Rhinitis: Allergic and Non-Allergic PDF

Rhinitis: Allergic and Non- Allergic Lary Ciesemier, DO FAAAAI FACOI Chair Internal Medicine...

Rhinitis: Allergic and Non- Allergic Lary Ciesemier, DO FAAAAI FACOI Chair Internal Medicine Kirksville College Osteopathic Medicine Allergy Asthma Immunology Copyright © 2024, A.T. Still University/Kirksville College of Osteopathic Medicine. This presentation is intended for ATSU/KCOM use only. No part of this presentation may be distributed, reproduced or uploaded/posted on any Internet websites without the expressed written consent from the author or ATSU/KCOM Department Chairperson. Allergic Rhinitis: Objectives Understand the difference between allergic and nonallergic rhinitis in terms of mechanism and treatment. Know how to diagnose and treat rhinitis Know the mediators of allergic rhinitis. Understand the treatment of rhinitis, allergic and PNAR. Generally understand how immunotherapy alters the immune system. (Do not memorize all the mechanisms-know how it affects Th1 vs Th2) Know what anti-IgE is and how it may affect the treatment of allergic diseases. Understand the immunology of allergic diseases Know what the IgE-mediated conditions are Define the triggers of allergic rhinitis, and how to avoid them Allergic Rhinitis: Burden Affects 10-30% of adults and up to 40% of children worldwide – Worldwide prevalence increasing Impacts quality of life – Morbidity, reduced work productivity, lost school days High cost to individuals and society – $3-4 billion in direct costs in the United States per year – Individuals with Allergic Rhinitis (AR) spend an average of $650 annually on AR-related medical and pharmacy services http://www.aaaai.org/about-aaaai/newsroom/allergy-statistics, accessed 1/2024 Meltzer et al. Ann Allergy Asthma Immunol 2011. Tkacz JP. Immunology 2021 Allergic Rhinitis: Risk Factors Family history of atopic disease Serum IgE >100 IU/mL before age of 6 Higher socioeconomic status Exposure to environmental irritants such as pollution or tobacco smoke Early life exposure to antibiotics Positive skin prick test Indoor allergen sensitization can begin between 6 months and 2 years old Pollen sensitization develops between 2-7 years old Wallace, et al. J Allergy Clin Immunol 2008 Xu X. Clin Rev Aller Immunol. 2023. Kim DH. Allergy Asthma Immunol Res. 2018 Allergic Rhinitis - Pathophysiology IgE-mediated reaction to inhaled allergen Allergen interacts with IgE on surface of mast cell to trigger degranulation Early phase: release of histamine induces sneezing, rhinorrhea Late phase: release of arachidonic acid metabolites induces congestion Food allergy is rarely responsible for isolated nasal symptoms Tissue eosinophils contribute to local inflammation and damage Priming effect can contribute to disease severity When an antigen is introduced repeatedly, the amount required to induce an immediate response decreases Air pollutants can also contribute to the priming effect Wallace, et al. J Allergy Clin Immunol 2008 Peden DB. Otolaryngol Head Neck Surg. 1996.  Definition- Rhinitis Rhinitis is characterized by 1 or more of the following nasal symptoms: Congestion Rhinorrhea Sneezing Itching Classified as Allergic or Non-allergic Both may be present in 44-87% of patients Differential Diagnoses should be considered Chronic rhinosinusitis, nasal polyposis, cerebrospinal fluid leak, structural abnormalities (deviated septum, masses) Wallace, et al. J Allergy Clin Immunol 2008 Peters, et al. Ann Allergy Asthma Immunol 2014 Seasonal Allergic Rhinitis Patterns of Symptoms Spring: trees Summer: grasses Fall: weeds esp. ragweed Perennial: cockroaches, dust mites, pets, mold Globally Important Sources of Allergens House dust mites Grass, tree and weed pollen Pets Cockroaches Molds 8 ragweed Anyanimalsinthe house CD4+ T helper cells Th1- “Anti-allergy” T helper cell Stimulates phagocyte-mediated defense Intracellular antigens IFN- Th2- “Allergy-producing” T helper cell Extracellular antigens Stimulates IgE, eosinophil, mast cells Downregulate Th1 response IL-4, IL-5, IL-13 The Hygiene Hypothesis Birth Th2 Older siblings More infections Only child: Th2 stimuli Fewer infections Th2 Stimuli No Allergies Allergies Th1 Still Th2 Atopic Conditions Anaphylaxis Allergic rhinosinusitis Allergic conjunctivitis Asthma Atopic dermatitis Urticaria/angioedema Food allergies Drug allergies Stinging insect allergies Latex allergy Approach to the Atopic Patient History Onset of symptoms: 90% begin by age 10 Character, duration, frequency and severity of sx Temporal nature of symptoms: Seasonal: spring-trees, summer-grass, fall-weeds Perennial-dust mites, cockroaches, pets Environmental nature of sx: (home, school, work) Home-pets, school, work… Family history: maternal and paternal Approach to Patient with Atopy Physical exam: Skin: dermatographism, urticaria, dermatitis nasal polypsinchildisofuntil otherwise proven us adults allergyaspirin Eyes: allergic shiners, conjunctival papillae Nose: pale/bluish mucosa with clear mucus, crease, polyps Oropharynx: drainage, tonsils, setifnoallergies height Lungs: wheeze, increased E:I ratio Confirm history and physical with allergy testing Approach to Patient with Atopy Primary Tests: Skin tests: Demonstrates the presence of specific IgE Ab Available for aeroallergens, foods, insect venoms, PCN (+) and (-) control. Percutaneous and intradermal testing is done. Patients must be off of antihistamines, tricyclics, blockers Tests performed on the back or forearm RAST (radioallergosorbent test) x Tests for specific IgE Very expensive, not as sensitive as skin tests, delay in results, no uniformity as to what is positive Skin Testing thishappenseverytime Xucomesat2nd exposure IgE-dependent Release of Inflammatory Mediators Mast Cell IgE FcRI FcRI binding site Immediate Release Over Hours Cytokine production: Granule contents: Specifically IL-4, IL-13 Histamine, TNF-, Proteases, Heparin Over Minutes Lipid mediators: Mucus production Prostaglandins Sneezing Leukotrienes Eosinophil recruitment Nasal congestion Itchy, runny nose Watery eyes Wheezing Bronchoconstriction  Allergic Rhinitis: Treatment (1) Allergen Avoidance is a key treatment. recommend pets avoiding Allergen Effective avoidance measures Dust mites Home humidity