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Prevalence of Allergic Rhinitis by Age Group

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Title: Prevalence of Allergic Rhinitis by Age Group


1
Prevalence of Allergic Rhinitisby Age Group
2
Related Anatomic StructuresCompromised by
Allergic Rhinitis
3
Differential Diagnosis of Rhinitis and Nasal
Obstruction
  • Rhinitis
  • Allergic, seasonal, or perennial
  • Infectious, chronic, or acute (frequent
    recurrences)
  • Obstructive foreign body
  • Secondary to topical decongestants (eg,
    rhinitis medicamentosa)
  • Nonallergic with eosinophilia (NARES)
  • Nonallergic vasomotor
  • Atrophic (eg, cocaine abuse)
  • Due to hormonal changes (eg, pregnancy)
  • Nasal Obstruction
  • Allergic or nonallergic rhinitis
  • Rhinosinusitis
  • Anatomic abnormality (eg, deviated septum)
  • Nasal polyps
  • Tumor (eg, angiofibroma)
  • Cerebrospinal fluid leakage secondary to
    perforation of the cribriform plate by
    fracture or tumor
  • Granulomatous disorders (eg, Wegeners
    granulomatosis, sarcoidosis)
  • Foreign body

4
Seasonal Allergic Rhinitis Mechanism of
Therapeutic Agents
  • Cells in Nasal Mucosa Mediators Cytokines
  • Antihistamines Decrease eosinophils Inhibit
    histamine
  • and neutrophils release by blocking H1
  • receptors
  • Reduce expression of ICAM-1 Reduce PGD2 in nasal
  • on epithelial cells secretions
  • Nasal Decrease T cells (CD3, Decrease ECP,
  • corticosteroids CD4, CD8), Langerhans
    cells, histamine, tryptase,
  • mast cells, basophils, and IL-3, IL-5, and
    GM-CSF
  • activated (EG2) eosinophils
  • Attenuation in cell numbers after allergen
    challenge
  • ECPeosinophil cationic protein
    GM-CSFgranulocyte macrophage colony-stimulating
    factor

5
First-generation Antihistamines
  • H1 Sedative Anticholinergic GI
    Blockade Effects Effects Effects
  • Ethylenediamines (tripelennamine)
  • Ethanolamines (diphenhydramine)
  • Alkylamines (chlorpheniramine)
  • Piperazines (hydroxyzine)
  • Piperidines (azatadine)
  • Strongly positive effec

6
Second-generation Antihistamines
  • H1 Sedative Anticholinergic GI
    Blockade Effects Effects Effects
  • Fexofenadine (60 mg bid)
  • Astemizole (10 mg qd)
  • Loratadine (10 mg qd)
  • Cetirizine (10 mg qd)
  • Negative effect
  • Strongly positive effect

7
Advantages of Second-generation Nonsedating
Antihistamines
  • Bind strongly to histamine (H1) receptors
  • negligible affinity for nonhistamine receptors
  • no anticholinergic effects
  • Do not cross the blood-brain barrier
  • do not affect cognitive functions or
    psychomotor performance
  • do not potentiate impairment caused by alcohol
    or benzodiazepines
  • do not impair driving skills

8
Treatment of SAR With Fexofenadine Safety
(N575)
  • No sedation
  • No ECG abnormalities
  • including no prolongation of QTc at 60, 120, or
    240 mg bid
  • 60-mg bid dose optimal
  • frequency of adverse events similar among all
    groups

9
Safety and Efficacy of Once-a-day Dosage for
Adult SAR
10
Once-a-day Fexofenadine for Adult SARAdverse
Events (gt2)
  • Fexofenadine HCI, N
    ()
  • Placebo 120 mg 180 mg Total Active N293 N287 N
    283 N570
  • EffectOverall occurrence 88 (30.0) 86 (30.0) 86
    (30.4) 172 (30.2)
  • Headache 22 (7.5) 21 (7.3) 30 (10.6) 51 (8.9)
  • Upper respiratory 9 (3.1) 6 (2.1) 9 (3.2) 15
    (2.6)tract infection
  • Pharyngitis 9 (3.1) 8 (2.8) 6 (2.1) 14 (2.5)
  • Back pain 4 (1.4) 8 (2.8) 8 (2.8) 16 (2.8)
  • Pain 10 (3.4) 7 (2.4) 5 (1.8) 12 (2.1)

11
Decongestants
  • Actions
  • Constrict mucous membranes shrinkage promotes
    drainage, improves ventilation, relieves
    nasal stuffiness
  • Routes of administration
  • Systemic, topical
  • Indications
  • Allergic rhinitis, vasomotor rhinitis, sinusitis,
    eustachian tube congestion
  • Side effects
  • Systemic stimulation (CNS, cardiovascular)
  • Topical rhinitis medicamentosa, CNS stimulation,
    local irritation

12
Drugs for Pediatric Allergy (lt12 years)
  • Antihistamines
  • Brompheniramine maleate
  • Cetirizine
  • Chlorpheniramine maleate
  • Clemastine fumarate (12-hour liquid)
  • Diphenhydramine HCl
  • Loratadine
  • Decongestants
  • Phenylephrine HCl
  • Phenylpropanolamine
  • Pseudoephedrine
  • Antihistamine/decongestants
  • Chlorpheniramine maleate/
    phenylpropanolamine
  • Brompheniramine maleate/ pseudoephedrine
  • Intranasal preparations
  • Nonsteroid Cromolyn sodium
  • Corticosteroid Beclomethasone (AQ and
    aerosol) Budesonide (aerosol) Flunisolide
    (AQ) Fluticasone (AQ)

13
Safety of a Second-generation Antihistamine in
Children
Most Frequently Reported (?2) Adverse Even
Fexofenadine HCl (bid)
Placebo N () N () 15 mg 30 mg 60
mg Total (N229) (N224) (N209) (N213) (N646)
Total occurrence 83 (36.2) 79 (35.3) 77 (36.8) 73
(34.7) 230 (35.6) Headache 15 (6.6) 18 (8.0) 15
(7.2) 20 (9.4) 53 (8.2) URTI 4 (1.7) 11 (4.9) 9
(4.3) 3 (1.4) 23 (3.6) Pharyngitis 9 (3.9) 9
(4.0) 6 (2.9) 6 (2.8) 21 (3.3) Coughing 3 (1.3) 3
(1.3) 8 (3.8) 5 (2.3) 16 (2.5) Injury, accident 3
(1.3) 4 (1.8) 6 (2.9) 9 (4.2) 19 (2.9) Abdominal
pain 8 (3.5) 6 (2.7) 4 (1.9) 5 (2.3) 15
(2.3) Fever 2 (0.9) 4 (1.8) 5 (2.4) 4 (1.9) 13
(2.0)
URTI upper respiratory tract infection
14
Safety of a Second-generation Antihistamine in
Children
Frequency of ECG Outliers

  • Fexofenadine HCl (bid)
  • Placebo N ()
  • N () 15 mg 30 mg 60 mg
  • ECG Parameter (N229) (N224) (N209) (N213)
  • PR (gt200 msec and 0 0 0 1 increase gt20 msec)
  • QTc (gt450 msec and 7 6 6 3 increase gt10 msec)

15
Symptoms of Chronic Sinusitis in Children
  • Symptom Occurrence ()
  • Chronic nasal obstruction 100
  • Purulent nasal discharge 90
  • Headache 90
  • Cough 71
  • Fetid breath 67
  • Postnasal drainage 63
  • Behavioral changes 63

16
Sinus Areas Susceptible to Infection
17
Allergy vs Infectious Sinusitis Symptoms in
Children
  • Allergy
  • Itching of eyes, nose, and palate
  • Clear rhinorrhea
  • Sneezing
  • Other symptoms
  • eczema
  • food allergy
  • Infection
  • Purulent anterior rhinorrhea or postnasal drip
  • Frequent head pain
  • Other
  • intractable cough
  • sore throat
  • purulent sputum

18
Treatment of Pediatric Chronic Sinusitis
  • Decongestants
  • Antihistamines
  • Antibiotics
  • Amoxicillin (40 mg/kg tid 14-21 days)
  • Amoxicillin-clavulanate (40 mg/kg tid)
  • Azithromycin (10 mg/kg day 1 5 mg/kg days 2
    to 5)
  • Cefixime (8 mg/kg qd or bid)
  • Cefuroxime axetil (20-30 mg/kg bid)
  • Clarithromycin (15 mg/kg bid)
  • Loracarbef (30 mg/kg bid)
  • Trimethoprim/sulfamethoxazole (8 mg/kg TMP and 40
    mg/kg SMX bid)
  • Functional endoscopic sinus surgery
  • Immunotherapy

19
Pathogenesis of Otitis Media With Effusion
20
Pathogenesis of Otitis Media With Effusion
(contd)
21
Risk Factors Associated With Otitis Media
  • Viral URT infection
  • Allergic rhinitis
  • Eustachian tube dysfunction
  • Cigarette smoking by parents (especially
    mother)
  • Bottle feeding (questionable)
  • Male gender
  • Immunologic deficiency
  • Ciliary dysfunction
  • Adenoidal hypertrophy
  • Cleft palate disorders
  • Genetic predisposition

22
Tympanic Membrane Changes and Symptoms
  • A. Normal

B. Affected by OME
23
Treatment of Otitis Media
  • Antibiotics
  • First choice amoxicillin
  • Amoxicillin/clavulanate
  • Erythromycin/sulfisoxazole
  • Cephalosporin (for ?-lactamase- producing H
    influenzae or M catarrhalis)
  • Clarithromycin or azithromycin (for suspected
    penicillin-resistant S pneumoniae)
  • Decongestants
  • For coexisting allergic rhinitis
  • Antihistamine/decongestants
  • Intranasal corticosteroids
  • Intranasal cromolyn
  • Allergen immunotherapy
  • Follow-up physical examination
  • Other measures
  • Tympanometry (persistent OME)
  • Antibiotic prophylaxis

24
Asthma and Allergic Rhinitis
25
Environmental Allergens and Childhood Asthma
  • Dust mites
  • Furry pets
  • Molds
  • Cockroaches

26
Compliance With Environmental Control Measures
  • Response
  • Dust my house frequently 34.1
  • Do not have pets inside my house 20.8
  • Avoid outdoor activities 18.7
  • Wash bedding in hot water 15.0
  • Wrap mattresses in plastic cover 6.0
  • Do not have carpeting (or rugs) in my house 2.1
  • No measures 25.4
  • Note Respondents (481 patients with
    self-reported allergic rhinitis) were asked to
    check all items that apply.

27
Drug Compliance Rates Allergy and Asthma
  • Noncompliance rates significantly high
  • estimated 50 to 80 noncompliance
  • Factors in treatment success
  • education/clear communication write it down
  • simplicity of dosing schedule
  • minimal adverse effects, especially
    cognitive/behavioral

28
Noncompliance Among Pediatric Patients
  • Poor physician communication with
    parents/caregivers
  • Inconvenient or complex dosing schedules
  • Troublesome adverse effects
  • Cost not affordable

29
Strategies to Encourage Compliance in Pediatric
Patients
  • Educate regarding allergen avoidance measures
  • Promote the need for medication compliance
  • Enlist parental support
  • Seek allergy specialist care
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