RI N A E ARIA UPD W ATE At-A-Glance Pocket …

1 BA SED ON THE ALLERGICRHI NIT IS ANDITS IMPACT ON ASTHMAWO RK SHOPREPORTIn collaborationwith th e Wor ld He alth Organisation,GA2 LEN , an d Alle rGe n ARIAAt-A-GlancePo ck et Reference2007 NEWARIAUPDATEARIAAt -A-GlancePoc ketReferenc e20071stEd itionAR IAUPDATEIn 1999,duringthe ARIA(AllergicRhinitisand its Impacton Asthma)WHOworkshop,anevidence-baseddocum entwas producedusingan extensivereviewof the literatureavailableup to statementsof evidencefor the developmentof ARIA havefollowedWHOrulesand werebasedon thoseof newclassificationfor allergicrhinitiswhichwas subdividedinto intermittent or persistent disease,and basedon severityaccordingto quality-of-lifeand symptoms.

2 Anotherimportantaspectof ARIAwas to considerco-morbiditiesof allergicrhinitis, ARIA documentwas intendedto be a state-of-the-arttextbookfor the specialistas well asfor the generalpractitionerand otherhealthcareprofessionals: To updatetheirknowledgeof allergicrhinitis. To highlightthe impactof allergicrhinitison asthma. To providean evidence-baseddocumentedapproachto diagnosis. To providean evidence-basedapproachto treatment. To proposea stepwiseapproachto the managementof the ARIA updatewas startedin ARIA wereextensivelyreviewedusingthe Shekelleevidence-basedmodel,and paperspublishedin peer-reviewedjournalsonthe topicsof.

3 Tertiarypreventionof allergy,complementaryand alternativemedicine,pharmaco-therapyand anti-IgEtreatment,allergen-specificimmun otherapy,linksbetweenrhinitisand asthma,and mechanismsof a needfor a globaldocumentwhichwouldhighlighttheinte ractionsbetweenthe upperand the lowerairwaysincludingdiagnosis,epidemiol ogy,commonrisk factors,management,and largelist of treatmentswas ,intranasalcorticosteroidsare the first-linetherapyin patientswithmoderateto severedisease,H1-antihistaminesare importanttreatmentsfor all patients,and leukotrienereceptorantagonists(LTRAs)are particularlyimportantfor patientswithbothrhinitisand (SIT)has provento be a safeand a symptomaticdisorderof the noseinducedafterallergenexposuredue to anIgE-mediatedinflammationof the membranesliningthe was definedin 1929as follows: Thethreecardinalsymptomsin nasalreactionsoccurringin allergyare sneezing,nasalobstructionand mucousdischarge.

4 Allergicrhinitisis a countries,all ethnicgroups,andall prevalenceof diagnosedasthmainpatientswithallergicrhi nitisincreasesas a functionof the persistenceand severityof sleep,dailyactivities,and workand can increasetheseverityof economicimpactof allergicrhinitisis diagnosisof allergicrhinitisis ofteneasy,but in somecasesit maycauseproblemsandmanypatientsgo undiagnosed,oftenbecausetheydo not perceivethe symptomsof rhinitisasa A RECOMMENDATIONS1- Allergicrhinitisis a majorchronicrespiratorydiseasedue to its:- Prevalence- Impacton quality-of-life- Impacton work/schoolperformanceand productivity- Economicburden- Linkswithasthma2- In addition,allergicrhinitisis associatedwith sinusitisand Allergicrhinitisshouldbe consideredas a risk factorfor asthmaalongwith otherknownrisk A newsubdivisionof allergicrhinitishas beenproposed.

5 - Intermittent(IAR)- Persistent(PER)5- The severityof allergicrhinitishas beenclassifiedas mild or moderate/severe dependingon the severityof symptomsand Dependingon the subdivisionand severityof allergicrhinitis,a stepwisetherapeuticapproachhas The treatmentof allergicrhinitiscombines:- Allergenavoidance(whenpossible)- Pharmacotherapy- Immunotherapy- Education8- Patientswithpersistentallergicrhinitissh ouldbe evaluatedfor asthmaby meansof amedicalhistory,chestexamination,and,if possibleand whennecessary,the assessmentofairflowobstructionbeforeand Patientswithasthmashouldbe appropriatelyevaluated(historyand physicalexamination)

6 For Ideally,a combinedstrategyshouldbe usedto treatthe upperand lowerairwaydiseasesto optimizeefficacyand IACLASSIFIC ATI ONOFRHINITISP roperdiagnosisand classificationof patientswithallergicrhinitisare essentialto symptomsof allergicrhinitisincluderhinorrhea,nasalo bstruction,nasalitching,and sneezing,whichare reversiblespontaneouslyor termittentsy mp tom s <4 da ys per wee k or<4 weeksMildall of th e foll owi ng normalsl eep no impairm ent of dailyact ivit ies ,spo rt, lei su re no impair mentof workand school no tr oubl esomesymptom sModera te-Se ve reone or mor e item s abno rma l sleep imp airmentof da ily activities,sport , leis ur e imp air ed workand school tr oub les omesymptomsPersis te ntsym ptoms >4 day s/week and>4 weeksSTRENGTHOFEV IDENCEFOREFFICACYOFRHINI TISTREATMENTEV IDENCE-BASEDRECOMMENDATIONS3 ARI A2007 Interve nt ionSA RPARPER adul ts chil dr en adu lts childr enOra lH1 An tihi st amineAA AAAI ntra nas al H1 An tihis tamin e AA AAA**Intra nas al CSAA AAA**Intra nas al cr omo neA A(>12 yrs)

7 AALTR AsAA AA**Subc utan eou sSI TAA AAA**Sub lingua l/nasa lSITAA ABA**Alle rge navo idanc eDDA* B*Ev idence -ba se dre co mme nd ati on sClin ica lreco mm en da tio nson eff ica cy foran inte rven tio nReco mm en da tio nsfor aninter ve nt ionSa fetyincl udingpost-marketingsur veil lanceHealtheco nom icsPa tie nt s viewsThe stre ngthof ev idencebase d on efficacyaloneis insufficientto dete rm ine propertre at ment .The new GRADE classificat ion cons id ers add it iona l factors as indicated in the figureshownbelowan d provides importantnewinformationaboutthe qual ity of clinical information usedto makethera put ic dec isi s 1st Ed it ion of the AR IA PocketRef erencerefle cts the ARI A 2007 WorkshopRepor t.

8 An expert panelme eti ng was conductedon June 20, 2007 ;the panelmade48 cl inicalrecom mendations base d on the fin al re view, theserecommendationswi ll be publ ishedlat er in 2007 .SAR- SeasonalAllergicRhinitisPAR- PerennialAllergicRhinitisPER- PersistantAllergicRhinitis*not ef fecti ve in the ge neralpopulation**extr apolated fromst udiesin SAR/PAR4 ALGORITHMFORALLERGICRHINIT IS DIAGNOSIS ANDMANAGEMENTmod era te- mildsev er eNo t in pr efer re d orde roral H1- antih ista mi neor in tra nasa lH1-a ntihi stamin eand/ or deco ng estantor in tra nasa l CSor LTRA*(or cro mo ne )if failu re : ste p- upif im prov ed.

9 Co ntinuefor 1 monthDi agno sis of all erg icrh initisInt er mit ten tsymp tomsmildNotin preferred orderoral H1-a ntihistamin eor intr an asalH1-an tihistamineand/or decon gestantor LTR A*mode ra tesever eIn pre ferr ed ord erint ranasal CSH1-a nti hi stam ine or LTR A*step- downand co nti nuetrea tmentfor 1 mont hPer sist entsy mp tom sincre aserhi no rrh eain tra nasalCSad d ipra tro pi umdos eitc h/ sne ezebl oc ka gead d H1 ant ihi st am in ead ddeco ng es ta ntor oral CS(sh or t- term )su rgical re fer ra lIf conjunc tivi tisadd:oralH1-antihistamineor intraocularH1-antihistamineor intraocularcromone(or saline)

10 Consi der spe ci ficimmunot her apyrev iew the pat ien taft er 2- 4 wksim pr ove dfail urefail ur erevie w dia gno sisrevie w co mp li ancequer y infect ion sor other cau se sin pers is te nt rhin itisrev iew th e pa tientafter 2- 4 wee ksAlle rgenandirritant avoidancema y be appropriateCheck for asthm aesp ecially inpatients withmoder ate-sever ean d/or per sistentrhinitis*In particular,in TI S MEDI CATIONSOO rraall HH11 aannttiihhiissttaammiinneessNNaammee aannddAAllssoo kknnoowwnn aassGGeenneerriicc nnaammeeMMeecchhaanniissmm ooffaaccttiioonnSSiiddee eeffffeeccttssCCoommmmeennttss22nndd ggeenneerraattiioonnAcriva st inAz el ast ineCet ir izineDes lor atadineEbas tineFe xo fe nadineLev oc et ir izineLor ata dineMequitazineMi zola st ineRu pata dine11sstt ggeenneerraattiioonnChlorphen ir amineClemas tineDim eth indeneHydrox yzineKeto tif enOx at omineOthersCCaarrddiioottooxxiicc**As tem izoleTerf ena dine- new ge ne ra tio ndrug s can b e u sedonce dai ly- no de velop me nt oftac hyp