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Room 403, 4th Flr. Medical Arts Bldg. Dr. Fe del Mundo Medical Center, 11 Banawe St.,
Quezon City
Telephone No: 712-9432
ALLERGIC RHINITIS
history + skin
prick tests
or serum
specific IgE
Allergen
avoidance
Intermittent
symptoms?
oral H1-blocker
Intranasal H1-blocker
and/or decongestant
10
Mild
symptoms?
Moderate
to severe
symptoms
Persistent
symptoms
9
Mild
symptoms?
Go to # 6
oral H1-blocker
Intranasal H1-blocker
11
and/or decongestant
Moderate
to severe
symptoms
Intranasal
CS
review the
patient after
2-4 weeks
13
in persistent rhinitis
review the patient
after 2-4 weeks
15
16
14
(chromone)
12
intranasal CS
Failure?
Go to Fig. 2
17
Improved:
continue for
one month
Figure 1
Step-up
ALLERGIC RHINITIS
1
Improved?
Step down
and continue
treatment for
one month
Failure
review diagnosis
review compliance
query infections or
other cause
increase
intranasal
CS dose
7
Itch/sneeze?
Rhinorrhea?
10
add
H1-blocker
9
add
ipratropium
blockage
11
add
decongestant
or oral CS
(short term)
12
13
Failure
Surgical
referral
* If conjunctivitis add:
oral H1-blocker
or intraocular H1-blocker
or intraocular chromosome
(or saline)
Consider specific immunotherapy
Figure 2
ALLERGIC RHINITIS
Classification
sneezing
Clinical assessment
History
nasal discharge
blockage
sneezing
Persistent
symptoms
> 4 days per week
and > 4 weeks
Mild
Moderate-Severe
one or more items
normal sleep
abnormal sleep
normal daily
impairment of daily
activities, sport, leisure
activities, sport, leisure
normal work and
problems caused
school at work or school
Figure 1
Intermittent
symptoms
< 4 days per week
or < 4 weeks
Epidemiology
sneezers and runners
blockers
Table 1
sneezing
especially
paroxysmal
little or none
rhinorrhea
watery
anterior and
posterior
thick mucus
more
posterior
itching
yes
no
nasal
blockage
variable
often severe
diurnal
rhythm
worse during
day improving
at night
constant, day
and night, maybe
worse at night
A. Incidence
In a series of studies from different countries,
considerable variations occur in the estimate of
prevalence of allergic rhinitis ranging from 0.5%
(Switzerland) to 28% (Finland)
Allergic rhinitis usually develops in school age or
adolescence.
Incidence (new onset) peaks between ages 10 and
15; declines after age 35.
More frequent in boys than in girls (childhood);
same frequency from adolescence.
Risk Factors
Early allergic rhinitis in persons with a family history of atopy.
More common in non-whites than in whites, in
upper than in lower classes (SIBBALD, 1993)
Birth 1-3 months before the pollen seasons increases risk of allergic rhinitis.
Allergic rhinitis more common in urban than rural
areas.
Diagnosis
The diagnosis of allergic rhinitis is based on:
a typical history of allergic symptoms
allergic symptoms are those of sneezers and runners. However, these symptoms are not necessarily
of allergic origin
diagnostic tests
- In vivo and in vitro tests used to diagnose allergic
diseases are directed towards the direction of free
or cell-bound IgE. The diagnosis of allergy has
been improved by allergen standardization providing satisfactory diagnostic vaccines for most
inhalant allergens.
- Immediate hypersensitivity skin tests are
widely used to demonstrate an IgE-mediated
allergic reaction. These represent a major diagnostic tool in the field of allergy. If properly
performed, they yield useful confirmatory evidence for the diagnosis of a specific allergy. As
there are many complexities for their performance and interpretation, it is recom-mended
that trained health professionals should carry
them out.
- The measurement of allergen-specific IgE in
serum is of importance and is of similar value to
skin tests.
- Nasal challenge tests with allergens are used
in research and, to a lesser extent, in clinical
practice. They may be useful, especially in the
diagnosis of occupational rhinitis.
Imaging is not usually necessary.
Management
A. Environmental Control and Avoidance
Preventive Measures
First, remove all rugs, curtains and draperies from
the room except the clothes for daily use. Always
keep closet doors closed.
Clean the woodwork, window sills, screens,
closets and floor of the room. Wax the floor.
Change all mattresses and pillows in the bedroom
to solid rubber foam. No cotton, kapok, coconut
ALLERGIC RHINITIS
ALLERGIC RHINITIS
Sneezing
Nasal itch
Eye symptoms
++
++
0
++
++
0
+
+
0
+++
++
0
++
0
+++
Corticosteroids
intranasal
+++
+++
+++
+++
++
Chromones
intranasal
intraocular
+
0
+
0
+
0
+
0
0
++
Decongestant
intranasal
oral
0
0
0
0
++++
+
0
0
0
0
Anti-cholinergics
++
Anti-leukotrienes
++
++
Adapted from van Cauwenberge, P., et al., Consensus statement on the treatment of allergic rhinitis, European Academy of
Allergology and Clinical Immunology. Allergy, 2000; 55(2): 0. 116-34.
Reference:
Management of Allergic Rhinitis and its Impact on Asthma
(A Pocket Guide for Physicians and Nurses) 2001 - Based on
the ARIA Workshop Report in collaboration with WHO.
ALLERGIC RHINITIS
Biogenerics
Diphenhydramine
Dramelin
Drugmaker's Biotech
Diphenhydramine
Europharma
Diphenhydramine
Hizon
Diphenhydramine Inj
Pharex Diphenhydramine
Disodium cromoglycate
Vividrin Nasal Spray
Hydroxyzine diHCl
Iterax
Levocetirizine
Xyzal
Loratadine
Claritin
Loradex
Loratadine/Bethamethasone
Claricort
Loratadine/Pseudoephedrine
Clarinase
Rhinase
Mebhydrolin napadisylate
Fabahistin
Mequitazine
Primalan
Olopatadine HCl
Patanol
Promethazine HCl
Phenergan
Thaprozine
Corticosteroids
Betamethasone/
Chlorphenamine maleate
Betneton
Betamethasone/
Dexchlorphenamine maleate
Celestamine
Prednisolone/
Chlorphenamine maleate
Clormetalone
Triamcinolone acetonide
Kenacort
Decongestants
Brompheniramine maleate/
Phenylephrine HCl
Dimetapp
Bromphenamine maleate/
Phenylpropanolamine
Nasatapp
Camphor/Menthol/Eucalyptol
Broncho Rub White
Camphor/Menthol/Methyl
Salicylate
Neozep Vaporizing Rub
Carbinoxamine/Phenylephrine
HCl/Phenylpropanolamine
Rhinopront
Chlorphenamine maleate/
Phenylpropanolamine HCl
Coldrex Reformulated Tab
Langex
Nafarin
Chlorphenamine maleate/
Phenylpropanolamine HCl/
Paracetamol
Alledec
Decolgen/Decolgen Forte
Nagelin
Neozep/Neozep Forte
Resttab
Chlorpheniramine maleate
Phenylpropanolamine/
Paracetamol
Colvan
Nafarin-A
Sinutab Extra Strength
Chlorphenamine/
Phenylpropanolamine/
Phenylephrine
UL Anti-Cold
Phenylpropanolamine HCl
Disudrin
Propadrin
Sinurex
Phenylpropanolamine HCl/
Paracetamol
A-P-Histallin (Reformulated)
ALLERGIC RHINITIS
Nasathera
Phenylpropanolamine HCl/
Phenyltoloxamine/
Paracetamol
Sinutab
Sodium chloride
Salinase
Nasal Preparations
Azelastine HCl
Azep
Budesonide
Budecort Nasal/NT
Cetirizine
Virlix
Zyrtec
Fluticasone propionate
Flixotide Aqueous
Nasal Spray
Fusafungine
Locabiotal 1%
Mometasone furoate
Nasonex AQ Nasal
Spray
Rinelon
Oxymetazoline HCl
Drixine Nasal Spray/
Ped Drops
Nasivin
Sodium chloride
Salinase
Xylometazoline HCl
Otrivin