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ALLERGIC RHINITIS WHEN ALL FAILS. ADIL WARIS. SPONSOR MESSAGE. BAYER SPONSORED SESSION. Diagnosis. Usually not difficult Symptoms can be seasonal or perineal Allergic salute Allergic crease Look up nostrils at the inferior turbinates. Investigations. Usually not needed Eosinophilia
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ALLERGIC RHINITIS WHEN ALL FAILS ADIL WARIS
SPONSOR MESSAGE • BAYER SPONSORED SESSION
Diagnosis • Usually not difficult • Symptoms can be seasonal or perineal • Allergic salute • Allergic crease • Look up nostrils at the inferior turbinates
Investigations • Usually not needed • Eosinophilia • Serum IgE • Skin prick allergy test
TREATMENT 1 Antihistamines • For how long • Value of changing molecules • 6 percent alcohol • Systemic delivery or local • For mild disease • For rhinorrhea • For sneezers
TREATMENT 2 Nasal steroids • Treatment of choice for blockers especially • Little side effects • Local application • Changing molecules • Different preservatives and propellents • Some with antihistamines • Onset of action 7 days and wears off in 7 days • BanovC, LaForce C, Lieberman P. Double blind trial of Astelin nasal spray in the treatment of vasomotor rhinitis. Ann Allergy Asthma Immunol 2000; 84:138.
TREATMENT 3 Saline douches • Washes out the cytokines • Do it before the steroid spray • Sea sprays • Saline sprays
TREATMENT 4 Montelukast • Systemic • Quick onset • Not all benefit • Useful is asthma is onboard
Cromolyn sodium nasal spray • 1-2 sprays 3-4 times daily • No adverse effects • Cromolyn is less effective than glucocorticoid nasal sprays • Controlling mild symptoms.
Ipratropium bromide • 0.03 percent nasal spray • Decreasing rhinorrhea • Decreasing the release of substance P. • less effective than glucocorticoid nasal sprays • Useful in children or adults who have profuse rhinorrhea not otherwise controlled with topical nasal corticosteroids • Adult patients with concomitant allergic and nonallergic (or vasomotor) rhinitis.
TREATMENT 5 Prevention • Allergy testing • House dust mite • Grass pollens especially Bermuda grass • Mould spores • Milk • Animal dander … remove pet all or nothing /hypoallergic animals • Other foods very unlikely
RESULTS • Children aged 1 to 18 years • 2005 to date • 1150 patients results • Atopic asthmatics • Allergic rhinitis • Combinations of above
POLLENS Mould Mix445- 38.7% Bermuda Grass251- 21.8% Grass Pollen Mix193- 16.8% Tree Pollens Mix149 - 12.9% Weed Pollen Mix38- 0.03% Pyrethrum4- 0.003% Aspergillus2- 0.001%
LIVING CREATURES House dust mite 704 - 61.2% Cat405- 35.2% Cockroach372- 32.3% Dog335 - 29.1% Feathers320- 27.8% Horse5- 0.004% Rabbit5- 0.004%
FOODS Egg White160- 13.9% Milk155- 13.4% Soya140- 12.1% Citrus Mix68- 5.9% Egg Yolk44- 3.8% Cereal mix26- 2.2%
NON ATOPIC STATE DEFINED All negative 83 - 7.2%
Nasal decongestant sprays • Phenylephrine,oxymetazoline, xylometazoline, and naphazoline. • Downregulation of the alpha-adrenergic receptor develops after three to seven days, • Rebound nasal congestion may result. • Then viscious cycle --eventual dependency -- rhinitis medicamentosa.
Chronic nonallergic rhinitis • 50 percent of patients with chronic rhinitis have a component of nonallergic rhinitis • Perennial symptoms and mild or absent nasal itching and sneezing. • Chronic nasal congestion and/or rhinorrhea changes in temperature and relative humidity, odors, or alcohol. • They have little nasal itching or sneezing. • Headaches, anosmia, and sinusitis are common. • Negative skin tests to inhalant allergens. • Include vasomotor rhinitis, gustatory rhinitis, and nonallergic rhinitis with nasal eosinophilia syndrome.
Nasal hyperreactivity • Non IgE mediated • Biomass fuels • Oudh and incense • Smokers • Mossi chips and coils • Painting /varnishing • Scented candles
Nasal hyperreactivity • Karvol/ vicks /Echinacea • Humidifiers …mould counts • Vaporisers
Chronic rhinosinusitis • Inflammatory condition involving the paranasal sinuses and linings of the nasal passages • CRS can coexist with allergic rhinitis • Requires anytwo of the following symptoms, present for at least 12 weeks: • •Anterior and/or posterior mucopurulent drainage • •Nasal obstruction • •Facial pain, pressure, and/or fullness • •Decreased sense of smell
Rhinitis due to systemic medications • Birth control pills, antihypertensive drugs (alpha-adrenergic blockers, beta-adrenergic blockers, angiotensin-converting enzyme [ACE] inhibitors), erectile dysfunction drugs, and NSAIDs. • Psychiatric medications chlorpromazine, thioridazine, perphenazine, chlordiazepoxide, amitriptyline, and alprazolam. • cyclosporine and mycophenolic acid
Alternative therapies • Traditional Chinese medicine (TCM) includes herbal therapy, acupuncture, massage, and dietary therapy. • Studies of acupuncture for the treatment of allergic rhinitis have shown modest benefit • There are several herbal therapies that have demonstrated efficacy, including Ayurvedic mixes, butterbur, and Tinosporacordifolia. • Nasal sprays consisting of dilute solutions of capsaicin have shown efficacy for allergic rhinitis in randomized trials when administered several times daily. • National Center for Complementary and Alternative Medicine. Expanding Horizons of Health Care: Strategic Plan 2005-2009. NIH publication no. 04-5568, National Center for Complementary and Alternative Medicine; NIH, Bethesda, MD 2005.
Allergic rhinitis under in infancy • Does it exist • Airway sensitization • Role of milk allergy via breast milk • Ng ML, Warlow RS, Chrishanthan N, et al. Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (I). ClinExp Allergy 2000; 30:1314.
NEVER FORGET • Are the patients adherent • Is the inhaler technique for the nose spray correct • Douche first then steroid spray • Have you treated asthma?
Kenya future • Allergen immunotherapy … takes long and do you have the correct ingredients