst
Rev. 2007 (1): CD001936
SCIT for Seasonal Allergic RhinitisSystematic Review and Meta-analysis
Symptom scores
Cochrane Database Syst Rev 2007; (1):CD001936.
Medication scores
Cochrane Database Syst Rev 2007; (1):CD001936.
Subcutaneous immunotherapy in seasonal allergic rhinitis: Cochrane Review
• Significant improvement in rhinitis symptom scores
• Significant reduction in rhinitis medication scores
• Increases in serum allergen-specific IgG4 concentrations
• Only adult studies
Calderon M et al. Cochrane Database Syst Rev. 2007 (1): CD001936
Sublingual
Immunotherapy
for allergic rhinitis
(Review)
Radulovic S,
Calderon M, Wilson
D, Durham S
Comparison SLIT versus Placebo – Children: Outcome: Symptoms Score
Cochrane Database Syst Rev 2010, Dec 8(12): CD002893
15 Studies
Passalacqua G. Ann AllergyAsthma Immunol.2011;107:401– 406.
Ongoing Efficacy of Treatment
IT cost effective in asthmatic patients with pollen & HDM allergy
• Cost of Immunotherapy (IT) vs Conventional Therapy (CT) at 1, 7 &
10 years
time
CT
IT
CT IT
CT
IT
years1
7 years
10
Schadlich PK, Brecht JG. Economic evaluation of specific immunotherapy versus symptomatic treatment of allergic rhinitis in Germany. Pharmacoeconomics17(1),37-52 (2000).
Immunotherapy clinic
Case Studies
Case Study
• Yasmin age 4 year old
• 12 month history of bad smell from nose
and recurrent otitis media
• 1 appointments in ENT, 2 General
Paediatric appt
• 1 course of betnesol drops
• Several courses of oral antibiotic
• Regular nasal steroid
Case Study
• Diagnosis
Case Study
• Management
1. Removal by ENT Surgeon from nostril
2. Naseptin bd for 7 days to clear localised
infection
3. Discharged!
Case Study
• Mohammad age 12
• Referral for severe uncontrolled Asthma
Seretide 250mcg bd
Montelukast 5mg
8 courses of Prednisolone in 12months,
4 A&E admissions
Outpatient Appointment
• ? Compliance
• ? Intensive support
• ???
Investigations
• Spirometry
FVC 70%
FEV1 69%
39% reversability
FeNO Chest 20
Nasal NO Left 210 Rt 290
Investigations
• Skin Prick Testing
- House Dust Mite 18mm
- Grass Pollen 11mm
- Sliver Birch 6mm
- Cat 2mm
Investigations
• NIPF 70 / 60 / 60
• Examination
Nose
- swollen / pale turbinates
(complains has itchy nose and hayfever in the summer)
Treatment Given
• Asthma medication – same
• Flixonase Nasules (1 month)
• Followed by Avamys daily
• Daily antihistamine
Outpatient Review (6months later)
• No exacerbations of asthma
• Lung Function – normal
• FeNO Chest 8
Nasal NO Left 509 Rt 710
Subsequent Appointments
• Step down in Asthma medication
• Currently well controlled on:
- Regular rhinitis treatment
- Beclomethasone 100mcg bd
- Montelukast (when unwell)
- Infrequent salbutamol use.
Any Questions?
James Gardner
Children’s Allergy Nurse Consultant
0191 282 1712
@allergynurseuk