Diagnosis and management of allergic rhinitis Presented by Pannipa Kittipongpattana, MD. December21, 2018

1. Allergic rhinitis
(Part II)
Pannipa Kittipongpattana, M.D.
21 December 2018
Division of Allergy and Immunology , Department of Pediatrics
King Chulalongkorn Memorial Hospital

2. Outline
 Definition and classification
 Epidemiology
 Pathophysiology and mechanisms
 Risk factors
 Evaluation and diagnosis
 Associated conditions
 Management

3. Outline
 Definition and classification
 Epidemiology
 Pathophysiology and mechanisms
 Risk factors
 Evaluation and diagnosis
 Associated conditions
 Management

4. Evaluation and diagnosis: History
 Classic symptoms of allergic rhinitis:
 Nasal congestion or obstruction
 Frequently alternates between both sides
 Persistent unilateral obstruction: Anatomical defects,
Inflammatory mass (nasal polyp), Tumor
 Sneezing: in allergic disease often marked is by explosive
paroxysms of 5 to 10 sneezes or more
 Rhinorrhea: most often clear to white in color
 Purulent secretions: chronic sinusitis or atrophic rhinitis
 Nasal pruritis
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.
Middletons ’s Allergy: Principle and Practice, 8th edition

5. Evaluation and diagnosis: History
 Ocular pruritis, erythema,
and/or tearing
 Oral cavity or pharyngeal
pruritis
 Wheezing or cough
(reactive airway disease
and/or asthma)
 Hyposmia or anosmia
 snoring or sleep-disordered
breathing
 Aural congestion or pruritis
 Sore throat
 Halithosis
Associated symptoms Additional associated symptoms
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

6. Evaluation and diagnosis: History
 Presence of temporal patterns
 All rhinitis symptoms are most intense during the early
morning hours (circadian variations)
 Decrease in symptoms throughout the day: presence of an
indoor allergen (HDM, animal dander, mold, cockroach)
 Clear-cut worsening of symptoms in outside environments:
probability of allergy to an outdoor allergen (pollen, mold)
Middleton’s Allergy: Principle and Practice, 8th edition

7. ARIA 2008: Symptoms of allergic rhinitis
to specialist

8. Evaluation and diagnosis: Physical examination
 General observation:
 Facial pallor, elongated facies, mouth breathing
 Eyes:
 Allergic shiner, Dennie-Morgan line
 Dermatitis outer eyelids
 Excessive lacrimation, erythema and
swelling of the bulbar ± conjunctiva,
Cobblestone papillae
Middleton’s Allergy: Principle and Practice, 8th edition

9. Evaluation and diagnosis: Physical examination
 Nose
 Transverse crease (due to allergic salute)
 Nasal turbinate hypertrophy, edema, pallor
 Clear nasal discharge
 Dried blood commonly is observed (trauma)
 Polyps (rarely)
Middleton’s Allergy: Principle and
Practice, 8th edition

10. Inferior Turbinate Classification System
(A) Grade 1 (0%–25% of total airway space)
(B) Grade 2 (26%–50% of total airway space)
(C) Grade 3 (51%–75% of total airway space)
(D) Grade 4 (76%–100% of total airway space)
Camacho et al. Laryngoscope 125: February 2015

11. Evaluation and diagnosis: Physical examination
 Throat:
 Halitosis
 High arched palate (chronic mouth breathing)
 Malocclusion (common)
 Tonsillar hypertrophy
 Cobblestoning of the oropharyngeal wall
 Pharyngeal postnasal discharge
Middleton’s Allergy: Principle and Practice, 8th edition

12. Evaluation and diagnosis: Physical examination
 Ear
 Middle ear effusion
 TM retraction
 Chest
 Audible wheezing
 diminished breath sound
 Skin
 Eczema, urticaria, dermatographism
Middleton’s Allergy: Principle and Practice, 8th edition

13. Investigation
 The hallmark of allergic rhinitis is evidence of
specific IgE to a relevant allergen
 Allergy testing
 Skin prick test
 Serum antigen-specific IgE
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

14. Skin-prick test (SPT)
 To confirm the diagnosis of AR and differentiate
from non-allergic types of rhinitis
 High sensitivity and specificity (around 80%)
 more sensitive than serum testing with the added
benefit of lower cost
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

15. Medications that affect allergy skin testing
Medication Withhold Aggregate grades of evidence
H1 antihistamines Should be discontinued 2-7 days prior to testing A
H2 antihistamines Ranitidine suppresses skin wheal response, may result in false negatives B
Topical antihistamines (nasal, ocular) Should be discontinued 2 days prior to testing Unable to determine from one
Level 1b study.
Anti-IgE (omalizumab) Results in negative allergy skin test
(skin test responses return to normal within 8 weeks of discontinuation)
A
Leukotriene receptor antagonists May be continued during testing A
Tricyclic antidepressants Agents with antihistaminic properties suppress allergy skin test
responses
Unable to determine from one
Level 2b study.
Topical (cutaneous) corticosteroids Skin tests should not be placed at sites of chronic topical steroid
treatment
A
Systemic corticosteroids does not significantly impair skin test responses C
Selective serotonin reuptake inhibitors
(SSRIs)
Does not suppress allergy skin test response B
Benzodiazepines May suppress skin test responses C
Topical calcineurin inhibitors
(ie. tacrolimus, picrolimus)
Conflicting results regarding skin test suppression D
No studies were identified that examined the effect of intranasal or inhaled steroids on skin test results
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

16. Serum antigen-specific IgE (sIgE)
 Radioallergosorbent test (RAST)
 Radioactive anti-IgE for labeling IgE in serum
 The safety profile of serum sIgE testing is the best of all
available allergy tests
 Not influenced by drugs or skin disease
 levels of sIgE may correlate with severity of AR symptoms
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

17. J Investig Allergol Clin Immunol 2010; Vol. 20(5): 364-371

18. J Investig Allergol Clin Immunol 2010; Vol. 20(5): 364-371

19. Radiographic imaging
 Routine radiographic imaging is not recommended for the
diagnosis of allergic rhinitis
 Consider to rule in/out other conditions:
 Complications or comorbidities: rhinosinusitis, nasal polyposis
 Symptoms not typical of chronic rhinitis (chronic purulent rhinorrhea,
alteration in sense of smell)
 Headache
 Not responsive to therapy of rhinitis
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.
Middletons ’s Allergy: Principle and Practice, 8th edition

20. Differential diagnosis in chronic rhinitis
BSACI guideline Revised Edition 2017.Clin Exp Allergy. 2017;47:856–889.

21. Outline
 Definition and classification
 Epidemiology
 Pathophysiology and mechanisms
 Risk factors
 Evaluation and diagnosis
 Associated conditions
 Management

22. AR & Multimorbidities
Clin Transl Allergy. 2017 Jun 1;7:17.
AR
Asthma
Atopic
dermatitis
Food allergy
Eosinophilic
esophagitis
Conjunctivitis
Rhinosinusitis
Turbinate hypertrophy
Adenoid hypertrophy
Hearing impairment
OME
Laryngitis
GER
OSA
Fatigue
Learning problem

23. Outline
 Definition and classification
 Epidemiology
 Pathophysiology and mechanisms
 Risk factors
 Evaluation and diagnosis
 Associated conditions
 Management

25. Management of Allergic rhinitis
 Control the symptoms & Prevent the complication
 Allergen avoidance
 Pharmacotherapy
 Immunotherapy

26. Allergen avoidance and environmental controls:
House dust mites
Remove dust
- Remove carpets
(D)
- Remove dust-
accumulating objects
(D)
Portnoy J, et al. Ann Allergy Asthma Immunol. 2013; 111(6): 465-507.
Protect patient
- Encase bedding
(,B)
Control mites
- Wash bedding
(,B)
- Vacuum with HEPA filter
(,B)
- HEPA cleaner
(,C)
- Acaricides
(,B)
- Humidity control 35-50%
(,B)
Strength of recommendation
 Strong
 Moderate
 Weak
 Support  Against
Level of evidence
A RCT/SR of RCT
B Experimental study
C Non-experimental study
D Expert opinion

27. Portnoy J, et al. J Allergy Clin Immunol. 2013 Oct;132(4):802-8.e1-25.
Factors that facilitate cockroach populations (food and water, paths of ingress, and
microenvironments that can provide shelter) should be mitigated.
+++ D
Pesticides should be used judiciously and applied by a professional exterminator. + C
Boric acid is effective, but surviving cockroaches produce more allergen. + C
Reservoirs of cockroach contaminants should be cleaned or removed. +++ A
Integrated pest management with a combination of interventions appears to be the
most effective method for preventing and eliminating cockroach infestations.
+++ B
Allergen avoidance and environmental controls:
Cockroach

28. Allergen avoidance and environmental controls:
Pets
Portnoy J, et al. Ann Allergy Asthma Immunol. 2012; 2018:223.e1-15.
Patients should be advised to consider removing the cat or dog from the environment. A
If cat still living in the house, a combination of measures may be helpful C
Tannic acid can give short-term reduction of cat allergen, but there is no clinical evidence. C
Hypochlorite bleach improves QoL, reduces atopy, but can cause respiratory symptoms. C
Washing pets weekly reduces Fel d 1/Can f 1, but there is no clinical evidence. B
Microfiber encasings (pore < 6 mcm) blocks cat allergen, but there is no clinical evidence. C
Nonwoven microfiber encasings collect allergen and are unsuitable for allergen avoidance. C
Central vacuum cleaners reduces Fel d 1/Can f, but there is no clinical evidence. B
HEPA air cleaners reduces pets allergen concentrations, but there is no clinical evidence. B
Dry heat should not be used specifically to reduce exposure. C
Sufficient control requires a combination of measures. C

30. Pharmacotherapy
 Omalizumab
 Cromolyn
 Antihistamines
 Leukotriene receptor antagonists (LTRAs)
 Intranasal anticholinergics
 Decongestants
 Nasal saline
 Corticosteroids
 Combination therapy

31. Nature Reviews Immunology volume 8, pages 218–230 (2008)
Omalizumab

32. J Allergy Clin Immunol Pract. 2014 May-Jun;2(3):332-40.e1
Omalizumab for the Treatment of Inadequately Controlled Allergic Rhinitis:
A Systematic Review and Meta-Analysis of Randomized Clinical Trials
Clear benefit in
- Symptom control
- Reduce rescue medication
- Improve quality of life
Adverse event not different from
placebo, and NONE reported
anaphylaxis
Dosage varies, approximate cost
= 20,000 baht / month
FDA NOT approved as monotherapy
for Allergic rhinitis

33. Roger Altounyan
1922-1987
Degranulation of a mast cell. A, Mast cell undergoing gross degranulation
shows free granules. B, The pores occupy a large area of the cytoplasm. C,
Sensitized mast cell fails to degranulate after challenge when pretreated
with cromolyn sodium. (Courtesy Rhone-Poulenc Rorer Pharmaceuticals, Inc,
Collegeville, Pa.)
Sodium Cromoglycate
(Cromolyn Sodium )

34. Cromolyn tends to perform better in
most studies
- Both for SAR & PAR
- Both in children & adults
- In various dosage
Cromolyn
vs.
placebo
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018
Feb;8(2):108-352.

35. Cromolyn performs worse than INCS
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

36. Sodium Cromoglycate (Cromolyn Sodium )
• Available in many forms to treat: asthma, AR, and allergic conjunctivitis
• For AR, clear benefit over placebo,
less effective than intranasal corticosteroid
• Short half-life, requiring 3-6 doses per day → Poor compliance
• Excellence safety profile
• Nasal irritation
• Sneezing
• Epistaxis
• Bad taste

37. Middleton’s Allergy: Principleand Practice, 8th edition
Antihistamine

38. Oral H1 antihistamines
 lipophilic and readily crossed the
blood-brain barrier
 side effects: sedation,
drowsiness, fatigue, impaired
concentration and memory,
and anti-muscarinic effects
 not recommended for AR
 Cross blood-brain barrier
at minimal amount
 Less CNS side effect
 recommended for AR
1st generation antihistamine 2nd generation antihistamine
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

39. Properties of 2nd generation antihistamine
Medication Approved
age
Onset
(hr)
Duration
(hr)
Dose adjustment Pregnancy
category
NED Price at KCMH
Cetirizine ≥ 6 mo 0.7 ≥ 24 Renal and hepatic B ก Cetrizin(10) 1 ฿/tab
Ormist(5mg/5ml, 60ml) 15.5฿
Zyrtec(5mg/5ml, 75 ml) 100 ฿
Levocetirizine ≥ 6 mo 0.7 ≥ 24 Renal and hepatic B X Xyzal (5) 18.50฿/tab
fexofenadine ≥ 2 yr 1-3 24 Renal C X VIFAS(60) 2.75฿/tab
Telfast (60) 7.50 ฿/tab
Fenafex(180) 6.25฿/tab
Telfast(180) 23฿/tab
Telfast suspension (30mg/5ml, 150
ml) 306 ฿
loratadine ≥ 2 yr 2 24 Hepatic B ก
ข
Lorsedin(10) 1.50 ฿/tab
Claritin syr (5mg/5ml, 100ml) 159฿
desloratadine ≥ 6 mo 2-2.6 ≥ 24 Renal and hepatic C X Aerius (5) 22.50 ฿/tab
Aerius syr (2.5mg/5ml, 60ml) 204฿
Bilastine ≥ 12 yr 2 24 None NA X Bilaxten(20) 16 ฿/tab
Rupatadine ≥ 12 yr 2 24 Use not
recommended
NA X Rupafin(10) 39฿/tab
Immunol Allergy Clin N Am 2011;31:509-543.

40. 2nd generation antihistamine dosage
Medication Age range
6-11 mo 12-23 mo 2-5 yr 6-11 yrs ≥ 12 yrs
Cetirizine [Zyrtec] 2.5 mg OD 2.5 mg OD/BID
Or 5 mg OD
2.5-5 mg OD 5-10 mg OD 5-10 mg OD
Levocetirizine
[xyzal]
1.25 mg OD 1.25 mg OD 1.25 mg OD 2.5 mg OD 5 mg OD
loratadine
[Claritin]
- - 5 mg OD 10 mg OD 10 mg OD
desloratadine
[Aerius]
1 mg OD
-
1.25 mg OD
-
1.25 mg OD 2.5 mg OD 5 mg OD
fexofenadine
[Telfast]
15 mg bid (FDA
USA)
15 mg bid (FDA
USA)
30 mg bid 30 mg bid 60 mg bid or 180
mg OD
Bilastine - - - - 20 mg OD
Rupatadine - - - - 1 tablet (10 mg)
once daily
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

41. Safety of 2nd generation antihistamine
medication Sedative effect Anticholinergic
effect
Drug interaction Food interaction
Cetirizine [Zyrtec] Yes Yes Yes No
Levocetirizine
[xyzal]
Yes Yes No No
loratadine
[Claritin]
Yes (low) No Yes No
desloratadine
[Aerius]
No No Yes No
fexofenadine
[Telfast]
No No No Yes
Federal Aviation Administartion: The nonsedating antihistamines loratadine,
desloratadine, and fexofenadine may be used while flying

42. Intranasal H1-antihistamines
 2 intranasal antihistamine are currently approved by the US FDA for treatment of
allergic rhinitis
 Azelastine hydrochloride
 Olopatadine hydrochloride
 Not available in Thailand
 Benefits:
 Rapid onset of action (15-30 minutes)
 can be administered "on demand”
 more effective for nasal congestion than oral antihistamines
 Systemic absorption may occur: sedation
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

43. STATEMENT 8. INTRANASAL ANTIHISTAMINES: Clinicians may offer intranasal
antihistamines for patients with seasonal, perennial, or episodic AR. Option based on RCTs
with minor limitations and observational studies, with equilibrium of benefit and harm.
Seidman et al ,Otolaryngology–Head and Neck Surgery 2015, Vol. 152(1S)

44. Leukotriene receptor antagonist (LTRA)
Montelukast
Pulm Pharmacol Ther. 2016 Dec;41:52-59.

45. Leukotriene receptor antagonist (LTRA)
- Better than placebo
- Worse than INCS
- Worse or equal to oral antihistamine
- Equal to pseudoephedrine
- Higher cost
NOT recommended as
monotherapy for AR
without asthma
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

46. Intranasal anticholinergics
Submucosal gland Rhinorrhea
Mast cell
c-fiber
Parasympathetic nerve
(muscarinic)
Direct effect
Indirect effect
Muscarinic
receptor
G
Ipratropium
bromide Acetylcholine
Adapted from Global Resources in Allergy: Allergic rhinitis 2011

47. Intranasal anticholinergics
 Effective in reducing rhinorrhea in PAR, with or without INCS
 Quick onset
 Short half-life
 Low bioavailability
 Side effect: only local
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

48. Decongestant
• Topical and systemic decongestants
• α-adrenergic stimulation vascular constriction and a reduction of nasal blood supply
 reduce nasal congestion (no effect on other symptoms of AR)
Decongestant Topical Oral
Commonly used Pseudoephedrine hydrochloride,
Phenylephrine
xylometazoline, oxymetazoline
Onset of action Rapid onset within 5-15 min Active within 30-60 min
Rebound effect Prolonged use > 5-10 days may lead to
tachyphylaxis, rhinitis medicamentosa
No
Systemic side effect No insomnia, nervousness, anxiety, tremors, palpitations,
headache, and increased blood pressure
Other Adverse effect: nasal burning, stinging,
dryness, epistaxis, and mucosal ulceration.
Caution: In patient with HT, heart disease, seizure
disorders, hyperthyroidism, prostate enlargement, using
MAOI
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.
Middletons ’s Allergy: Principle and Practice, 8th edition

49. Decongestant
Oxymetazoline Hydrochloride Drops and Nasal Spray
Oral Decongestant

50. Nasal Saline
● Variety of “saline”: isotonic, hypertonic, seawater, buffered solution
● Variety of regimens: volume 300 mcl - 500 ml, different frequency
● Proposed mechanisms of nasal saline
● Mechanical effect
→ remove mucus & inflammatory mediators
→ dilute antigen
● Mucociliary clearance
→ increase ciliary beat frequency
● Proven benefits in many studies, both in adult and children
● Low adverse effects, low cost

51. Head K, Snidvongs K, Glew S, Scadding G, Schilder AGM, Philpott C, Hopkins C. Saline irrigation for allergic rhinitis. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD012597.
Nasal saline improves
symptoms in both children
& adult up to 4 weeks and
beyond
Nasal saline as an adjunct to
pharmacologic treatment
shows no significant benefit

52. Head K, Snidvongs K, Glew S, Scadding G, Schilder AGM, Philpott C, Hopkins C. Saline irrigation for allergic rhinitis. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD012597.
Various regimens of saline shows
benefit in reducing symptoms.
Evidences are not enough to
compare between regimens.

53. Nature Reviews Immunology volume 8, pages 218–230 (2008)
Intranasal corticosteroid

54. Okano M. Clin Exp Immunol. 2009; 158: 164–73
Intranasal corticosteroid: Mechanism

55. Intranasal corticosteroid
1st generation: systemic bioavailability 10-50%
2nd generation: systemic bioavailability <1% or undetectable
Beclomethasone
dipropionate (BDP,
Beconase)
Budesonide (BUD,
Rhinocort)
Triamcinolone
acetonide (TA,
Nasocort)
Fluticasone propionate
(FP, Flixonase)
Mometasone
Furoate (MF,
Nasonex)
Fluticasone Furoate
(FF, Avamys)

56. Intranasal corticosteroid: Efficacy
• The most effective medication for AR
• Effective for all nasal symptoms
• May also benefit ocular symptoms through naso-ocular reflex
• Onset: 3-hour up to 60-hour after the first dose
• Maximum effect: up to 2-week
• No significant differences between available agents
• PRN dosing in SAR also effective compared to placebo
• improve asthma control in AR-asthma comorbidity
• also effective for non-allergic rhinitis, esp. NARES &vasomotor rhinitis
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

57. Intranasal corticosteroid: Local side effect
• Most common: dryness, burning sensation
• Epistaxis (4-8% in 2-12 weeks)
*no difference from placebo --> application related > effect of steroid
• Rare: septal perforations
• No evidence: nasal mucosa atrophy
Reduction of squamous metaplasia suggests a favorable effect.
Seidman M, et al.,Otolaryngology-Head and Neck surgery 2015, Vol. 152(1s)

58. Intranasal corticosteroid: Systemic side effect

59. Laryngoscope. 2018 Sep 19. doi: 10.

60. Laryngoscope. 2018 Sep 19. doi: 10.

61. Laryngoscope. 2018 Sep 19. doi: 10.

62. Intranasal corticosteroid: Systemic side effect
• The development of ophthalmic problems
• a systematic review showed no impact on
• Ocular pressure
• Glaucoma
• Lens opacity
• Cataract formation
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

63. Intranasal corticosteroid: Systemic side effect
Hypothalamic Pituitary Adrenal axis suppression
• Show no adverse effects in adult and children
✓Morning cortisol concentrations
✓Co-syntropin stimulation
✓24-hour serum cortisol
✓24-hour urinary free cortisol
ISCAR: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.

64. Mener DJ, Shargorodsky J, Varadhan R, Lin SY. Topical intranasal corticosteroids and growth
velocity in children: a meta-analysis. Int Forum Allergy Rhinol. 2015;5:95–103.
INCS & Growth
Budesonide
Triamcinolone
Fluticasone
Fluticasone
Mometasone
Budesonide
Budesonide
Triamcinolone
Fluticasone
Fluticasone
Mometasone
Budesonide
Short term growth lower in INCS group

65. Mener DJ, Shargorodsky J, Varadhan R, Lin SY. Topical intranasal corticosteroids and growth
velocity in children: a meta-analysis. Int Forum Allergy Rhinol. 2015;5:95–103.
INCS & Growth
Fluticasone
Mometasone
Budesonide
Beclometasone
Fluticasone
Mometasone
Budesonide
Beclometasone
Effect on long term growth not significant

66. INCS & Growth: The research continues...
Limitations of previous studies
- Inclusion of possible-growth spurt age group
- Varying regimen of nasal corticosteroid
- Inaccurate/different growth measurement
- Growth suppression occurred even when HPA axis test normal
Suggestion
- Design: DBRCT (with treatment duration ~ 12 months)
- Assessment of baseline growth velocity (~ 4-5 months)
- follow-up period to verify catch-up (~ 2 months)
- Height measured with calibrated stadiometer & trained personnel
- Age of subjects: 3-year-old to prepubertal (steady GV)
www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatoryInformation/ Guidances/ucm071968.pdf.

67. Pediatrics. 2015 Feb;135(2):e348-56.
Intranasal TAA for AR in children 3-9 years old reduces small, yet
statistical significant, growth velocity during treatment period.
Whether this gap could be catched-up, can not be inferred from this
study.
GV drops from baseline: 1.09 cm/y (0.35-1.83), p 0.0043

68. Systemic bioavailability of intranasal steroid
BSACI guideline Revised Edition 2017.Clin Exp Allergy. 2017;47:856–889.

69. Lipophilicity
First pass effect
J Allergy Clin Immunol. 2000 Oct;106(4 Suppl):S179-90

70. Generic Trade Strength NED Price per unit Price per puff
Triamcinolone
Acetonide
NASACORT AQ
55 mcg/dose,
120 doses
X 282 2.35
Budesonide BUNASE
100 mcg/dose,
150 doses
ข 241 1.61
Budesonide RHINOCORT AQUA
64 mcg/dose,
120 doses
ข 282 2.35
Fluticasone
Furoate
AVAMYS
27.5 mcg,
120 doses
ง 288 2.40
Fluticasone
Propionate
FLIXONASE
50 mcg/dose,
120 doses
X 319 2.66
Mometasone
Furoate
NASONEX
50 mcg /dose,
140 doses
X 705 5.04
KCMH

71. Intranasal corticosteroid
Drug Tradename Approved
age (yr)
Adult dose
(>12 yr)
Child dose Pregnancy/
nursing risk
Alcohol BKC
propylene gylcol
Beclomethasone
dipropionate
Beconase 6 1-2 spray /nos
bid
1-2 spray/nos
bid
C Alcohol BKC
Budesonide Rhinocort 6 1-4 spray /nos
OD
1-2 spray/nos
OD
B No alcohol No BKC
Triamcinolone
acetonide
Nasocort 2 1-2 spray /nos
OD
1-2 spray/nos
OD
C No alcohol BKC
Fluticasone
propionate
Flixonase 4 2 spray /nos OD 1 spray/nos OD C Alcohol BKC
Mometasone
Furoate
Nasonex 2 2 spray /nos OD 1-2 spray/nos
OD
C No alcohol BKC
Fluticasone
Furoate
Avamys 2 2 spray /nos OD 1-2 spray/nos
OD
C No alcohol BKC
BKC, benzalkonium chloride J Allergy Clin Immunol 2008;122:S1-84.

72. Agent Sneezing Itching Congestion Rhinorrhea Eye
Antihistamines: oral ++ +++ ± ++ ++
Antihistamines: nasal ++ ++ + ++ -
Nasal corticosteroids +++ +++ +++ +++ ++
Decongestants: oral - - + - -
Decongestants: nasal - - ++++ - -
Leukotriene modifier + + + + +
Mast-cell stabilizer: nasal + + + + -
Anticholinergic agent: nasal - - - ++ -
Lien L., Pediatric Allergic Rhinitis: Treatment. Immunol Allergy Clin N Am 25 (2005) 283-299
Symptomatic effects of pharmacologic treatments
Therapeutic options efficacy in nasal and ocular symptoms

73. ARIA recommendation for management of allergic rhinitis

75. Allergen Immunotherapy
Shamji MH, Durham SR. J Allergy Clin Immunol. 2017 Dec;140(6):1485-1498.

76. Allergen Immunotherapy
AIT indicated if:
- IgE mediated diseases
- Limited spectrum allergy
- Can not avoid allergen
- Not adequately controlled with
medications
- Able to comply with protocol
AIT (relatively) contraindicated if:
- Uncontrolled asthma
- Concurrent beta-blocker therapy
- Concurrent
infection/inflammatory diseases
- Younger than 5-year old
- Pregnancy
Canonica GW, Durham SR. Allergen Immunotherapy for allergic rhinitis and asthma: A Synopsis. World Allergy Organization Education Program. Updated October 2016. Accessed
15/12/2018: http://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergen-immunotherapy-a-synopsis

77. Subcutaneous Immunotherapy (SCIT)
Canonica GW, Durham SR. Allergen Immunotherapy for allergic rhinitis and asthma: A Synopsis. World Allergy Organization Education Program. Updated October 2016. Accessed
15/12/2018: http://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergen-immunotherapy-a-synopsis
- High dose deep SC injection of allergen extract
- Up-dosing: weekly dose x 8-16 weeks
- Maintenance: monthly dose (optional extended to 6-8 weeks) x 3-5 years
- Adverse events management
- Should measure peak-flow before and after 30 minutes of injection
- Must be observed with physician availability for at least 30 minutes
- Rhinitis, mild wheezing → antihistamine, bronchodilator
- Asthma, urticaria, angioedema → antihistamine, IV hydrocortisone
- Adrenaline 0.5 mg IM if symptom progress rapidly
- Provide out-of-office-time contact & self-management advice
- Delay reaction usually mild

78. Sublingual Immunotherapy (SLIT)
Canonica GW, Durham SR. Allergen Immunotherapy for allergic rhinitis and asthma: A Synopsis. World Allergy Organization Education Program. Updated October 2016. Accessed
15/12/2018: http://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergen-immunotherapy-a-synopsis
- A daily tablet, should be kept under the tongue for 2 minutes
before swallow
- Usually well tolerated with minimal local side effect
- Tongue & lips swelling occur in up to 50% of patients, resolved
within 1-2 weeks
- Systemic reactions are rare, dead has never been reported

79. SCIT vs. SLIT
Canonica GW, Durham SR. Allergen Immunotherapy for allergic rhinitis and asthma: A Synopsis. World Allergy Organization Education Program. Updated October 2016. Accessed
15/12/2018: http://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergen-immunotherapy-a-synopsis
SCIT SLIT
Effective for SAR High quality evidence High quality evidence
Effective for PAR Moderate quality evidence High quality evidence
Long-term remission Moderate quality evidence High quality evidence
Pediatrics Need more study Need more study
Local AE Pain & swelling Itching, lips & tongue swelling
Systemic AE More frequent Rarely
Administration Specialist clinic Self-administration
Compliance Ensured Hard to monitor

80. Other routes
Canonica GW, Durham SR. Allergen Immunotherapy for allergic rhinitis and asthma: A Synopsis. World Allergy Organization Education Program. Updated October 2016. Accessed
15/12/2018: http://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergen-immunotherapy-a-synopsis
- Intranasal: local side effects, poorly tolerated
- Inhale: induce asthma
- Oral: less effective, limited study
- Epicutaneous: systemic side effects, limited study
- Intralymphatic: cost-effective > SCIT, limited study

81. Surgical treatment
 Significant anatomical nasal defect (e.g. nasal septal deviation):
nasal obstruction affects quality of life
 Turbinate reduction surgery
 Indication
 Patients with refractory mucosal edema only if pharmacotherapy and
immunotherapy have been tried and failed
 Involve 2 different methods
 1. entire portions of the turbinate (turbinectomy)
 2. only the tissues between the mucosal covering and/or the bone of the
turbinate (submucous resection); or shrinking the volume of the turbinate
(tissue ablasion)
Seidman M, et al.,Otolaryngology-Head and Neck surgery 2015, Vol. 152(1s)

82. J Allergy Clin Immunol. 2012 Nov;130(5):1049-62.

83. A PRACTALL report. Allergy 2015; 70: 474–494.
Assessment of rhinitis control

84. The EAACI guideline: suggests a stepwise therapeutic approach
BSACI guideline Revised Edition 2017.Clin Exp Allergy. 2017;47:856–889.