Clinical pharmacy in Immunoallergology Medical diseases

1. Clinical Pharmacy inClinical Pharmacy in
ImmunoallergologyImmunoallergology
Medical diseasesMedical diseases

2. AllergiesAllergies
 Allergic RhinitisAllergic Rhinitis ('hay fever')('hay fever')
 AsthmaAsthma
 Chronic SinusitisChronic Sinusitis
 Eczema (Atopic Dermatitis)Eczema (Atopic Dermatitis)
 Chronic Hives & Angioedema (swelling)Chronic Hives & Angioedema (swelling)
 Food AllergiesFood Allergies
 Allergies to Insect StingsAllergies to Insect Stings
 Contact DermatitisContact Dermatitis
 Less common conditions includingLess common conditions including
anaphylaxis, drug allergies and immuneanaphylaxis, drug allergies and immune
deficiencies.deficiencies.

3. What Are Allergies?What Are Allergies?
 Allergies are a reaction by the body'sAllergies are a reaction by the body's
immune system to harmlessimmune system to harmless
substances that it sees as harmful. substances that it sees as harmful.
The allergy causing substances areThe allergy causing substances are
called allergens. It is as if the immunecalled allergens. It is as if the immune
system is overly-active in response tosystem is overly-active in response to
otherwise innocuous substances.otherwise innocuous substances.

4. TERMS
 Allergen—A substance that provokes an
allergic response.
 Anaphylaxis—Increased sensitivity caused by
previous exposure to an allergen that can result
in blood vessel dilation (swelling) and smooth
muscle contraction. Anaphylaxis can result in
sharp blood pressure drops and difficulty
breathing.
 Antibody—A specific protein produced by the
immune system in response to a specific
foreign protein or particle called an antigen.
 Antigen—A foreign protein to which the body
reacts by making antibodies.

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6. Mast cells, one of the major players in allergic
reactions, capture and display a particular
type of antibody, called immunoglobulin type
E (IgE) that binds to allergens.
Inside mast cells are small chemical-filled
packets called granules. Granules contain a
variety of potent chemicals, including
histamine.

7. How do Alergies occur?How do Alergies occur?
The immune system is the body's naturalThe immune system is the body's natural
defense against infection and other foreigndefense against infection and other foreign
material. Before the person can has a reactionmaterial. Before the person can has a reaction
to a particular substance, immune system mustto a particular substance, immune system must
first be sensitized to it. This happens in anfirst be sensitized to it. This happens in an
earlier contact with the substance. Onceearlier contact with the substance. Once
sensitized, the body will react when one hassensitized, the body will react when one has
contact with that substance. Many substancescontact with that substance. Many substances
cause an allergic reaction. The most commoncause an allergic reaction. The most common
are:are: pollens, molds, house dust mites, animalpollens, molds, house dust mites, animal
dander, latex, medicines, insect stings anddander, latex, medicines, insect stings and
foods.foods.

8. Food allergic reactions may be severe or fatal.Food allergic reactions may be severe or fatal.
Common foods that may cause allergyCommon foods that may cause allergy
symptoms include fish, eggs, milk, nuts, peanutssymptoms include fish, eggs, milk, nuts, peanuts
and wheat. Food allergies often occur inand wheat. Food allergies often occur in
children, who may outgrow them.children, who may outgrow them.
It is also possible to have an allergic reaction toIt is also possible to have an allergic reaction to
sunlight, temperature extremes, water contactsunlight, temperature extremes, water contact
and other elements in your physicaland other elements in your physical
environment.environment.

9. Allergic reactions
immediate hypersensitivity reactions,
which are predominantly mast cell-
mediated and occur within minutes of
contact with allergen;
delayed hypersensitivity reactions,
mediated by T cells (a type of white blood
cells) and occurring hours to days after
exposure.

10. Inhaled or ingested allergens usually cause
immediate hypersensitivity reactions. Allergens
bind to IgE antibodies on the surface of mast
cells, which spill the contents of their granules
out onto neighboring cells, including blood
vessels and nerve cells. Histamine binds to the
surfaces of these other cells through special
proteins called histamine receptors. Interaction
of histamine with receptors on blood vessels
causes increased leakiness, leading to the fluid
collection, swelling and increased redness.
Histamine also stimulates pain receptors,
making tissue more sensitive and irritable.
Symptoms last from one to several hours
following contact.

11. Routes:
Allergens enter the body through
the airways, the skin, the gastrointestinal tract, and the
circulatory system
SYMPTOMS
Airborne allergens cause the sneezing, runny nose,
and itchy, bloodshot eyes of hay fever (allergic rhinitis).
Airborne allergens can also affect the lining of the
lungs, causing asthma, or the conjunctiva of the eyes,
causing conjunctivitis (pink eye). Exposure to cockroach
allergans have been associated with the development
of asthma. Airborne allergans from household
pets are another common source of environmental
exposure.

12. SYMPTOMS
Allergens in food can cause itching and swelling of the
lips and throat, cramps, and diarrhea. When absorbed
into the bloodstream, they may cause hives (urticaria)
or more severe reactions involving recurrent,
noninflammatory swelling of the skin, mucous
membranes, organs, and brain (angioedema). Some
food allergens may cause anaphylaxis, a potentially life-
threatening condition marked by tissue swelling,
airwayconstriction, and drop in blood pressure. Allergies
to foods such cow’s milk, eggs, nuts, fish, and legumes
(peanuts and soybeans) are common. Allergies to fruits
and vegetables may also occur.

13. SYMPTOMS
In contact with the skin, allergens can cause reddening,
itching, and blistering, called contact dermatitis.
Skin reactions can also occur from allergens introduced
through the airways or gastrointestinal tract.
This type of reaction is known as atopic dermatitis.
Dermatitis may arise from an allergic response (such
as from poison ivy), or exposure to an irritant causing
nonimmune damage to skin cells (such as soap, cold,
and chemical agents).

14. SYMPTOMS
Injection of allergens, from insect bites
and stings or drug administration, can
introduce allergens directly into the
circulation, where they may cause system-
wide responses (including anaphylaxis),
as well as the local ones of swelling and
irritation at the injection site.

15. The following types of drugs commonly
cause allergic reactions:
• penicillin or other antibiotics
• flu vaccines
• tetanus toxoid vaccine
• gamma globulin

16. SYMPTOMS (cont’d)
Symptoms depend on the specific type of allergic
reaction. Allergic rhinitis is characterized by an itchy,
runny nose, often with a scratchy or irritated throat due
to post-nasal drip. Inflammation of the thin membrane
covering the eye (allergic conjunctivitis) causes redness,
irritation, and increased tearing in the eyes. Asthma causes
wheezing, coughing, and shortness of breath.

17. SYMPTOMS (cont’d)
Symptoms of food allergies depend on the tissues most
sensitive to the allergen and whether the allergen spread
systemically by the circulatory system. Gastrointestinal
symptoms may include swelling and tingling in the lips,
tongue, palate or throat; nausea; cramping; diarrhea; and
gas. Contact dermatitis is marked by reddened, itchy,
weepy skin blisters, and an eczema that is slow to heal. It
sometimes has a characteritic man-made pattern, such as
a glove allergy with clear demarkation on the hands,
wrist, and arms where the gloves are worn, or on the
earlobes by wearing earrings.

18. Skin reactions
Skin reactions
include the raised, reddened, and itchy patches called
hives that characteristically blanch with pressure and
resolve within twenty-four hours. A deeper and more
extensive skin reaction, involving more extensive fluid
collection and pain, is called angioedema. This usually
occurs on the extremities, fingers, toes, and parts of the
head,neck,and face.

19. Anaphylaxis
Anaphylaxis is marked by airway constriction, blood
pressure drop, widespread tissue swelling, heart rhythm
abnormalities, and in some cases, loss of
consciousness. Other syptoms may include, dizziness,
weakness, seizures, coughing,flushing, or cramping.
The symptoms may begin within five minutes after
exposure to the allergan up to one hour or more later.
Mast cells in the tissues and basophils in the blood
release mediators that give rise to the clinical symptoms
of this IgE-mediated hypersensitivity reaction. Commonly,
this is associated with allergies to medications, foods,
and insect venoms.

20. Anaphylaxis
In some individuals, anaphylaxis can
occur with exercise, plasma exchange,
hemodialysis, reaction to insulin,
radocontrast media used in certain types
of medical tests. and rarely during the
administration of local anesthetics.

21. The allergic response

22. Treatment
Avoiding allergens is the first line of defense to reduce
the possibility of an allergic attack.
Complete environmental control is often difficult to
accomplish, hence therapuetic interventions may
become necessary. A large number of prescription and
over-the-counter drugs are available for treatment of
immediate hypersensitivity reactions. Most of these
work by decreasing the ability of histamine to provoke
symptoms. Other drugs counteract the effects of histamine
by stimulating other systems or reducing immune
responses in general.

23. Treatment
ANTIHISTAMINES block the histamine
receptors on nasal tissue, decreasing the
effect of histamine released by mast cells.
They may be used after symptoms
appear, though they may be even more
effective when used preventively, before
symptoms appear. Antihistamines are help
reduce sneezing, itching, and rhinorrhea.

24. Treatment
I generation antihistamines side effect
Drowsiness
dry mouth,
tachycardia,
blurred vision,
constipation,
lower the threshold for seizures.
diphenhydramine (Benadryl and generics)
chlorpheniramine (Chlor-trimeton and generics)
brompheniramine (Dimetane and generics)
clemastine (Tavist and generics)
These medicatios care should be taken when operating motor vehicles

25. Treatment
Newer antihistamines that do not cause
drowsiness or pass the blood-brain barrier
are available by prescription and include the
following:
• loratidine (Claritin)
• fexofenadine (Allegra)

26. Treatment
MAST CELL STABILIZERS
Cromolyn sodium prevents the release of mast cell
granules, thereby preventing the release of
histamine and other chemicals contained in
them. It acts as a preventive treatment if it is
begun several weeks before the onset of the
allergy season.
It can also be used for year round allergy
prevention. Cromolyn sodium is available as a
nasal spray for allergic rhinitis and in aerosol (a
suspension of particles in gas) form for asthma.

27. Treatment
LEUKOTRIENE MODIFIERS
These medications are useful for individuals
with aspirin sensitivity,sinusitis,
poliposis, urticaria. Examples include
zafirlukast (Accolate), montelukast
(Singulair), and zileuton (Zyflo).
When zileuton is used, care must be taken to measure liver
enzymes.

28. ALLERGIC RHINITIS
Allergic rhinitis, more commonly referred to as hay
fever, is an inflammation of the nasal passages caused by
allergic reaction to airborne substances.
Allergic rhinitis (AR) is the most common allergic
condition and one of the most common of all minor
afflictions.
There are two types of allergic rhinitis: seasonal and
perennial. Seasonal AR occurs in the spring, summer,
and early fall, when airborne plant pollens are at their
highest levels. In fact, the term hay fever is really a
misnomer, since allergy to grass pollen is only one cause
of symptoms for most people. Perennial AR occurs all
year and is usually caused by home or workplace
airborne pollutants. A person can be affected by one or
both types.
Symptoms of seasonal AR are worst after being
outdoors, while symptoms of perennial AR are worst
after spending time indoors.

29. ALLERGIC RHINITIS
Causes
Allergic rhinitis is a type of immune reaction.
Normally, the immune system responds to
foreign microorganisms, or particles, like pollen
or dust, by producing specific proteins, called
antibodies, that are capable of binding to
identifying molecules, or antigens, on the foreign
particle. This reaction between antibody and
antigen sets off a series of reactions designed to
protect the body from infection. Sometimes, this
same series of reactions is triggered by
harmless, everyday substances. This is the
condition known as allergy, and the offending
substance is called an allergen.

30. Virtually any type of tree or grass may cause AR. A
few types of weeds that tend to cause the most trouble for
people include the following:
• ragweed
• sagebrush
• lamb’s-quarters
• plantain
• pigweed
• dock/sorrel
This illustration
depicts excessive
mucus
production in the
nose after
inhalation of
airborne pollen

31. ALLERGIC RHINITIS. Symptoms
Inflammation causes
itching, sneezing, runny nose, redness, and
tenderness. Sinus swelling can constrict the
eustachian tube that connects the inner ear to
the throat, causing a congested feeling and “ear
popping.”
The drip of mucus from the sinuses down the
back of the throat, combined with increased
sensitivity, can also lead to throat irritation and
redness. AR usually also causes redness,
itching, and watery eyes. Fatigue and
headache are also common.

32. ALLERGIC RHINITIS. Treatment
Avoidance of the allergens is the best treatment, but
this is often not possible. When it is not possible to avoid
one or more allergens, there are two major forms of
medical treatment, drugs and immunotherapy.
DRUGS
ANTIHISTAMINES. Antihistamines block the histamine
receptors on nasal tissue, decreasing the effect of
histamine release by mast cells. They may be used after
symptoms appear, though they may be even more effective
when used preventively, before symptoms appear. A
wide variety of antihistamines are available.

33. ALLERGIC RHINITIS. Treatment
Older antihistamines often produce
drowsiness as a major side effect. Such
antihistamines include the following:
• diphenhydramine (Benadryl and generics)
• chlorpheniramine (Chlor-trimeton and
generics)
• brompheniramine (Dimetane and generics)
• clemastine (Tavist and generics).

34. ALLERGIC RHINITIS. Treatment
Newer antihistamines that do not cause
drowsiness are available by prescription and
include the following:
• astemizole (Hismanal)
• loratidine (Claritin)
• fexofenadine (Allegra)
• azelastin HCl (Astelin).
– Hismanal has the potential to cause serious heart
arrhythmias when taken with the antibiotic
erythromycin, the antifungal drugs ketoconazole and
itraconazole, or the antimalarial drug quinine.

35. ALLERGIC RHINITIS. Treatment
Decongestants constrict blood vessels to
counteract the effects of histamine. Nasal sprays
are available that can be applied directly to the
nasal lining and oral systemic preparations are
available. Decongestants are stimulants and
may cause increased heart rate and
bloodpressure, headaches, and agitation. Use of
topical decongestants for longer than several
days can cause loss of effectiveness and
rebound congestion, in which nasal passages
become more severely swollen than before
treatment.

36. ALLERGIC RHINITIS. Treatment
Topical corticosteroids reduce mucous membrane
inflammation and are available by prescription. Allergies
tend to become worse as the season progresses
because the immune system becomes sensitized to
particular antigens and can produce a faster, stronger
response. Topical corticosteroids are especially effective
at reducing this seasonal sensitization because they
work more slowly and last longer than most other
medication types. As a result, they are best started
before allergy season begins.
Side effects are usually mild, but may include headaches,
nosebleeds, and unpleasant taste sensations.

37. ALLERGIC RHINITIS. Treatment
MAST CELL STABILIZERS
Cromolyn sodium prevents the release of
mast cell granules, thereby preventing
release of histamine and the other
chemicals contained in them. It acts as a
preventive treatment if it is begun
severalweeks before the onset of the
allergy season. It can be used for
perennial AR as well.

38. ALLERGIC RHINITIS. Treatment
Immunotherapy, also known as desensitization or
allergy shots, alters the balance of antibody types in the
body, thereby reducing the ability of IgE to cause allergic
reactions. Immunotherapy is preceded by allergy testing
to determine the precise allergens responsible. Injections
involve very small but gradually increasing amounts of
allergen, over several weeks or months, with periodic
boosters. Full benefits may take up to several years to
achieve and are not seen at all in about one in five
patients.

39. Treatment of anaphylaxis
The emergency condition of anaphylaxis is treated with
injection of adrenaline (epinephrine).
Paticular care should be taken to assess the affected
individual’s airway status, and he or she should be placed
in a recumbent pose and vital signs determined.
If a reaction resulted from insect sting or an injection, a
tourniquet may need to be placed proximal to the area
where the agent penetrated the skin. This should then be
released at intervals of ten minutes at a time, for one to
two minutes duration.
Oxygen may be given, as well as intravenous
replacement fluids.
Antihistamines may be used for skin rash, and
aminophylline for bronchial constriction. If the upper
airway is obstructed, placement of a breathing tube or
tracheostomy tube may be needed.

40. Immunologic Reactions to Drugs &Immunologic Reactions to Drugs &
Drug AllergyDrug Allergy
Immediate (Type I) Drug Allergy,Immediate (Type I) Drug Allergy,
Autoimmune (Type II) Reactions to Drugs,Autoimmune (Type II) Reactions to Drugs,
Serum Sickness & Vasculitic (Type III)Serum Sickness & Vasculitic (Type III)
Reactions.Reactions.

41. Drug hypersensitivityDrug hypersensitivity is defined as an immune-is defined as an immune-
mediated response to a drug agent in a sensitizedmediated response to a drug agent in a sensitized
patient.patient. Drug allergyDrug allergy is restricted specifically to ais restricted specifically to a
reaction mediated by IgE.reaction mediated by IgE.
Immune-mediated reactions account for 5Immune-mediated reactions account for 5
to 10 percent of all drug reactions andto 10 percent of all drug reactions and
constitute true drug hypersensitivity, withconstitute true drug hypersensitivity, with
IgE-mediated drug allergies falling into thisIgE-mediated drug allergies falling into this
category.category.
Type I reactions (IgE-mediated); Type IIType I reactions (IgE-mediated); Type II
reactions (cytotoxic); Type III reactionsreactions (cytotoxic); Type III reactions
(immune complex); and Type IV reactions(immune complex); and Type IV reactions
(delayed, cell-mediated).(delayed, cell-mediated).

42. DRUG HYPERSENSITIVITYDRUG HYPERSENSITIVITY
The most important drug-related risk factorsThe most important drug-related risk factors
for drug hypersensitivity concern the chemicalfor drug hypersensitivity concern the chemical
properties and molecular weight of the drug.properties and molecular weight of the drug.
Larger drugs with greater structural complexityLarger drugs with greater structural complexity
(e.g., nonhuman proteins) are more likely to be(e.g., nonhuman proteins) are more likely to be
immunogenic. Heterologous antisera,immunogenic. Heterologous antisera,
streptokinase, and insulin are examples ofstreptokinase, and insulin are examples of
complex antigens capable of elicitingcomplex antigens capable of eliciting
hypersensitivity reactions. Most drugs have ahypersensitivity reactions. Most drugs have a
smaller molecular weight (less than 1,000smaller molecular weight (less than 1,000
daltons), but may still become immunogenic bydaltons), but may still become immunogenic by
coupling with carrier proteins, such as albumin,coupling with carrier proteins, such as albumin,
to form simple chemical-carrier complexesto form simple chemical-carrier complexes
(hapten).(hapten).