Allergic Rhinitis in Children

Alfred TamMBBS(HK), FRCP(Edin., London, Glasg.)

FHKCPaed, FHKAM(Paediatrics)

Department of Paediatrics and Adolescent Medicine, University of Hong Kong

Allergic Rhinitis in Children

• What is allergic rhinitis?

• Diagnosis and differential diagnosis

• Assessment and classification of AR

• What can make AR worse or better?

• Health effects of AR

• What can we do to make AR better?

What is allergic rhinitis?

• Rhinorhoea• Nasal blockage• Postnasal drip• Itchiness• Sneezing• Associated health

effects

‼ IgE mediated

Allergic rhinitis is increasingLee SL et al. Pediatr Allergy Immunol 2004; 15: 72-8.

05

1015202530354045

%

1995 (3618) 2001(4448)

Prevelance Rates 1995-2001

Ever rhinitis

Current rhinitis

Currentrhinoconjunctivitis

Ever eczema

AR prevalence varies in different citiesWong G et al. Clin Exp Allergy 2001; 31: 1225.

Past 12 mths %(95%CI)

HK BJ GZ

Numbers 3110 4227 3565

Wheeze 5.8(5.0-6.7) 3.8(3.3-4.4) 3.4(2.8-4.1)

Rhinoconjunctivitis 15.0(13.9-16.4) 6.7(5.9-7.5) 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)

Atopic sensitization is not that different!Wong G et al. BMJ 2004; 329:486-9.

%(95%CI) HK BJ GZ

Numbers 1341 1044 1098

Atopic 41.2(38.5-43.8) 23.9(21.3-26.4) 30.8(28.1-33.5)

D. pter 34.1(31.5-36.6) 7.5(5.9-9.1) 20.0(17.6-22.4)

D. far 25.9(23.5-28.2) 5.7(4.3-7.1) 17.9(15.6-20.2)

Cat 3.7(2.7-4.7) 5.6(4.2-6.9) 4.3(3.1-5.5)

Cockroach 11.5(9.8-13.2) 13.3(11.3-15.4) 17.8(14.8-19.2)

Allergic Rhinitis in HanoiNguyen et al. Pediatr Allergy Immunol 2003; 14:272-9.

Symptoms % n

Ever allergic rhinitis 34.9 338

Allergic rhinitis in past 12 months 27.6 267

Allergic rhinoconjunctivitis in past 12 months 10.7 104

AR limiting activities 17 165

Ever hay fever 7.8 76

Doctor diagnosed hay fever 11.2 109

Diagnosis of Allergic Rhinitis

1. Clinical symptoms of recurrent or persistent rhinitis and/or associated health effects

2. Signs of atopy and recurrent or persistent rhinitis

3. Demonstration of IgE allergy

4. Exclusion of other causes of rhinitis

Diagnosis of Allergic Rhinitis

1. Clinical symptoms of recurrent or persistent rhinitis and/or associated health effects

– Rhinorhoea– Nasal blockage– Postnasal drip– Itchiness– Sneezing– Others: conjunctivitis, eczema, asthma, chronic rhin

osinusitis, otitis media with effusion, sleep obstruction…

Diagnosis of Allergic Rhinitis

2. Signs of atopy and recurrent or persistent rhinitis

Diagnosis in Primary Care Setting

Diagnosis of Allergic Rhinitis

3. Demonstration of IgE allergy

Immunoassay• Not influenced by

medication• Not influenced by skin

disease• Does not require

expertise• Quality control

possible• Expensive

Skin test• Higher sensitivity• Immediate results• Requires expertise• Cheaper

Immunoassay vs Skin Test for Diagnosis of Allergy

Other Causes of Rhinitis in Children

• Infection– Viral, bacterial, – Rhinosinusitis

• Foreign body in the nose• Rhinitis associated with physical or chemical fact

ors• Drug, food induced rhinitis• NARES, aspirin sensitivity• Vasomotor rhinitis

Health Effects of Allergic Rhinitis

• Social inconvenience• Sleep disturbances/obstruction• Learning difficulties• Impaired maxillary growth• Dental problems• Infection: nose and sinuses• Co-morbidities: conjunctivitis, asthma, rhin

osinusitis, otitis media

Adapted from Meltzer EO et al. J Allergy Clin Immunol. 1997;99:S815

Short Form Health Survey (SF-36) Profiles of Patients with Allergic Rhinitis

*

*

*

*

**

50

55

60

65

70

75

80

85

90

PhysicalFunctioning

Role– Physical

Bodily Pain

GeneralHealth

Vitality Social

Functioning

Role– Emotional

MentalHealth

Change inHealth

allergic rhinitis (n=312)

controls (n=139)

†

Declininghealthstatus

Domains

scale: 0 to 100

Perennial Rhinitis: an Independent Risk Factor for

Asthma(European Community Respiratory Health Survey)

Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; 104:301

Asthma (%)

Atopic Non atopic

no rhinitis, N=5198

rhinitis, N=1412

OR=11

OR=17

0

5

10

15

20

25

Looking for asthma…

In Patients with Rhinitis:

• Routinely ask for symptoms suggestive of

asthma

• Perform chest examination

• Consider lung function testing

• Consider tests for bronchial

hyperresponsiveness in selected cases

Moderate-severe

one or more items. abnormal sleep. impairment of daily

activities, sport, leisure

. abnormal work and school

. troublesome symptoms

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

Intermittent

. Š 4 days per week

. or Š 4 weeks

ARIA Classification

in untreated patients

sneezing rhinorrhea nasal nasaleye obstruction itchsymptoms

H1-antihistamines

oral +++ +++ 0 to + +++++

intranasal ++ +++ + ++0

intraocular 0 0 0 0+++

Corticosteroids +++ +++ ++ +++

Cromones

intranasal + + + +0

intraocular 0 0 0 0++

Decongestants

intranasal 0 0 ++ 00

oral 0 0 + 00

Anti-cholinergics 0 +++ 0 00

Anti-leukotrienes 0 + ++ 0++

Medications for Allergic Rhinitis - ARIA

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

Bachert C et al. J Allergy Clin Immunol 2004:114:838

Efficacy of an Antihistamine over 6 Months inPersistent Allergic Rhinitis

Sneezing Rhinorrhea Pruritus Nose Pruritus Eyes Congestion

*

*

*

*

*

*

*

*

*

*

*

*

*

1.0

0.8

0.6

0.4

0.2

01 wk

4 wk6 mo 1 wk

4 wk6 mo 1 wk

4 wk6 mo 1 wk

4 wk6 mo 1 wk

4 wk6 mo

meanIndividualsymptom

scoreimprovement

* P<0.05

Levocetirizine, 5 mg, N = 276Placebo, N = 271

Baseline total symptom score: 8.95

Efficacy of an Antihistamine in the Treatment of Allergic Rhinitis with Perennial Symptoms

(n= 337)(n= 339)

Simons FER et al., J Allergy Clin Immunol 2003;111:617

Newer Generation Oral AntihistaminesSomnolence/Drowsiness

Active Placebo Data Source

Cetirizine

10 mg qd13.7% 6.3% www.PDR.net

Desloratadine

5 mg qd2.1% 1.8% www.PDR.net

Fexofenadine

60 mg bid1.3% 0.9% www.PDR.net

Levocetirizine

5 mg qd6.8% 1.8%

Bachert et al

JACI 2004;114:838

Loratadine

10 mg qd8% 6% www.PDR.net

• First line treatment for mild allergic rhinitis

• Effective for– Rhinorrhea– Nasal pruritus– Sneezing

• Less effective for– Nasal blockage

• Possible additional anti-allergic and anti-inflammatory effect • In-vitro effect > in-vivo effect

• Minimal or no sedative effects

• Once daily administration

• Rapid onset and 24 hour duration of action

Newer Generation Oral Antihistamines

Decongestants: Alpha-2 Adrenergic Agonists

• Oral

Pseudoephedrine

• Nasal

Phenylephrine

Oxymetazoline

Xylometazoline

vasoconstriction

Decongestants: Alpha-2 Adrenergic Agonists

nasal airway lumen

nasalturbinates

nasal septum

DecongestantsEFFICACY:

• 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

nucleus

cytosolicphospholipase A2

arachidonicacid

5-lipoxygenaseactivating

protein

leukotriene A4

5-lipoxygenase leukotriene C4

synthase

leukotriene C4

leukotriene C4

leukotriene D4

leukotriene E4

CysLT1receptor

mast cellsbasophilseosinophilsmacrophages

+

Cysteinyl-Leukotriene Production and the CysLT1 Receptor

Daytime Nasal Symptoms Score (0-3 point scale)

-0.6

-0.4

-0.2

0

Adapted from Nayak, et al. Ann Allergy Asthma Immunol. 2002;88: 592

Change frombaseline

(mean, 95% CI)

mean baseline=2.0

* *placebo, N=149

montelukast, N=155

loratadine, N=301*p<0.01 vs placebo

Efficacy of a CysLT1 Receptor Antagonistin Allergic Rhinitis with Seasonal Symptoms

Anti-Leukotriene Treatment in Allergic

RhinitisEfficacy

• Equipotent to H1 receptor antagonists but with onset of action after 2 days

• Reduce nasal and systemic eosinophilia• May be used for simultaneous treatment of allergic

rhinitis and asthma

Safety

• Dyspepsia (approx. 2%)

Nasal Corticosteroids

Beclomethasone dipropionate

Budesonide

Ciclesonide*

Flunisolide

Fluticasone propionate

Mometasone furoate

Triamcinolone acetonide

* Currently only approved for asthma

Nasal Corticosteroids

reduction ofsymptoms and exacerbations

reduction ofmucosal inflammation

reduction oflate phase reactions

primingnasal hyperresponsiveness

1

reduction ofmucosal mast cells

reduction ofacute allergic reactions

2

• suppression ofglandular activityand vascular leakage• induction ofvasoconstriction

3

Meltzer E. et al. J Allergy Clin Immunol. 1999;104:107.

Efficacy of Nasal Corticosteroid Sprays in Children with Allergic Rhinitis and Seasonal Symptoms

Mandl M. et al. Ann Allergy Asthma Immunol 1997;79:370

Comparative Efficacy of Nasal Corticosteroids

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)

Adapted from Galant, S. P. et al. Pediatrics 2003;112:96

Nasal Corticosteroid vs Placebo: Effects on 12-Hour Urinary Free Cortisol in 2-3

Year-Old Children6-week treatment

0.98SE=1.14

N=31

0.94SE=1.15

N=29

Adjusted Geometric Meanof the Change from Baseline

1.0

0.8

0.6

0.4

0.2

0FluticasoneProprionateNasal Spray200 µg daily

Placebo

Value of 1 indicatesno change from baseline

Other Management Aspects

• Manage other co-morbidities: – Allergic conjunctivitis– Asthma– Sinusitis…

• Environmental manipulations: – allergen avoidance– Pollution treatment

• Nutritional support• Activities and sports

Environmental Control

• House dust mites• Pets• Cockroaches• Molds• Pollen

1. Allergens

2. Pollutants and Irritants

House dust mite allergen avoidance

– Provide adequate ventilation to decrease humidity

– Wash bedding regularly at 60°C

– Encase pillow, mattress and quilt in allergen

impermeable covers

– Use vacuum cleaner with HEPA filter

– Dispose of feather bedding

– Remove carpets

– Remove curtains, pets and stuffed toys from bedroom

Allergen Avoidance• Pets

• Remove pets from bedrooms and, even better, from the entire home

• Vacuum carpets, mattresses and upholstery regularly

• Wash pets regularly (±)

• Molds

• Ensure dry indoor conditions

• Use ammonia to remove mold from bathrooms and other wet spaces

• Cockroaches

• Eradicate cockroaches with appropriate gel-type, non-volatile, insecticides

• Eliminate dampness, cracks in floors, ceilings, cover food; wash surfaces, fabrics

to remove allergen

• Pollen

• Remain indoors with windows closed at peak pollen times

• Wear sunglasses

• Use air-conditioning, where possible

• Install car pollen filter

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

Thank you for staying awake!

Or, you may now wake up and ask questions!