ALLERGIC RHINITIS IN ELDERLY LITERATURE READING Lina Marlina Supervisor : Dr. Melati Sudiro, Mkes.,SpTHT-KL(K) Dept of Otorhinolaryngology – HNS Hasan Sadikin General Hospital Bandung 2015 1 Introduction Rhinitis : inflamation of the nose and is characterizized by nasal symptoms including anterior or posterior rhinorrhoea, sneezing, itching, and nasal congestion Allergic rhinitis (AR) as symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 2 Introduction • Allergic rhinitis represent a global health problem • Geriatric patients often have multiple medical problems and take multiple medications • Undertaking evaluation and treatment of allergies Coordination of care with the patient’s primary care of other specialists will ensureThe best possible treatment outcome. Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 3 Epidemiology(2) • The incidence of allergic rhinitis decreases with age • According to the 2005 report of the National Center for Health Statistics • 7.8% of adults 18 - 44 years • 10.7% of those 45 - 64 years • 7.8% of those 65 - 74 years, and • 5.4% of those 75 years and older are affected in the United States. 2008 Massoud Mahmoudi, Prevalence of Allergic Diseasw in .Children, Adults, and the Elderly.2008 4 Epidemiology(3) • People 65 years old or more are the fastest growing segmen of the population in the developed countries • 2030, it is estimated that this group will comprise about 20% of the total population, and among elderly persons, the percentage of patients aged above 80 years will increase disproportionately • The prevalence of allergic diseases, in the elderly is estimated around 5-10% Victoria Cardona, et allAllergic disease in the elderyly.. 2011 . 2008 5 Rhinitis in Aging Rhinitis is an inflammatory disease, mechanisms and presentation of condition are altered as immune function changes with age A critical componen of the immune system is the thymus, which involutes from adolescence to near middle age The decline in functional mass depressed production of T-cells impaired cell-mediated immunity. Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 6 Pathophysiology Of Rhinitis Powerpoint Templates Pathophysiology of Allergic and Nonallergic Rhinitis, Betul Sin and Alkis Page7 7 Pathophysiology Of Rhinitis Pathophysiology of Allergic and NonallergicPowerpoint Rhinitis, Betul Sin and Alkis Togias Templates Page8 8 • Aging process altered lymphocyte response to specific antigen and diminished IL-2 • Imbalance in Th1/Th2 with a shift toward Th2 • This is somewhat of a paradox since the incidence of allergic rhinitis declines with age • The diminished T-cell response may be associated with the increased incidence of malignancy and infections in the geriatric population Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 9 Alteration in Nonspecific host defense • Age-related effectiveness in chemotaxis may be reduced in less vascular tissues in vivo, such as in the skin, which also has a number of other changes that may impair the ability of cells in the vascular compartment to reach a site of infection Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 10 Number and phagocytic capacity are preserved but in vitro neutrophil functions is reduced Endothelial adherence migration Granule secretion Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 apoptosis 11 • Alterations in signal transduction of TLR and GM-CSF receptors → defective function of neutrophils with decreased response to stimuli such as infection with gram positive bacteria • With aging Defective production of cytokines Diminished expression of MHC class II molecules Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 12 Alteration in Specific Host • Most studies show no significant changes with human aging in the total number of peripheral blood cells, including total lymphocytes, monocytes, NK cells, or PMN leukocytes • No changes in the percentages of B- and Tlymphocyte populations in the peripheral blood Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 13 Qualitative changes in T-cell function Aged → Decreased thymic function Changes in thymic dependent immunityadaptive T-cell immunity Increase in inert memory lymphocytes A relative expansion of the memory T-cell pool 14 Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 Naive CD4+ T cells isolated from aged humans Decreased in vitro responsiveness and altered profiles of cytokine secretion to mitogen stimulation Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 15 Decreased Increased Thymic output Naive peripheral T-cells Diversity of T- and B-cell Co-stimulatory stimuli to T-cells CD28+ T cells CD45+ T cells IL-2, INF-γ, IL-12, IL-10, IL-13 Proliferation with mitogens Delayed type hypersensitivity Response to vaccination Memory T and B cells Oligoclonal expansion of memory lymphocytes CMV specific CD8+/CD4+ T cells CD45 RO+ T cells CD28- T cells IL-6, SCF+, LIF Anergic T cells Fillit M, Howard, et all, Geriatric medicine and gerontology, 2010 16 Histology of Nasal Mucosa Probst R. Grevers G, Iro H. Basic Otorhinolaryngology: A Step–By-Step Learning Guide. New York :Thieme. 2006:8-13. 17 • The normal respiratory epithelium is described as pseudostratified ciliated columnar with patchy areas of squamous metaplasia and goblet cell hyperplasia covered by blanket of mucus • Ciliated epithelium decrease with age • Thin atrophic epithelium with conspicuously thickened basement membranes is only seen above the age of 40 years and is frequently found in older subjects S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle turbinate, 2003 18 In the middle aged group (26 to 50 years) we found a remarkably high amount of squamous metaplasia, resulting in overall thicker epithelium becoming thinner in older subjects S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle turbinate, 2003 19 Age related decrease ephitelium S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle turbinate, 2003 20 Reduced epitheleal differentiation Lead to reduction ciliary mucus clearence 21 Maria Teresa Ventura, MD et all, Clinical and cytologic charateristics of allergic rhinitis in eldery patients. 2012 • These include atrophy of the collagen fibers and mucosal glands, loss of dermal elastic fibers, and reduced blood flow to nasal tissues • These changes can result dehydrated, drying, increased nasal congestion, and nasal crusting in elderly patients. Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 22 Stratified ciliated epithelium in a 24-year-old subject Disintegrating epithelium in healthy 37-year-old subject S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle turbinate, 2003 23 An atrophic epithelium in a 55-year-old subject S. Sophia, Histological evaluation of age related changes in human respiratory mucosa of the middle turbinate, 2003 24 AGING Body water content Nasal glandular atropy Nasal mucociliary dysfunction Thick tenacious mucus in nose and nasopharynx Post nasal drip Chronic cough Nasal obstruction Nasal crusting Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 25 Trigger of Allergic Rhinitis Allergens Aeroallergens mites, pollens, animal danders, insects, plant origin, moulds Food allergens: milk, egg, wheat, soya Occupational rhinitis rare Aspirin allergy Pollutants Indoor air pollution domestic allergens, indoor gas pollutants (tobacco smoke) Outdoors air pollution Automobile pollution 26 Effects of rhinitis on Quality of life • Allergic rhinitis can result in significant sleep disturbance and fatigue • Complaints of poor sleep are already common • Lack of sleep can alter physiologic processes such as glucose metabolism, cognition, appetite control Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 27 Quality of Life Maria Teresa Ventura, MD et all, Clinical and cytologic charateristics of allergic rhinitis in eldery patients. 2012 28 Diagnostics History Allergy history vital Family history of atopic disease Environmental history Any treatment given Krouse J., Derebery J., Chadwick S., Managing the allergic patient, Elsevier, 2008 Updated ARIA Recomendation 2008 29 Physical Examination Rhinoscopy Anterior Ear • Concha hypertophy • Mucosa livid • Mucous serous • Otitis media • Otitis media effusion 30 Nasoendoscopy Rigid / Flexible fiber optic endoscope. 3rd Step 1st Step 2nd Step Inferior Concha – Nasopharynx Middle Concha and Middle meatus Superior concha, resesus sphenoethmoida lis, resessus frontalis Allergen Testing: IgE, Skin Prick Test 31 MANAGEMENT 32 Therapeutic considerations Allergen avoidance indicated when posibble Pharmacotherapy Surgery Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the Clin Immunology. 2008 geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. Immunotherapy 33 Antihistamines • First-generation H1 receptor antagonists liphophilic and can easily penetrate the blood brain barrier • Produce adverse effect in the CNS dyskinesia, anxiety, confusion, sedation, and reduced mental allertness • AH first generation lack of specifity for the H1 receptor, have additional dopaminergic, serotonergic, muscarinic and cholinergic adverse effect Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral Antihistamine, 2005 the allergic patient, Elsevier, 2008 34 Muscarinic/ cholinergic effect α-adrenergic effects • Urinary retention & hesistancy, constipation, sedation, impaired coordination and memory dysfunction • Arrythmia, peripheral vasodilation, postural hypotension, tachycardia, dizziness AH second generation low potential to cross the blood brain barrier and have antiinflamatory effect Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral Antihistamine, 2005 the allergic patient, Elsevier, 2008 35 Antihistamine Drug Special Adverse Effect Contraindications Cetirizine Cephalalgia, vertigo, agitation, sleepiness, xerostomia, urinary retention Severe renal dysfunction Loratadine Alopecia, liver dysfunction Other medication inhibiting loratadine liver metabolism Terfenadine Tachyarrhytmia, cardiac arrest, GI complaints, elevated transaminase, cholestasis, hepatitis, alopecia Decreased liver function Ebastine Cephalgia, xerostomia, Severe hepatic or renal dysfunction Fexofenadine Cephalgia, dizzines and nausea Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral Antihistamine, 2005 the allergic patient, Elsevier, 2008 36 Drug Special Adverse Effect Contraindications Azelastine Xerostomia, sleepiness Severe hepatic or renal dysfunction Levocetirizine Cephalgia, sleepiness, xerostomia Lactose intoleralnce, Desloratadine Sedation, xerostomia, cephalgia Severe renal dysfunction Newer second-generation antihistamines such as fexofenadine, levocetirizine, ebastine and desloratadine have the least adverse effects and are therefore preferred in the elderly patient. Juga Hansen, et allPharmacological Management of Allergic Rhinitis in the Elderly Safety issues with oral 37 Antihistamine, 2005 the allergic patient, Elsevier, 2008 Decongestant Oral decongestant • Activate adrenergic receptors reduce nasal swelling reducing nasal congestion • commonly used agent is pseudoepherine. Central nervous system stimulation by these agents may result in anxiety, irritability, insomnia, and palpitations • These drugs may aggravate urinary with bladder neck obstruction cautiously in the elderly and should be avoided in patients with poorly controlled hypertension, coronary artery disease, cerebralvascular disease, and bladder neck obstruction • Combined with antihistamine more effective than alone Topical decongestant • Rebound effect (Rhinitis medicamentosa) Raymond G Slavin, Treating rhinitis in the older population : special consideration. 2011, Managing the allergic patient, Elsevier, 2008 38 Corticosteroid • Intranasal steroids have become first-line treatment for moderate to severe allergic rhinitis and effectively treat all symptoms of rhinitis • Intranasal steroids are generally well tolerated by older patients however, they can aggravate nasal dryness, epistaxis, and mucosal crusting in geriatric patients careful instruction in use Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 39 Anticholinergik & Leukotriens • Leukotriene receptor antagonists (e.g. montelukast, zileuton)decrease the inflammatory response in allergic rhinitis and limit symptoms of congestion sneezing, and rhinorrhea • Long-term data has not been reported to determine safety of leukotriene inhibitors in the older patients, yet these medications seem to be well tolerated in this population Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 40 Anticholinergik & Leukotriens • Intranasal cromolyn sodium can be effective in minimizing allergic rhinitis symptoms • This agent inhibits the degranulation of sensitized mast cells thereby preventing the release of mediators of the allergic response and inflammation Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 41 Immunotherapy Immunotherapy can be considered in the treatment of patients of all ages, and the risk/benefit assessment must be evaluated in every situation Some patients might be taking medications that could make treatment of anaphylaxis with epinephrine more difficult or have significant comorbid medical conditions β-blockers Hypertension, coronary arter disease, cerebrovascular disease, and/or cardiac arrhythmias 42 Calabria C, et all. Allergen Immunotheraphy : A practise parameter third update. 2004 Background • The role of specific immunotherapy (SIT) in elderly allergic patients is still debated Objection • To assess whether SIT is associated with a better control of symptoms and a better quality of life also in older allergic patients Method • The effect of injection SIT was assessed in patient >54 yo and <54 yo → SIT → measure of SIT outcome Result • Patients submitted to SIT reported a much better quality of life and an improved symptom control by standard therapy, as shown by the reduced use of standard therapy Conclusion • Injection SIT can be considered an effective therapeutic option in otherwise healthy elderly patients with a short disease duration whose symptoms cannot be adequately controlled by drug therapies alone 43 Asero R, Efficacy of injection Imunotheraphy with Ragweed and Birch Pollen in Elderly Patients, 2004 Surgery . Surgical treatment is also an option in the geriatric population septoplasty with or without inferior turbinate reduction has been shown to be beneficial in older patients Functional endoscopic sinus surgery can be used to address concomitant sinus disease. Jayant M Pinto and Seema Jeswani, Allergic Rhinitis in the geriatric population ,Allergy Asthma Clin Immunol. 2010; 6(1): 10. 44 • ESS in elderly population have complication was higher than in younger population despite it is relatively safe procedure even in the elderly population with a low incidence of complication 45 Ramadan H, Hasan, VanMetre Ray, Endoscopic Sinus Surgery In Geriatric Population. 2003 • Both elderly and younger patients showed improvement and Quality of Life after ESS did not differ by age group Douglas D. Reh, et all, Impact of age on presentation of Chronic rhinosinusitis and outcomes of endoscopic sinus surgery.2006 46 Conclusion • Aging rhinitis is common disorder in the elderly and result from natural aging process in the nose. • Prevalence rhinitis allergic decrease with aging proces, increased malignancy and infection • The structure and function of the aging nos emay contribute to the manifestation and mechanism of this condition • Allergic rhinitis in elderly population have a higher effect on quality of life than young adult 47 • Management allergic of rhinitis in elderly such as avoidance allergen, pharmacotherapy, immunotheraphy and surgery • the management is different with young people, need special management, due to changes in physiologic 48 Thank you 49
