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Allergic Rhinits
Allergic rhinitis refers inflammation of
ALLERGIC RHINITIS
Allergic Rhinitis
..Constellation of symptoms
Classical Symptoms
Repetitive sneezing Watery rhinorrhea Nasal itch
Others
Eye symptoms Ear symptoms Postnasal drainage
Nasal congestion
Symptoms last usually not more than an hour!
Allergic Rhinitis
simple yet .. complicated illness
An extremely common disease worldwide, affecting 10 to 25% of the population 1 in 6 people are said to be suffering from rhinitis The condition impacts heavily on health-related Quality of Life or Sleep
Work
QOL affected
Family Social
Allergic Rhinitis
..affects sleep quality
SOMNIAAR study
prospective, observational, multicentre survey 2275 patients with Allergic rhinitis were evaluated for effects on Sleep Results
53% had poor sleep quality 21% suffered from excessive diurnal somnolence
Colas C. Clin Exp Allergy 2012 Jan 18
Allergic Rhinitis
Pathophysiology & Symptoms
allergen IgE
preformed & newly formed mediators/cytokines
mast cell
IMMEDIATE RESPONSE
(5 -30 mins)
Histamine
(Sneezing)
Leukotrienes
(Aggravate inflammation / mucosal swelling including Congestion)
*PER Persistent
Allergic Rhinitis
Management
Pharmacotherapy
Antihistamines
First generation ( CPM)- Sedation, dryness of mouth, urinary retention Second generation- Less Sedative (do not cross BBB)
Nasal sprays Azelastine, Olopatadine bitterness, nose bleeding, sores in nose, birth defects (preclinical studies)
Decongestants
Local short-term use to prevent tolerance Oral tachycardia, High BP, prostate disease, glaucoma
Corticosteroids
For Severe allergic rhinitis
Pharmacotherapy
..choice of Antihistaminics
Fexofenadine Drug Metabolite of Terfenadine Desloratidine Active isomer of Loratidine Levocetirizine Active isomer of Cetirizine
Mechanism
Onset of action Half-life Somnolence Sedation Work performance
Selective H1 antagonist
0.5 hr 15 hrs 0 0 (Non-sedating by US FDA) No impairment of Work or Driving performance
Selective H1 antagonist
3 hr 27hr 0.7% 0.1% No impairment of Work or Driving performance
Selective H1 antagonist
1 hr 8 hr 2.1% 0.4% May hamper Work or Driving performance
Pharmacotherapy
..choice of Anti-histaminics
Clinical efficacy often predicted by Wheal-flare suppression response
Comparative in-vitro study involving 30 volunteers given single dosages of Fexofenadine, Desloratidine & Levocetirizine
0 -0.1 -0.2 -0.3 -0.4 -0.5 -0.6 -0.7 -0.8 -0.9 -1
Fexofenadine
Desloratidine
Levocetirizine
-0.3 mm
-0.3 mm
-0.9 mm
Dhanya NB. IJDVL 2008; 74: 361-3
Oral Antihistaminic
Intranasal Steroids
*PER Persistent
In asthmatics, Combination with LTRAs are preferred for concomitant Allergic Rhinitis
XARIA PLUS
Rationale
Fexofenadine potent and highly selective antagonist of the peripheral histamine H1 receptors Duration of action is 24 hrs Reduces Histamine induced sneezing, nasal itching, rhinorrhea Only LTRA that is given once daily Reduces Leukotriene induced inflammation FOR additional nasal decongestant property Montelukast selective and orally active leukotriene receptor antagonist (LTRA) that inhibits the actions of leukotrienes
Complimentary action on Chemical mediators for Synergistic control of Allergic Rhinitis symptoms
XARIA PLUS
Rationale
XARIA PLUS
Adapted from ARIA 2007
Fexofenadine-Montelukast Combination
..relieves nasal obstruction, increases air flow
12 pts with Persistent Allergic Rhinitis Fexofenadine or Monteleukast or Fexofenadine + Monteleukast combination administered for 1 wk Significant improvement in Nasal obstruction for Combination arm (p<0.05)
20 % Relative improvement in Nasal air flow after 1 wk compared to placebo 16% 13%
15 % 10
11%
Monteleukast+Fexofenadine FDC
Fixed dose combinations offers:
Simplification of treatment regimen Better patient adherence Reduces number of medications
Allergens
Dust Smoke Pollution Grass Weeds Moulds Dander Feather Pollen grains
Allergen
Stage 1 Stage 2
Antibody
IgE
Degranulation
Glemont F
Glemont F
Intranasal CS + Glemont F
*PER Persistent
Treating allergic rhinitis helps in controlling asthma symptoms, and improving lung function tests
Combination with Monteleukast prevents Pro-inflammatory changes in Asthmatics Safely coprescribed with Anti-asthmatic medications
XARIA PLUS
(Montelukast+ Fexofenadine)