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Allergic rhinitis 2

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Allergic rhinitis 2

  1. 1. Nathan Hare MD 2/19/13 Allergic Rhinitis
  2. 2. Outline  Epidemiology  Description  Pathophysiology  Triggers  Co-morbidities  Local Allergic Rhinitis  Treatment  Environmental Modifications  Medications  Subcutaneous Immunotherapy  Sublingual Immunotherapy
  3. 3. Allergic Rhinitis (AR)  Affects 10-40% of children world-wide 1  Affects up to 40% of children in the U.S.  Affects 10-30% of adults in the U.S.2 1. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Editorial Group: Topical nasal steroids for intermittent and persistent allergic rhinitis in children Cochrane Ear, Nose and Throat Disorders Group, Published Online: 21 JAN 2009 2. http://www.aaaai.org/conditions-and-treatments/library/allergy-library/rhinitis.aspx
  4. 4. Symptoms of Allergic Rhinitis  Nasal Congestion  Nasal Pruritus  Sneezing  Rhinorrhea  Post Nasal Drainage  Daytime inattention  Irritability  Hyperactivity
  5. 5. Bischoff Nature Reviews Immunology 7, 93–104 (February 2007) | doi:10.1038/nri2018 Pathophysiology
  6. 6. Common Triggers for Allergic Rhinitis Seasonal Perennial  Tree Pollen  Grass Pollen  Weed Pollen  Mold Spores  Dust Mites  Cockroaches  Cat  Dog  Mouse (inner city schools) * Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W. Allergens in urban schools and homes of children with asthma. Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6. •Exposure is to airborne allergens •Have to think of indoor exposure beyond the home
  7. 7. Inner City School Allergen Exposures  Settled dust and airborne allergen levels  12 schools, vs homes  Mouse levels were “substantial”  Cat and Dog levels low, but were higher at school  Dust mite and cockroach levels were low Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W. Allergens in urban schools and homes of children with asthma. Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.
  8. 8. Allergic Rhinitis: Comorbidities  Important to remember impacts on children beyond the nose  Asthma , eczema, food allergy (28%, 50%, 38% of 108 4 yo pts w AR1)  Oral Allergy Syndrome (25% of 8 year olds 1)  Sleep Disordered Breathing  ADHD (?)  Daytime inattention  Irritability  Hyperactivity 1. Westman M, Stjärne P, Asarnoj A, Kull I, van Hage M, Wickman M, Toskala E. Natural course and comorbidities of allergic and nonallergic rhinitis in children. J Allergy Clin Immunol. 2012 Feb;129(2):403-8. doi: 10.1016/j.jaci.2011.09.036. Epub 2011 Nov 5.
  9. 9. AR & Sleep Disordered Breathing in Children  Jan 2013 Review, covered last 25 years  Ages 7-17  Case-series or Case-Control articles  10 articles studied habitual snoring  6 articles studied OSA  12/18 articles: statistically significant association between AR and SDB  Evidence grade B Lin SY, Melvin TA, Boss EF, Ishman SL. The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review. Int Forum Allergy Rhinol. 2013 Jan 10. doi: 10.1002/alr.21123. [Epub ahead of print]
  10. 10. ADHD & Allergic Rhinitis  Taiwan  Cross-sectional study: increased prevalence of AR in ADHD pts 1  Second study: Significant association among ADHD, tic disorder, and AR 2  Third study: increased prevalence of ADHD in AR patients (≥226,000 pediatric patients) 3 1. Chou PH, Lin CC, Lin CH, Loh EW, Chan CH, Lan TH. Prevalence of allergic rhinitis in patients with attention-deficit/hyperactivity disorder: a population-based study. Eur Child Adolesc Psychiatry. 2012 Dec 30. [Epub ahead of print] 2. Chen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, Bai YM. Attention deficit hyperactivity disorder, tic disorder, and allergy: Is there a link? A nationwide population-based study. J Child Psychol Psychiatry. 2012 Nov 12. doi: 10.1111/jcpp.12018. [Epub ahead of print] 3.. Tsai MC, Lin HK, Lin CH, Fu LS. Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study. Allergy Asthma Proc. 2011 Nov-Dec;32(6):41-6. doi: 10.2500/aap.2011.32.3489
  11. 11. Local Allergic Rhinitis  Negative prick skin tests, negative intradermal skin tests, negative allergen-specific serum IgE  Symptoms after nasal challenge with allergen  Local allergen-specific IgE produced after challenge with allergen  47-62.5% prevalence in European studies Rondón C, Campo P, Togias A, Fokkens WJ, Durham SR, Powe DG, Mullol J, Blanca M. Local allergic rhinitis: concept, pathophysiology, and management. J Allergy Clin Immunol. 2012 Jun;129(6):1460-7. doi: 10.1016/j.jaci.2012.02.032. Epub 2012 Apr 18. Review.
  12. 12. Allergic Rhinitis: Treatment  Can we change the environment to reduce the patient‟s exposure to triggers?  Can we modify the patient‟s symptoms?  Can we modify the patient‟s immune system?
  13. 13. Environmental Modifications  Does pet ownership make a difference in the development of AR?  Dust Mite Avoidance Measures  Getting Rid of Pets if the patient is allergic  Washing the pet  Keep windows closed and run the AC during pollen and mold seasons  Clean any visible mold
  14. 14. Does Pet Ownership in Children Change Anything?  2012 International Survey  “Early-life exposure to cats is a risk factor for … rhinoconjunctivitis … in 6- to 7-year-old children, especially in less-affluent countries. “ Brunekreef B, Von Mutius E, Wong G, Odhiambo J, García-Marcos L, Foliaki S; ISAAC Phase Three Study Group. Exposure to cats and dogs, and symptoms of asthma, rhinoconjunctivitis, and eczema. Epidemiology. 2012 Sep;23(5):742-50.
  15. 15. Does Pet Ownership in Children Change Anything?  Australian Birth Cohort  Followed 620 infants for first 12 yrs of life  “Pets at birth either decreased or had no effect on allergic disease up to age 12. “  “We found no evidence that exposure to cats or dogs at birth increases the risk of allergic disease in high-risk children.” Lodge CJ, Lowe AJ, Gurrin LC, Matheson MC, Balloch A, Axelrad C, Hill DJ, Hosking CS, Rodrigues S, Svanes C, Abramson MJ, Allen KJ, Dharmage S Pets at birth do not increase allergic disease in at-risk children. Clin Exp Allergy. 2012 Sep;42(9):1377-85. doi: 10.1111/j.1365-2222.2012.04032.x.
  16. 16. Does Pet Ownership in Children Change Anything?  2012 Meta-analysis  Children ages 6-10  ≥22,000 children from 11 European Birth Cohorts from 1990s  Owning a furry pet or bird during the first 2 years of life did not affect the risk of developing allergic rhinitis. Lødrup Carlsen KC, Roll S, Carlsen KH, Mowinckel P, Wijga AH, Brunekreef B, Torrent M, Roberts G, Arshad SH, Kull I, Krämer U, von Berg A, Eller E, H Kuehni C, Spycher B, Sunyer J, Chen CM, Reich A, Asarnoj A, Puig C, Herbarth O, Mahachie John JM, Van Steen K, Willich SN, Wahn U, Lau S, Keil T; GALEN WP 1.5 „Birth Cohorts‟ working group. Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of Individual participant data from 11 European birth co PLoS One. 2012;7(8):e43214. doi: 10.1371/journal.pone.0043214. Epub 2012 Aug 29.
  17. 17. House dust mite avoidance measures for perennial Allergic Rhinitis  2010 Cochrane Review, assessed as up to date end of 2009.1  9 trials (501 participants satisfied criteria)  Mite-impermeable bedding covers (2 studies were good quality)  Acaricides (2 studies)  HEPA filters (2 studies)  Acaricides +/- covers (1 study) 1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group: House dust mite avoidance measures for perennial allergic rhinitis Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
  18. 18. House dust mite avoidance measures for perennial Allergic Rhinitis  Conclusions:  Trials to date … small and of poor methodological quality…difficult to offer any definitive recommendations on the role … of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis.  Use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms and, if considered appropriate, these should be the interventions of choice.  Isolated use of house dust mite impermeable bedding is unlikely to prove effective. 1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group: House dust mite avoidance measures for perennial allergic rhinitis Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
  19. 19. Washing the Pet Dogs: Hodson T, Custovic A, Simpson A, Chapman M, Woodcock A, Green R. Washing the dog reduces dog allergen levels, but the dog needs to be washed twice a week J Allergy Clin Immunol. 1999 Apr;103(4):581-5. Cats: Nageotte C, Park M, Havstad S, Zoratti E, Ownby D. Duration of airborne Fel d 1 reduction after cat washing. J Allergy Clin Immunol. 2006 Aug;118(2):521-2. Epub 2006 Jun 27. Drop in Cat allergen levels lasted only 1 day after washing. But, it was pointed out that Goetz DW. Washing the cat requires shampoo. J Allergy Clin Immunol. 2007 Mar;119(3):758; author reply 758-9. Epub 2007 Jan 19.
  20. 20. What about Hypoallergenic Dogs?  Hypoallergenic Breeds do not exist.  In this study, dogs from “hypoallergenic breeds” had higher allergen levels in hair and coat samples than control dogs.  Differences between breeds were small. Vredegoor DW, Willemse T, Chapman MD, Heederik DJ, Krop EJ. Can f 1 levels in hair and homes of different dog breeds: lack of evidence to describe any dog breed as hypoallergen J Allergy Clin Immunol. 2012 Oct;130(4):904-9.e7. doi: 10.1016/j.jaci.2012.05.013. Epub 2012 Jun 22.
  21. 21. Treating Symptoms  Nasal Saline Irrigation  Medications
  22. 22. Nasal Saline Irrigation (SNI)  “Meta-analysis”: 50 trials, >400 participants  Performed regularly up to 7 weeks  27.66% improvement in nasal symptoms  62.1% reduction in medicine consumption  31.19% acceleration of mucociliary clearance time  27.88% improvement in quality of life.  “no evidence showing that regular, daily SNI adversely affects the patient's health or causes unexpected side effects.”Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy. 2012 Sep-Oct;26(5):e119-25. doi: 10.2500/ajra.2012.26.3787.
  23. 23. Nasal Saline Irrigation in Children  4 week RCT, investigator blinded  220 children aged 5-9 yrs with seasonal AR  80 used hypertonic saline (2.7%), 80 used normal saline, 60 control subjects (no treatment)  Evaluated effect on Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi N Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.
  24. 24. Nasal Saline Irrigation in Children  Hypertonic Saline: “significant reduction” in all areas  Normal Saline: “significant reduction” in rhinorrhea and sneezing  Control: no significant change Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi N Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.
  25. 25. Medications  Anti-histamines  Oral, Intranasal  Leukotriene-modifying agents  Oral  Steroids  Oral, Intranasal  Mast-cell stabilizers  Intranasal
  26. 26. Bischoff Nature Reviews Immunology 7, 93–104 (February 2007) | doi:10.1038/nri2018 Pathophysiology
  27. 27. Antihistamines 1st Generation 2nd Generation  Diphenhydramine  Hydroxyzine  Chlorpheniramine  Brompheniramine  Loratadine, Deslorata dine  Cetirizine, Levocetirizi ne  Fexofenadine  Azelastine (Astelin, ≥5 yrs, Astepro, ≥12 yrs, intranasal)  Olopatadine (Patanase, ≥6*Also thought to work as a mast cell stabilizer (http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021545s013lbl.pdf)
  28. 28. Leukotriene-Modifiers  Montelukast (Singulair, ≥6 mo)  Zafirlukast (Accolate, ≥5 yrs)  Zileuton (Zyflo, ≥ 12 yrs)
  29. 29. Intranasal Steroids Liquid Dry Powder  Fluticasone (Flonase, ≥4 yrs)  Mometasone (Nasonex, ≥2yrs)  Ciclesonide (Omnaris, ≥6 yrs)  Triamcinolone (Nasacort AQ, ≥2 yrs)  Beclomethasone (Qnasl, ≥12 yrs old)  Ciclesonide (Zetonna, ≥12 yrs old)
  30. 30. Intranasal Steroids  6 week study of beclomethasone, placebo, and placebo/prednisone:  beclomethasone NOT INFERIOR to placebo in regards to suppression of hypothalamic-pituitary- adrenal axis function Ratner PH, Miller SD, Hampel FC Jr, Melchior A, Dunbar SA, Tantry SK. Once-daily treatment with beclomethasone dipropionate nasal aerosol does not affect hypothalamic-pituitary-adrenal axis Ann Allergy Asthma Immunol. 2012 Nov;109(5):336-41. doi: 10.1016/j.anai.2012.08.005.
  31. 31. Intranasal Steroids in Children  Cochrane Review published online 2009, assessed as up to date 2006  3 trials, total 79 children  Beclomethasone or flunisolide vs. placebo  Weak or unreliable evidence for effectiveness.1 1. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Topical nasal steroids for intermittent and persistent allergic rhinitis in children Editorial Group: Cochrane Ear, Nose and Throat Disorders Group, Published Online: 21 JAN 2009
  32. 32. Intranasal Steroids with add-on oral Antihistamine therapy in children  2010 Cochrane Review found only 1 RCT with 24 children (defined as under age 18).1  Sufficient data not provided to answer question  Conclusion: no evidence available for benefit of add-on antihistamine treatment to intranasal steroids for children with intermittent or persistent allergic rhinitis.  Take-away message: don‟t forget potential side effects of antihistamines, and keep in mind costs of adding a second medication. 1. Mona Nasser1,*, Zbys Fedorowicz2, Hamad Aljufairi3, William McKerrow4 Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 20 SEP 2009
  33. 33. Total Nasal Symptom Score  Intensity of nasal symptoms  Rhinorrhea, Nasal itching, Nasal Obstruction, Sneezing 0 = No symptoms 1 = Mild 2= Moderate 3= Severe  Total Possible Score ranges from 0 (no symptoms) to 12 (maximum symptom intensity) Valero A, Izquierdo I, Giralt J, Bartra J, del Cuvillo A, Mullol J. Rupatadine improves nasal symptoms, quality of life (ESPRINT-15) and severity in a subanalysis of a cohort of Spanish allergic rhinitis patients. J Investig Allergol Clin Immunol. 2011;21(3):229-35.
  34. 34. Combination Therapy: Intranasal steroid & Intranasal antihistamine  TNSS: Total Nasal Symptom Score  The TNSS improved 27.1% with fluticasone nasal spray, 24.8% with azelastine nasal spray, and 37.9% with the 2 agents in combination Ratner PH, Hampel F, Van Bavel J, Amar NJ, Daftary P, Wheeler W, Sacks H. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2008 Jan;100(1):74-81. doi: 10.1016/S1081-1206(10)60408-5.
  35. 35. Combination Intranasal steroid and Antihistamine  Fluticasone and azelastine in the same delivery device  Meta-analysis of 3 separate multicenter, randomized, double- blind, placebo- and active- controlled, parallel-group trials  Each trial conducted for 14 days during different allergy seasons  3398 patients (>11 yrs old)  Moderate to severe seasonal allergic rhinitisCarr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J. A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.
  36. 36. Combination Intranasal steroid and Antihistamine  Combination reduced mean reflective total nasal symptom score from baseline (-5.7 [SD, 5.3])  Fluticasone (-5.1 [SD, 4.9], P < .001)  Azelastine (-4.4 [SD, 4.8], P < .001)  Placebo (-3.0 [SD, 4.2], P < .001).  Available now as Dymista (≥12 yrs) Carr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J. A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.
  37. 37. Fig E1 Source: Journal of Allergy and Clinical Immunology 2012; 129:1282-1289.e10 (DOI:10.1016/j.jaci.2012.01.077 ) Copyright © 2012 American Academy of Allergy, Asthma & Immunology Terms and Conditions
  38. 38. Inferior Turbinate Surgery after failed Medical Treatment of Allergic Rhinitis  2010 Cochrane review was unable to find any randomized controlled trials comparing this surgery to continued medical treatment.1 1. Jemy Jose1,*, Andrew P Coatesworth2, Inferior turbinate surgery for nasal obstruction in allergic rhinitis after failed medical treatment Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 8 DEC 2010 Assessed as up-to-date: 5 JUL 2010
  39. 39. Altering the Immune Response  Helminths (Worms)  Subcutaneous Immunotherapy (Allergy Shots)  Sublingual Immunotherapy
  40. 40. Worms • Why look? Helminths modulate the natural immune responses of their human hosts, and may prevent or cure immune-mediated or allergic diseases (e.g. allergic rhinitis) in the host. Non- randomized studies support this hypothesis.1  “Trials using helminths like hookworm (Necator americanus) or porcine whipworm (Trichuris suis) show that they are safe and may be effective therapies for the control of the aberrant intestinal inflammation seen in Crohn's disease and ulcerative colitis.”2 1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date: 24 JUN 2011 2. Elliott DE, Weinstock JV. Where are we on worms? Curr Opin Gastroenterol. 2012 Nov;28(6):551-6. doi: 10.1097/MOG.0b013e3283572f73.
  41. 41. Helminth therapy (worms) for Allergic Rhinitis  2012 Cochrane Review, assessed as up to date 2011.1  They found 130 people…  1.8 to 7.7x increase in GI side effects vs placebo  Insufficient evidence, appears to be safe 1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date: 24 JUN 2011
  42. 42. Allergy Injection Immunotherapy (IT) for Seasonal Allergic Rhinitis  2009 Cochrane Review1, assessed as up to date 2006  51 of 1111 publications met criteria  2871 participants (1645 active, 1226 placebo)  Averaged 18 injections per participant  Duration of IT 3 days to 3 years 1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6 Allergen injection immunotherapy for seasonal allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13 NOV 2006
  43. 43. Allergy Injection Immunotherapy (IT) for Seasonal Allergic Rhinitis  Symptom Scores from 15 trials  an overall reduction in the immunotherapy group (SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)).  Medication score data from 13 trials  an overall reduction in the immunotherapy group (SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)). 1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6 Allergen injection immunotherapy for seasonal allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13 NOV 2006
  44. 44. Allergy Injection Immunotherapy (IT) for Seasonal Allergic Rhinitis  Epinephrine (adrenaline)  given in 0.13% (19 of 14085 injections) of those on active treatment  given in 0.01% (1 of 8278 injections) of the placebo group for treatment of adverse events.  Fatalities: None 1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6 Allergen injection immunotherapy for seasonal allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13 NOV 2006
  45. 45. Allergy Injection Immunotherapy (IT) for Seasonal Allergic Rhinitis  Authors‟ Conclusions:  Specific allergen injection immunotherapy in suitably selected patients with seasonal allergic rhinitis results in a significant reduction in symptom scores and medication use.  Injection immunotherapy has a known and relatively low risk of severe adverse events.  We found no long-term consequences from adverse events.1 1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6 Allergen injection immunotherapy for seasonal allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13 NOV 2006
  46. 46. Sublingual immunotherapy (SLIT) for Allergic Rhinitis  2011 Cochrane Review, assessed as up to date 2009.1  49/60 RCTs suitable for meta-analysis pooling  2333 SLIT, 2256 placebo participants  Significant reduction in symptoms  (SMD -0.49; 95% confidence interval (CI) -0.64 to -0.34, P < 0.00001)  Significant reduction in medication requirements  (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001) 1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date: 13 AUG 2009
  47. 47. Sublingual immunotherapy (SLIT) for Allergic Rhinitis  SLIT appears to be safe  None of the trials in this review reported  Severe systemic reactions  Anaphylaxis  Use of epinephrine 1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergic rhinitis Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date: 13 AUG 2009
  48. 48. Subcutaneous (SCIT) vs Sublingual (SLIT) Immunotherapy SCIT SLIT  Symptoms (SMD -0.73 (95% CI -0.97 to - 0.50, P < 0.00001)).  Medication need (SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)).  Epinephrine: 0.13% of treatment injections, vs. 0.01% of placebo  Fatalities: None  Symptoms (SMD -0.49; 95% confidence interval (CI) - 0.64 to -0.34, P < 0.00001)  Medication need (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001)  Epinephrine: No use  Severe systemic reactions: None  Anaphylaxis: None
  49. 49. When to consider Allergy Immunotherapy  Symptoms are not well controlled with medication.  Patient prefers to avoid medication  Patient is unable to tolerate medication  Possible decreased long-term cost of treatment  Co-existing Allergic Rhinitis and Asthma  Possible prevention of asthma
  50. 50. Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendations.  Safe when administered to carefully selected patients and in settings capable of responding to systemic reactions.  Recommended for patients with seasonal or perennial allergic rhinitis not responsive to conservative medical therapy, and whose symptoms significantly affect quality of life. Purkey MT, Smith TL, Ferguson BJ, Luong A, Reisacher WR, Pillsbury HC 3rd, Toskala E. Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendatio Int Forum Allergy Rhinol. 2013 Jan 11. doi: 10.1002/alr.21141. [Epub ahead of print]
  51. 51. Thank you!

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