Impact of allergic rhinitis on asthma Otitis Media

Impact of allergic rhinitis on asthma Otitis Media with Effusion 0, 5 1 3 7 a ge Upper Respiratory Infection Allergic Rhinitis INTERRELATIONSHIP BETWEEN ALLERGIC RHINITIS AND ASSOCIATED AIRWAY DISEASES Spector JACI 1997; 99: S 773 Asthma Sinusitis Nasal Polyposis

Upper airway disease Lower airway disease DISEASE SEVERITY Συνδέσεις μεταξύ ρινίτιδας και άσθματος rhinitis asthma Overall syndrome severity 4

Rhinitis 10 yr children: Conjunctivitis Asthma Secretory otitis media Allergic sensitisation Atopic eczema BHR EIB Anaphylaxis Bertelsen et al, Clin Exp Allergy 2010

Επιδημιολογία της Αλλεργικής Ρινίτιδας διεθνώς Παιδιά ηλικίας 13– 14 ετών % 13 - to 14 - year-olds (n=463, 801) 25 20 15 10 5 SA U K U ai Sw n ed en Sp a ut h A fr ic re ap o So ng Si do ne si a a di In In re ec e y G an ce er m hi n a l C ra zi B Fr an G A us tr al ia 0 Strachan D et al. Pediatr Allergy Immunol 1997; 8: 161– 76.

Ασθμα και Αλλεργική Ρινίτιδα Παθοφυσιολογία Mucosal inflammation Environmental factors Atopic sensitization Phenotype Genetic factors Structural changes 18

Παθοφυσιολογία ρινίτιδας και άσθματος Allergen Dendritic cell IL-1 MBP ECP Ig. E LTs PGs PAF Th 0 -cell B-cell IL-10 IL-4 IFN- Th 1 -cell Th 2 -cell Eosinophil Mast cell IL-13 Eotaxin IL-5 RANTES histamin VCAM-1 ICAM-1 E-selectin Systemic circulation 19

Φλεγμονώδης απάντηση σε αλλεργιογόνα Membrane-bound Ig. E Mast cell Preformed Mediators Cysteinyl leukotrienes Prostaglandins Platelet-activating factor Πρώιμη φάση Allergen Eosinophils T cells Cytokines Inflammatory mediators ¨Οψιμη Adapted from Casale TB et al Clin Rev Allergy Immunol 2001; 21(1): 27– 49; Kay AB N Engl J Med 2001; 344: 30– 37. φάση

Thorax 2009

Recognise allergic rhinitis Symptoms Q 1: yes to any one: usually NOT found in allergic rhinitis NB Diff Diagnosis Watery, runny nose + at least one of Q 2: probably allergic rhinitis Allergy 2010; 65: 1212– 1221.

Allergy 2010; 65: 1212– 1221.

Stepwise treatment of allergic rhinitis ARIA update 2007 Mild intermittent Not in preferred order - oral H 1 blocker - or intranasal H 1 -blocker - and/or decongestant or LTRA* *: in particular in patients with asthma Moderate. Mild Severe Persistent Intermittent Not in preferred order - oral H 1 blocker - or intranasal H 1 -blocker - and/or decongestant - or intranasal CS - or LTRA* (or chromone) In persistent rhinitis review the patient after 2 -4 wks If failure: step-up If improved: continue for 1 month

Stepwise treatment of allergic rhinitis ARIA update 2007 Moderate/severe rhinitis In preferered order - Intra-nasal corticosteroids - H 1 -blockers or LTRA* Review the patient after 2 -4 weeks Improved Failure Continue or step down treatment for > 1 month Review diagnosis Review compliance Query infections or other causes Add or Rhinorrhea increase Add INCS dose ipratropium Blockage: Add Decongestant or Oral CS If failure: referral to a specialist

ARIA revision Check for asthma especially in patients with severe and/or persistent rhinitis Diagnosis of allergic rhinitis Allergy Clin Immunol 2010 Intermittent symptoms Mild Not in preferred order oral H 1 blocker or intranasal H 1 -blocker and/or decongestant or LTRA* Persistent symptoms Moderate- Mild severe Not in preferred order oral H 1 blocker or intranasal H 1 -blocker and/or decongestant or intranasal CS or LTRA* (or chromone) Moderatesevere In preferred order intranasal CS H 1 blocker or LTRA* Review the patient after 2 -4 wks Improved In persistent rhinitis review the patient after 2 -4 wks If failure: step-up If improved: continue for 1 month Step-down and continue treatment for > 1 month Failure Review diagnosis Review compliance Query infections or other causes Add or increase Rhinorrhea intranasal CS add ipratropium dose Blockage add decongestant or oral CS (short term) Failure referral to specialist Allergen and irritant avoidance may be appropriate If conjunctivitis, add oral H 1 -blocker or intraocular cromone (or saline) Consider specific immunotherapy

Θεραπεία ρινίτιδας και άσθματος Allergen Αποφυγή αλλεργιογόνου Dendritic cell MBP ECP Ig. E Anti-Ig. E IL-1 LTs LTRA’s PGs PAF Th 0 -cell ΑνοσοθεραπείαIL-4 IL-10 IFN- Th 1 -cell B-cell Eosinophil IL-13 Eotaxin IL-5 RANTES Κορτικοειδή Th 2 -cell Mast cell VCAM-1 ICAM-1 E-selectin histamin Αντιισταμινικά Systemic circulation 43

Θεραπεία με Anti-Ig. E Asthma (mod-severe) Reduced exacerbation rates ≈ 600 children, 6 -12 yrs, not well controlled asthma despite med- dose ICS, 1 yr trial 31% first 24 weeks 43% last 25 -52 weeks Lanier et al JACI 2009; 124: 1210 -6 Steroid sparing effect Cochrane review 2006, n=3143 , 14 trials, >50% decrease in ICS: OR 2. 5 Walker et al, Cohrane Data. Syst Rev 2006; 2: CD 00355 Allergic Rhinitis Several trials (adults and adolescents) suggesting clinical benefit, and free Ig. E Kopp, Curr Allergy Asthma Rep, 2011; 11: 101 -6 Other (severe) allergic disease Combined with allergen specific immunotherapy: probably more effective than either alone Food allergy: anecdotal improved desensitisation Atopic eczema: uncertain Chronic urticaria: anecdotal suggestion of effect Busse, Immunological Reviews. Special Issue: Allergic Responses Volume 242, Issue 1, pages 258– 271, July 2011 Kopp, Curr Allergy Asthma Rep, 2011; 11: 101 -6

Νέες ανοσοτροποποιητικές θεραπείες Immunological Review Special Issue Allergic Responses 2011; 242: 258– 271