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Allergic rhinitis
ALLERGIC RHINITIS
                           DIAGNOSIS AND MANAGEMENT




DR. GHULAM SAQULAIN
ENT SURGEON
CDA HOSPITAL, ISLAMABAD
In a Islamabad based survey conducted by PMRC, out of
2821 households with a total of 16717 individuals were
surveyed, 1448 (8.66%) were reported suffering from allergy.




                                        Others (n=17), 0.14%
                                                                                      Multiple Allergies
                                                                                       (n=509), 3.04%
                                    Chronic Cough (n=24),
       Types of Allergies




                                            0.14%
                                           Conjunctivitis (n=53),
                            1                     0.32%
                                                          Skin Allergy (n=290),
                                                                  1.73%
                                                       Nasal Allergy (n=360),
                                                               2.15%
                                        Asthma (n=195), 1.17%



                            0.00%        0.50%         1.00%        1.50%         2.00%         2.50%       3.00%     3.50%
                                                                         Prevalence



                                                                                                           03/13/13
                                    Capital Hospital Islamabad                                             3
Distribution of Persons with Allergies by
Type of Allergy. (n=1448)




                          Urticaria,                Asthma,
                          20.00%                    13.50%
        Conjuctivitis,                                                   Rhinitis,
          3.70%                                                          24.90%

   Chronic Cough,
       1.60%

   Others, 1.20%



                                        Multiple
                                       allergies,
                                       35.10%




                                                              03/13/13
              Capital Hospital Islamabad                      4
Allergic Rhinitis

   Allergic Rhinitis is defined as an inflammation of the
   lining of the nose and is characterized by the symptoms
   of nasal congestion, rhinorhea, sneezing and itching .
   Other symptoms are nasal obstruction, paranasal pain
   or headache, pruritis, itchy or watery eyes, anosmia,
   dysosmia,    chronic    pharyngitis,   hoarseness    and
   recurrent inflammation of URT




                                             03/13/13
       Capital Hospital Islamabad            5
• Pollens
                             • Mold.
                             • Animal
                               dander.
                             • Dust mites.

                                   03/13/13
Capital Hospital Islamabad         6
Diagnosis


    • Careful History
    • Physical Examination
    • Laboratory Studies for
      Confirmation

                                 03/13/13
    Capital Hospital Islamabad   7
History:
The signs and symptoms of Allergic Rhinitis are
familiar to many:




                                        03/13/13
           Capital Hospital Islamabad   8
•Itching/ sneezing,
      • Nasal pruritis occurs,       History:
        particularly    in  pollen
        allergy with Itching eyes,
        nose and throat,
      • Sneezing is the most
        common symptom with
        pollen allergy,


•Watery Rhinorrhoea,


•Nasal congestion/Obstruction
at night causes:
      •    mouth breathing,
      •    snoring,
      •    restlessness, with
        complaints of dry, sore
        throat in the morning,       03/13/13
      Capital Hospital Islamabad
      •    fatique.                  9
Physical Examination
Intranasal Examination


•   Typically, the nasal mucosa is
    pale pink and swollen.
•   Discharge is thin watery, but
    becomes thick and purulent
    when secondary infection sets
    in.
•   Oropharyngeal wall may have
    typical clumps of lymphoid
    tissue.
•   Other     associated     allergic
    diseases such as a contact
    dermatitis   or   asthma     may
    correlate with flares of allergic
    symptoms.



                                        03/13/13
           Capital Hospital Islamabad   10
•Malocclusion:

•Allergic Shiners:
             – Dark circles
               under the eyes
               from venous
               stasis due to
               engorged nasal
               membranes

•Rabbit Nose:
             – The child may
               wrinkle the end of
               the nose constantly,

•Allergic salute
             – The child may rub
               the nose with the
               palm of the hand in
               an upward manner



                                      03/13/13
        Capital Hospital Islamabad    11
Laboratory Findings:
•   Peripheral Eosinophilia:
•   Nasal secretion cytology:
    –   Presence of 3-10% of eosinophils in nasal
        secretions is diagnostic of allergic rhinitis
        except during early infancy.

•   Immunoglobulin E
    –   IgE serum levels are elevated in almost half of
        cases with allergic rhinitis. However normal
        IgE does not exclude allergic rhinitis.

•   RAST testing
    –   This is a radio-immune assay where a
        patient's serum is incubated with different
        allergens and antigen/antibody complexes are
        then measured.
    –   It is a more specific blood test for allergy.
    –   This is not as sensitive as skin testing and
        more costly

•   Allergy Skin Tests :
    –   Done to identify specific allergens.


                                                          03/13/13
            Capital Hospital Islamabad                    12
COMPLICATIONS
OF ALLERGIC RHINITIS
  • Recurrent otitis media.
  • Hearing loss.
  • Sinusitis.
  • Nasal or sinus polyps.
  • Progression to asthma.
  • Anatomical changes in nasal and
    sinus cavities.
                                   03/13/13
      Capital Hospital Islamabad   13
The Basic Pathology

  Four types of hypersensitivity reactions


  •    Type I - IgE mediated reaction
  •    Type II - IgG/ IgM mediated
  •    Type III - IgG/ IgM mediated
  •    Type IV - T cell mediated
      (Delayed hypersensivity, Cell-mediated
        hypersensivity)
                                               03/13/13
         Capital Hospital Islamabad            14
PATHOLOGY & PATHOGENESIS


•   In allergic rhinitis we see an
    example of IgE mediated
    hypersensitivity. In this type
    with continued exposure
    atopic individual acquires
    antibodies of reagin type
    (IgE Immunoglobulins) from
    plasma cells.




                                       03/13/13
          Capital Hospital Islamabad   15
Along with
                                       submucosa
                                      Mast cells in
                                       epithelium       Occurs within
Allergy Causing Pollen                also imprtant      30 Sec. of
                                                         challenge


                                                      Excess Mucus
                                                        Production




                                                      03/13/13
                         Capital Hospital Islamabad   16
HISTAMINE
Origin:
•   Found in the most tissues of the body.
•   Most abundant in mast cells near blood vessels in
    connective tissue.
•   Found in small quantities in basophils(granular part of a
    cell).

Release:
•   when an allergen joins an IGE antibody on the surface of
    a mast cell or basophil, serine esterase(compound) is
    activated, and this activation induces the release of
    histamine.

                                               03/13/13
         Capital Hospital Islamabad            17
Effects:
• Reactions range from mild itching to shock and
  death.
• Response to histamine occurs in one to two
  minutes.
• Duration of action is about ten minutes.

• Produces effects by acting on H1 receptors.




                                         03/13/13
       Capital Hospital Islamabad        18
H1 RECEPTORS
  Stimulation causes:


  •   constriction of the bronchial smooth muscle.
  •   Increase mucus secretion in respiratory tract.
  •   Increased lacrimation.
  •   Dilation of arterioles and capillaries.
  •   Weakening of capillary walls.
  •   Constriction of small veins and venules.
  •   Dilation of large veins.
  •   Constriction of smooth muscle of the gut.
  •   Pain and burning sensations.                03/13/13
            Capital Hospital Islamabad            19
Type - I (IgE mediated reaction)
       1. Preformed                                          2. Newly formed
       •     Histamines                                      •    PAF
       •     NCF (Neutrophil                                 •    Leukotrienes (LTB4)
             Chemoattractant Factor)
                                                             •
       •     ECF (Eosinophil
             Chemoattractant Factor)
                                                                                     Prostaglandin's
   •       The preformed mediators are responsible for the early phase reaction.

   •       These mediators are responsible for the commissioning of Eosinophils
   •       Once the eosinophils are commissioned, the late-phase reaction begins

       •     Enzymes




                                                                                   03/13/13
                   Capital Hospital Islamabad                                      20
Type - I (IgE mediated reaction)


   Two clinical subgroups

   • 1. Atopy

   • 2. Anaphylaxis


                                  03/13/13
     Capital Hospital Islamabad   21
Atopy

  • The term applies to a group of diseases
    occurring in individuals with inherited
    tendency to develop IgE antibodies

  • Allergic Rhinitis serves as an outstanding
    example



                                  03/13/13
     Capital Hospital Islamabad   22
Anaphylaxis
  • Certain allergens               may   induce       IgE
    mediated response

  • Condition is potentially fatal.

  • Affect atopic and non-atopic patient.

  • Diseases       are:     Anaphylaxis,     Urticaria,
    Angioedema etc


                                            03/13/13
       Capital Hospital Islamabad           23
ALLERGIC RHINITIS
Essentials of Diagnosis

  • Nasal pruritis, congestion, rhinorrhea, sneeze
    attacks, eye irritation. Sometimes eczematous
    dermatitis

  • Environmental allergen exposure

  • Confirmed by evidence of specific IgE antibody




                                         03/13/13
        Capital Hospital Islamabad       24
TREATMENT
The three basic Principles of
 allergy management are :

     •   Avoidance Techniques

     •   Symptomatic Therapy

     •   Immunotherapy



                                          03/13/13
             Capital Hospital Islamabad   25
Avoidance Therapy
              The most effective part of the treatment



 •   But usually meets failure as the allergens in the
     environment often become unavoidable

 •   Cross-reactivity also plays its part




                                                03/13/13
         Capital Hospital Islamabad             26
Health Tips
  Pollen grains of trees like paper mulberry can be
   avoided by
        leaving the area densely populated by these plants.
        Minimize outdoor activity when pollen counts are high.
        Take medications at least 30 minutes prior to outdoor activity.
         Shut windows in your house on days pollen counts are high.
        Wearing face masks
        Use of air conditioners
     
         Air-filtering devices

  Avoiding Irritants.
        Do a thorough spring cleaning
        Wash bedding weekly in hot water.
        Dry laundry indoors.
        Keep pets off of furniture and out of the bedroom.
        Keep car windows closed during peak season.        03/13/13
        When mowing lawn Islamabad wear a filter mask.
          Capital Hospital or gardening,                    27
Drug Therapy
 Three classes of:


 • First generation       antihistamine   have   sedating
   potential.
 • Second generation antihistamine having better
   compliance & lesser sedating potential
 • Third generation antihistamine are non- sedating
   but usually the rescue dose comes with a sedating
   effect

                                            03/13/13
        Capital Hospital Islamabad          28
First Generation
    Chlorpheniramine
    Diphenhydramine
    Promathazine etc.


   •   First Generation have wide pharmacologic profile.
   •   They easily cross blood brain barrier that is why they
       cause Sedation
   •   They are not specific nor selective they cause
       anticholinergic side effects.
   •   They have Drug interactions.
   •   They do not work in late phase of Allergic Reactions.
   •   They are inconvenient B.I.D and T.I.D Dosage.
                                                03/13/13
        Capital Hospital Islamabad                29
Second/ Third Generations
   Loratadine
   Cetirizine
   Fexofenadine
   Disloratadine
   Levocetirizine

     Second generation are composed of Relatively Large and less
      Lipophilic molecules that cross the blood brain barrier less easily
     They cause minimal sedation.
     They Work in late phase of Allergic Reaction.
     Offer convenient once daily Dosage .
  
                                                           03/13/13
      They do not have Drug interactions.
         Capital Hospital Islamabad                        30
But all of them do not have all the
  Advantages


        Some of them cause cardiac side
         effects
        Some of them are not specific and
         selective
        Ant cholinergic side effects.

                                       03/13/13
          Capital Hospital Islamabad   31
What is the Right choice
   WHICH OFFERS:
   • High efficacy
   • Fast relief of Allergic Reactions
   • Long duration of action
   • Minimal sedation
   • Low side effects
   • Safe in long term use
   • Convenient OD dosage                03/13/13
       Capital Hospital Islamabad        32
Fast Relief
 Tandegyl Day provide quick relief of allergic symptoms.
 Because it achieves peak plasma concentration with in (0.9 hrs)

       3                                 fexofenad
                                            ine
      2.5

       2                       loratadine

      1.5               cetrizine
                Levocetiri
       1          zine

      0.5

       0
                 peack plazma concentaration         03/13/13
            Capital Hospital Islamabad               33
Slow dissociation Rate

    Ensure the strong antagonism of
     levocetirizine to histamine receptor
     which resulting in longer duration of
     action
    In symptoms like Sneezing,
     Rhinorrhoea, Nasal Obstruction, Itch
     and Flare.
                                   03/13/13
      Capital Hospital Islamabad   34
Safety

    Tandegyl Day have Minimal Sedation
     because it does not cross the blood brain
     barrier.
    Tandegyl Day has low side effects
     because it has 600 folds Higher selectivity
     towards H1 receptor.
    Tandegyl Day has a minimal Risk of Drug
     interaction because it is poorly
     metabolized.                     03/13/13
      Capital Hospital Islamabad    35
Low Volume Of Distribution
 Tandegyl Day has Low volume of distribution so it is better choice
  for long term use. Like in Allergic Rhinitis etc.



         120
         100
                                                                                    120
          80
          60
          40                    0.4            0.58              5.4                       Volum of
          20                                                                              Distribution
           0
                 Tandegyl Day


                                  Cetirizine



                                                  Fexofenadine



                                                                       Loratidine



                                                                                             03/13/13
               Capital Hospital Islamabad                                                    36
High compliance

    Convenient once daily
    Less drowsiness
    Low dryness of mouth
    Affordable price Rs 5.50
    Easily available
                                    03/13/13
    ACapital Hospital Islamabad of NOVARTIS
       quality product              37
LEVOCETIRIZINE (Tandegyl - Day)

•   Potent systemic antihistamine.
•   O.D dosage
•   Fast onset of action (0.9 Hours).
•   Economical (5.50/= per tablet)
•   Can be recommended from the age of 2 years
•   Has 600 times selectivity with H1 Receptors
•   Has 2 fold higher affinity towards H1 Receptors
    than Citirizine.
•   Low drug interactions
•   Minimal sedation                    03/13/13
     Capital Hospital Islamabad         38
Immunotherapy:
• Aim : Increase the patient's tolerance to the particular pollen.

    Otolaryngol Clin North Am,7:703-718, October 1874

    – Immunotherapy is indicated for those patients who fail
      environmental controls and medical therapy, or patients
      with extremely severe allergy.

    – Immunotherapy is rarely done in children less than six
      years of age, as allergic sensitivity is rapidly changing up
      to that age




                                                     03/13/13
            Capital Hospital Islamabad               39
Surgical Treatment:
• Indicated


   – When the turbinates
     have hypertrophied to
     a point making
     breathing difficult.
   – Associated structural
     problems causing
     obstruction to airway.
   – Complications like
     nasal polypi.

                                       03/13/13
          Capital Hospital Islamabad   40
RHINITIS & ASTHMA




                Nasal allergy
also seems to be highly correlated with
 asthma, recurring sinus infection, otitis
    media and possibly facial growth
             abnormalities.


                                  03/13/13
 Capital Hospital Islamabad       41
03/13/13
Capital Hospital Islamabad   42
Thank you


                       Answers




Questions?

                                 03/13/13
 Capital Hospital Islamabad      43

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Allergic rhinitis

  • 2. ALLERGIC RHINITIS DIAGNOSIS AND MANAGEMENT DR. GHULAM SAQULAIN ENT SURGEON CDA HOSPITAL, ISLAMABAD
  • 3. In a Islamabad based survey conducted by PMRC, out of 2821 households with a total of 16717 individuals were surveyed, 1448 (8.66%) were reported suffering from allergy. Others (n=17), 0.14% Multiple Allergies (n=509), 3.04% Chronic Cough (n=24), Types of Allergies 0.14% Conjunctivitis (n=53), 1 0.32% Skin Allergy (n=290), 1.73% Nasal Allergy (n=360), 2.15% Asthma (n=195), 1.17% 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% Prevalence 03/13/13 Capital Hospital Islamabad 3
  • 4. Distribution of Persons with Allergies by Type of Allergy. (n=1448) Urticaria, Asthma, 20.00% 13.50% Conjuctivitis, Rhinitis, 3.70% 24.90% Chronic Cough, 1.60% Others, 1.20% Multiple allergies, 35.10% 03/13/13 Capital Hospital Islamabad 4
  • 5. Allergic Rhinitis Allergic Rhinitis is defined as an inflammation of the lining of the nose and is characterized by the symptoms of nasal congestion, rhinorhea, sneezing and itching . Other symptoms are nasal obstruction, paranasal pain or headache, pruritis, itchy or watery eyes, anosmia, dysosmia, chronic pharyngitis, hoarseness and recurrent inflammation of URT 03/13/13 Capital Hospital Islamabad 5
  • 6. • Pollens • Mold. • Animal dander. • Dust mites. 03/13/13 Capital Hospital Islamabad 6
  • 7. Diagnosis • Careful History • Physical Examination • Laboratory Studies for Confirmation 03/13/13 Capital Hospital Islamabad 7
  • 8. History: The signs and symptoms of Allergic Rhinitis are familiar to many: 03/13/13 Capital Hospital Islamabad 8
  • 9. •Itching/ sneezing, • Nasal pruritis occurs, History: particularly in pollen allergy with Itching eyes, nose and throat, • Sneezing is the most common symptom with pollen allergy, •Watery Rhinorrhoea, •Nasal congestion/Obstruction at night causes: • mouth breathing, • snoring, • restlessness, with complaints of dry, sore throat in the morning, 03/13/13 Capital Hospital Islamabad • fatique. 9
  • 10. Physical Examination Intranasal Examination • Typically, the nasal mucosa is pale pink and swollen. • Discharge is thin watery, but becomes thick and purulent when secondary infection sets in. • Oropharyngeal wall may have typical clumps of lymphoid tissue. • Other associated allergic diseases such as a contact dermatitis or asthma may correlate with flares of allergic symptoms. 03/13/13 Capital Hospital Islamabad 10
  • 11. •Malocclusion: •Allergic Shiners: – Dark circles under the eyes from venous stasis due to engorged nasal membranes •Rabbit Nose: – The child may wrinkle the end of the nose constantly, •Allergic salute – The child may rub the nose with the palm of the hand in an upward manner 03/13/13 Capital Hospital Islamabad 11
  • 12. Laboratory Findings: • Peripheral Eosinophilia: • Nasal secretion cytology: – Presence of 3-10% of eosinophils in nasal secretions is diagnostic of allergic rhinitis except during early infancy. • Immunoglobulin E – IgE serum levels are elevated in almost half of cases with allergic rhinitis. However normal IgE does not exclude allergic rhinitis. • RAST testing – This is a radio-immune assay where a patient's serum is incubated with different allergens and antigen/antibody complexes are then measured. – It is a more specific blood test for allergy. – This is not as sensitive as skin testing and more costly • Allergy Skin Tests : – Done to identify specific allergens. 03/13/13 Capital Hospital Islamabad 12
  • 13. COMPLICATIONS OF ALLERGIC RHINITIS • Recurrent otitis media. • Hearing loss. • Sinusitis. • Nasal or sinus polyps. • Progression to asthma. • Anatomical changes in nasal and sinus cavities. 03/13/13 Capital Hospital Islamabad 13
  • 14. The Basic Pathology Four types of hypersensitivity reactions • Type I - IgE mediated reaction • Type II - IgG/ IgM mediated • Type III - IgG/ IgM mediated • Type IV - T cell mediated (Delayed hypersensivity, Cell-mediated hypersensivity) 03/13/13 Capital Hospital Islamabad 14
  • 15. PATHOLOGY & PATHOGENESIS • In allergic rhinitis we see an example of IgE mediated hypersensitivity. In this type with continued exposure atopic individual acquires antibodies of reagin type (IgE Immunoglobulins) from plasma cells. 03/13/13 Capital Hospital Islamabad 15
  • 16. Along with submucosa Mast cells in epithelium Occurs within Allergy Causing Pollen also imprtant 30 Sec. of challenge Excess Mucus Production 03/13/13 Capital Hospital Islamabad 16
  • 17. HISTAMINE Origin: • Found in the most tissues of the body. • Most abundant in mast cells near blood vessels in connective tissue. • Found in small quantities in basophils(granular part of a cell). Release: • when an allergen joins an IGE antibody on the surface of a mast cell or basophil, serine esterase(compound) is activated, and this activation induces the release of histamine. 03/13/13 Capital Hospital Islamabad 17
  • 18. Effects: • Reactions range from mild itching to shock and death. • Response to histamine occurs in one to two minutes. • Duration of action is about ten minutes. • Produces effects by acting on H1 receptors. 03/13/13 Capital Hospital Islamabad 18
  • 19. H1 RECEPTORS Stimulation causes: • constriction of the bronchial smooth muscle. • Increase mucus secretion in respiratory tract. • Increased lacrimation. • Dilation of arterioles and capillaries. • Weakening of capillary walls. • Constriction of small veins and venules. • Dilation of large veins. • Constriction of smooth muscle of the gut. • Pain and burning sensations. 03/13/13 Capital Hospital Islamabad 19
  • 20. Type - I (IgE mediated reaction) 1. Preformed 2. Newly formed • Histamines • PAF • NCF (Neutrophil • Leukotrienes (LTB4) Chemoattractant Factor) • • ECF (Eosinophil Chemoattractant Factor) Prostaglandin's • The preformed mediators are responsible for the early phase reaction. • These mediators are responsible for the commissioning of Eosinophils • Once the eosinophils are commissioned, the late-phase reaction begins • Enzymes 03/13/13 Capital Hospital Islamabad 20
  • 21. Type - I (IgE mediated reaction) Two clinical subgroups • 1. Atopy • 2. Anaphylaxis 03/13/13 Capital Hospital Islamabad 21
  • 22. Atopy • The term applies to a group of diseases occurring in individuals with inherited tendency to develop IgE antibodies • Allergic Rhinitis serves as an outstanding example 03/13/13 Capital Hospital Islamabad 22
  • 23. Anaphylaxis • Certain allergens may induce IgE mediated response • Condition is potentially fatal. • Affect atopic and non-atopic patient. • Diseases are: Anaphylaxis, Urticaria, Angioedema etc 03/13/13 Capital Hospital Islamabad 23
  • 24. ALLERGIC RHINITIS Essentials of Diagnosis • Nasal pruritis, congestion, rhinorrhea, sneeze attacks, eye irritation. Sometimes eczematous dermatitis • Environmental allergen exposure • Confirmed by evidence of specific IgE antibody 03/13/13 Capital Hospital Islamabad 24
  • 25. TREATMENT The three basic Principles of allergy management are : • Avoidance Techniques • Symptomatic Therapy • Immunotherapy 03/13/13 Capital Hospital Islamabad 25
  • 26. Avoidance Therapy The most effective part of the treatment • But usually meets failure as the allergens in the environment often become unavoidable • Cross-reactivity also plays its part 03/13/13 Capital Hospital Islamabad 26
  • 27. Health Tips Pollen grains of trees like paper mulberry can be avoided by  leaving the area densely populated by these plants.  Minimize outdoor activity when pollen counts are high.  Take medications at least 30 minutes prior to outdoor activity.  Shut windows in your house on days pollen counts are high.  Wearing face masks  Use of air conditioners  Air-filtering devices Avoiding Irritants.  Do a thorough spring cleaning  Wash bedding weekly in hot water.  Dry laundry indoors.  Keep pets off of furniture and out of the bedroom.  Keep car windows closed during peak season. 03/13/13  When mowing lawn Islamabad wear a filter mask. Capital Hospital or gardening, 27
  • 28. Drug Therapy Three classes of: • First generation antihistamine have sedating potential. • Second generation antihistamine having better compliance & lesser sedating potential • Third generation antihistamine are non- sedating but usually the rescue dose comes with a sedating effect 03/13/13 Capital Hospital Islamabad 28
  • 29. First Generation  Chlorpheniramine  Diphenhydramine  Promathazine etc. • First Generation have wide pharmacologic profile. • They easily cross blood brain barrier that is why they cause Sedation • They are not specific nor selective they cause anticholinergic side effects. • They have Drug interactions. • They do not work in late phase of Allergic Reactions. • They are inconvenient B.I.D and T.I.D Dosage. 03/13/13 Capital Hospital Islamabad 29
  • 30. Second/ Third Generations  Loratadine  Cetirizine  Fexofenadine  Disloratadine  Levocetirizine  Second generation are composed of Relatively Large and less Lipophilic molecules that cross the blood brain barrier less easily  They cause minimal sedation.  They Work in late phase of Allergic Reaction.  Offer convenient once daily Dosage .  03/13/13 They do not have Drug interactions. Capital Hospital Islamabad 30
  • 31. But all of them do not have all the Advantages  Some of them cause cardiac side effects  Some of them are not specific and selective  Ant cholinergic side effects. 03/13/13 Capital Hospital Islamabad 31
  • 32. What is the Right choice WHICH OFFERS: • High efficacy • Fast relief of Allergic Reactions • Long duration of action • Minimal sedation • Low side effects • Safe in long term use • Convenient OD dosage 03/13/13 Capital Hospital Islamabad 32
  • 33. Fast Relief  Tandegyl Day provide quick relief of allergic symptoms.  Because it achieves peak plasma concentration with in (0.9 hrs) 3 fexofenad ine 2.5 2 loratadine 1.5 cetrizine Levocetiri 1 zine 0.5 0 peack plazma concentaration 03/13/13 Capital Hospital Islamabad 33
  • 34. Slow dissociation Rate  Ensure the strong antagonism of levocetirizine to histamine receptor which resulting in longer duration of action  In symptoms like Sneezing, Rhinorrhoea, Nasal Obstruction, Itch and Flare. 03/13/13 Capital Hospital Islamabad 34
  • 35. Safety  Tandegyl Day have Minimal Sedation because it does not cross the blood brain barrier.  Tandegyl Day has low side effects because it has 600 folds Higher selectivity towards H1 receptor.  Tandegyl Day has a minimal Risk of Drug interaction because it is poorly metabolized. 03/13/13 Capital Hospital Islamabad 35
  • 36. Low Volume Of Distribution  Tandegyl Day has Low volume of distribution so it is better choice for long term use. Like in Allergic Rhinitis etc. 120 100 120 80 60 40 0.4 0.58 5.4 Volum of 20 Distribution 0 Tandegyl Day Cetirizine Fexofenadine Loratidine 03/13/13 Capital Hospital Islamabad 36
  • 37. High compliance  Convenient once daily  Less drowsiness  Low dryness of mouth  Affordable price Rs 5.50  Easily available 03/13/13  ACapital Hospital Islamabad of NOVARTIS quality product 37
  • 38. LEVOCETIRIZINE (Tandegyl - Day) • Potent systemic antihistamine. • O.D dosage • Fast onset of action (0.9 Hours). • Economical (5.50/= per tablet) • Can be recommended from the age of 2 years • Has 600 times selectivity with H1 Receptors • Has 2 fold higher affinity towards H1 Receptors than Citirizine. • Low drug interactions • Minimal sedation 03/13/13 Capital Hospital Islamabad 38
  • 39. Immunotherapy: • Aim : Increase the patient's tolerance to the particular pollen. Otolaryngol Clin North Am,7:703-718, October 1874 – Immunotherapy is indicated for those patients who fail environmental controls and medical therapy, or patients with extremely severe allergy. – Immunotherapy is rarely done in children less than six years of age, as allergic sensitivity is rapidly changing up to that age 03/13/13 Capital Hospital Islamabad 39
  • 40. Surgical Treatment: • Indicated – When the turbinates have hypertrophied to a point making breathing difficult. – Associated structural problems causing obstruction to airway. – Complications like nasal polypi. 03/13/13 Capital Hospital Islamabad 40
  • 41. RHINITIS & ASTHMA Nasal allergy also seems to be highly correlated with asthma, recurring sinus infection, otitis media and possibly facial growth abnormalities. 03/13/13 Capital Hospital Islamabad 41
  • 43. Thank you Answers Questions? 03/13/13 Capital Hospital Islamabad 43