notes by dr Claudio Italiano
cf >> Allergy management guidelines
If you are suffering from rhinitis, if you have a stuffy nose, if you have secretions and you have difficulty breathing or coughing, go to the doctor right away to get the treatment for your case. This article is only a reading and does not replace your doctor. Rhinitis is a serious condition that must be treated well, now.The diagnosis of seasonal allergic rhinitis depends to a large extent on the accuracy with which the anamnesis is conducted with regard to the frequency of rhinitis episodes coinciding with the pollination periods of the grasses, grasses or trees involved. The continuous nature of perennial allergic rhinitis from household contaminants or present in the workplace makes a correct anamnestic analysis difficult; it can exist. however, some variability in symptoms that can be related to exposure to animals, allergens of house dust mites, insects or present in the workplace (eg, latex). Patients with perennial rhinitis generally develop the symptomatology during their adult life: the disease affects the female sex more frequently and is complicated by nasal polyposis and thickening of the paranasal sinus membranes, evident from the radiological investigation. The term vasomotor rhinitis designates a condition of increased reactivity at the nasopharynx, in which a set of symptoms similar to those of perennial allergic rhinitis occur following a nonspecific stimulus; in this condition an allergic basis can not be demonstrated. Other possibilities that must be considered in the differential diagnosis are the structural anomalies of the nasopharynx, the rhinitis from exposure to irritants, the infections of the upper respiratory tract, the pregnancy with problems of nasal mucosa edema and the prolonged use topically, underneath form of nasal drops, of drugs (a-adrenergics drug rhinitis), as well as the use of particular therapeutic substances such as reserpine, β-adrenergic antagonists or estrogens Nasal polyps can be present independently of a septal obstruction nasal on an allergic basis, especially in patients with sensitivity to non-steroidal anti-inflammatory drugs and in cases of rhinosinusitis or bronchial asthma.
The most frequent side effect is local irritation of the mucosa, in which, although rarely, it can overlap a Candida infection. The local activity / systemic activity ratio of flunisolide and budesonide is much higher than beclometasone or triamcinolone, with minimal systemic absorption. During the pollen season, topical corticosteroid therapy is far more effective than that with only antihistamines, especially when there is high exposure to pollen. Therefore, if the patient does not derive adequate benefit from the full dosage of a last generation anti-H1 antihistamine, associated with maintenance doses of disodiocromoglycate and the use of an α1-adrenergic agent, the use of topical corticosteroids should be preferred. high efficacy. For the treatment of systemic symptoms, such as allergic conjunctivitis, therapy may be local or an oral antihistamine may be added. Immunotherapy, often referred to as hyposensitization, consists of a series of subcutaneous injections at gradually increasing concentrations of the allergen or allergens that are specifically responsible for triggering the symptoms. Controlled studies in a population of subjects treated for allergic rhinitis supported by allergy to ambrosia, grasses and dust mites have shown at least partial improvement of symptoms and signs. The duration of the immunotherapy goes from 3 to 5 years and can be interrupted if there are minimal manifestations for two consecutive seasons. The clinical benefits seem to be related to the administration of high doses of allergen on a weekly or biweekly basis. Patients should be observed for at least 20 minutes after administration of the allergen for help in case of anaphylaxis. Local reactions such as erythema and hardening of the injection site are not infrequent and may persist for 1-3 days. Immunotherapy is contraindicated in patients with severe cardiovascular disease or with unstable asthma; moreover, it should be used with particular caution in all patients treated with β-blockers, due to the difficulty of treating an anaphylactic reaction. The immunological characteristics of the response consist in a modest increase in specific IgE class antibodies in the early stages of treatment, followed by a plateau phase followed by a phase of progressive decrease in specific IgE with a decrease in the release of histamine by basophilic leucocytes. of peripheral blood stimulated with a fixed concentration of allergen. IgG class antibodies could significantly reduce or neutralize the amount of allergen available for interaction with the fixed mast cells; however, the most important mechanism seems to be linked to the synthesis of specific IgE. None of the individual parameters of response to immunotherapy correlate satisfactorily with the evaluation of clinical efficacy; therefore, the improvement is probably due to a complex series of events likely to include the reduction of cytokines by T cells.
Immunotherapy should be reserved only for clearly documented seasonal forms or perennial rhinitis, caused clinically by exposure to a known allergen. The nature of the triggering allergen must be confirmed by the response of 1gE allergen-specific. Furthermore, it must be documented that the symptoms of the patients are poorly controllable with attempts to remove from the allergens and with drug therapy for ineffectiveness of the drugs or for their side effects. An algorithm for the treatment of perennial or allergic rhinitis based on the specific identification of the allergen and on subsequent phases aimed at controlling the symptoms should include the following points: 1) identification of the allergen or pathogenic allergens with anamnestic examination and confirmation of the presence of IgE allergen-specific through skin tests c / o serological tests; 2) decrease in allergen exposure; 3) for mild symptoms, prophylactic treatment with administration of disodiocromoglicate or with a single dose of chlorpheniramine before bedtime; if this drug is associated with significant side effects, it can be replaced with astemizole or with terfenadine, in the absence of contraindic actions due to concomitant therapies or diseases; 4) for the most pronounced symptoms, topical use of beclometasone, which can be replaced with budesonide or flunisonide as needed up to the control of symptoms; 5) immunotherapeutic treatment in the forms refractory to the pharmacological treatment and to the removal from the allergen.
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