niezen: allergie of huis-tuin en keukensnottebel · sar: symptoms restricted to spring and/or...

Neus-, keel- en oorheelkundeHoofd- en halschirurgie

Niezen: allergie of huis-tuin en keukensnottebel

Prof. Dr. Philippe Gevaert

Dienst Neus-, keel- en oorheelkundeAllergienetwerk UZ-Gent


Casus 1: man 35 j, verstopte neus, moeilijk slapen en snurken



Casus 2: vrouw 55 j, waterige neusloop links




Casus 3: vrouw 28 j, waterige neusloop,niezen,tranende ogen, tintelende lippen bij eten appel,nachtelijke hoest van maart tot mei


Prevalence of Allergic Rhinitis in the EU

28,5%26,0% 24,5%

21,5% 20,6%

16,9%

BELGIUM U.K. FRANCE SPAIN GERMANY ITALY

Base: Total sample, Belgium (n=1602), UK (n=1625), France (n=1606), Germany (n=1613), Italy (n=1600), Spain (n=1600) Bauchau and Durham. Eur Respir J. 2004;24:758.


1973 1977 1981 1986 1989 1993

1816141210

8642 0

Allergic RhinitisAtopic Eczema

AsthmaContact Eczema

Prevalence of Allergic Disease in 18 Year Old Conscripts 1973-1993

Aberg et al, Clin Exp Allergy 1995


Environment

‘Developing’ countries

Large family size

Rural homes, livestock

Intestinal microflora-variable

Low antibiotic use

High helminth burden

Poor sanitation, high orofecal burden

’Westernized’ countries

Small family size

Affluent, urban homes

Intestinal microflora-stable

High antibiotic use

Low/absent helminth burden

Good sanitation, low orofecal burden

GenesNon-allergic Allergic

“Old friends theory” or “Hygiene Hypothesis”

Adapted from Wills-Karp et al, Nature Rev Immunol 2001


| | | | | | | | | | | | | |1 2 3 4 5 6 7 8 9 10 11 12 13 14

YEAR

30

20

10

7

P=0.02 One or no sibling and no day careTwo or more sibling or day care

P=0.02P=0.04

Per

cent

age

of C

hild

ren

with

Fre

quen

t Whe

ezin

g

N = 1246 children

Ball TM et al., 2000

Day Care and Number of Siblings


The Increasing Prevalence of Allergy

Trends in asthma, allergic rhinitis and

eczema among Swedish conscripts from

farming and non-farming environments. A

nationwide study over three decades.

(N= 1 309 652 male conscripts)

Bråbäck L, Hjern A, Rasmussen F.

Clin Exp Allergy. 2004 Jan;34(1):38-43.


Farmer’s Children

1620 children; 307 children of farmers

Adjusted ORs 0.34 Hayfever

0.31 Allergy

0.77 Wheeze

0.86 Eczema

Braun-Fahrlander et al. Clin Exp Allergy 1999


Clin Exp Allergy 2009

Mijnworm:protectief

Ascaris: exacerbatie


• Infectious diseases are still a significant threat and cost to the society

• Defence against infectious disease should not be undermined

• Hygiene standards need to be maintained

Hygiene Hypothesis: Drawbacks


Meta-analyses of 6 prevention and 4 treatment clinical trials indicate that current evidence favors the use of probiotics for prevention but not for treatment.

JACI 2008


Bousquet J, Van Cauwenberge P, et al. 2001

ARIA Update Allergy. 2008 Apr;63: 8-160

Bousquet J, et al. JACI 2001; Sibbald B, Rink E. Thorax 1991; Leynaert B, et al. JACI 1999; Brydon MJ. Asthma J 1996

Up to 80% of all asthmatic patients have allergic

rhinitis

All asthmatic patients

Coexistence Asthma – Allergic Rhinitis


20-40%of patients with allergic rhinitis have asthma


Fireman P. Allergy and Asthma Proc 2000


0

2

4

6

8

10

12 pos SPT (n=189)

neg SPT (n=501)

SAR or PAR (n=162)

No AR (n=528)

Asthma%

At follow –up (23 years later)

At diagnosis

Allergic rhinitis as a risk factor of asthma: ↑ risk x 3

Settipane, Allergy Proc 1994

Allergic Rhinitis: Risk Factor for Asthma Development


RAST: Radio-Allergo-Sorbent Test


Skin Prick Test


Clinical assessment of rhinitis

Neus‐, keel‐ en oorheelkundeHoofd‐ en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie

Shedden. Treat Respir Med. 2005;4:439.

Nasal congestion and Allergic Ocular Symptoms Are Bothersome

48

18

18

13

12

7

7

4

58

19

20

9

9

4

4

3

0 10 20 30 40 50 60

Nasal congestion

Itchy eyes

Runny nose

Itchy palate

Sneezing

Watery eyes

Itchy ears

Itchy nose

Symptom of AR Rated as the Most Bothersome

Respondents (%)

AdultsChildren


ARIA Classification

Moderate-severeone or more items

. abnormal sleep

. impairment of daily activities, sport, leisure

. abnormal work and school

. troublesome symptoms

Persistent . ≥ 4 days per week. and ≥ 4 weeks

Mildnormal sleep

& no impairment of daily activities, sport, leisure

& normal work and school

& no troublesome symptoms

Intermittent . < 4 days per week. or < 4 weeks

in untreated patients


Persistent33%

Intermittent67%

N=1,265 subjects with physician-based diagnosis SAR: symptoms restricted to spring and/or summer

PAR51%

SAR49%

SAR/PAR ARIAstudy step 1 (N=1,230)

Allergic rhinitis classifications Prevalences are different

Bauchau et al, Eur Respir J 2004


Strength of evidence for rhinitis treatments

Intervention SARAdult

SARChildren

PARAdult

PARChildren

PER

Oral anti-H1 A A A A ANasal anti-H1 A A A A A*Nasal GCS A A A A A*Nasal cromone A A A A A*Antileukotriene A A (>6y) A A A*Subcut SIT A A A ASublingual SIT A A A AAnti-IgE A A (>12y) A AHomeopathy D D D DAccupuncture D D D DPhytotherapy B D D DAllergen avoidance D D D D

2008 Update

afgeleide evidentie *


Measure Evidence of effect on allergen levels Evidence of clinical benefit

HOUSE DUST MITES

Encase bedding in impermeable covers Some None (adults): Evidence ASome (children): Evidence B

Wash bedding on a hot cycle (55–60°C) Some None: Evidence AReplace carpets with hard flooring Some None: evidence AAcaricides and/or tannic acid Weak None: Evidence AMinimize objects that accumulate dust None None: Evidence B

Use vacuum cleaners with integral HEPA filter and double-thickness bags Weak None: Evidence B

Remove, hot wash or freeze soft toys None None: Evidence B

PETS Remove cat/dog from the home Weak None: Evidence B

Keep pet from main living areas/bedrooms Weak None: Evidence B

Use HEPA-filter air cleaners Some None: Evidence BWash pet Weak None: Evidence BReplace carpets with hard flooring None None: Evidence B

Use vacuum cleaners with integral HEPA filter and double-thickness bags None None: Evidence B

SET OF ALLERGEN CONTROL MEASURES Some Some: Evidence B

Effectiveness of avoidance measures in rhinitis and asthma for certain indoor allergens

Neus-, keel- en oorheelkundeHoofd- en halschirurgie Philippe

Molds

Ensure dry housing

Use ammonia to remove mold from bathrooms and other wet spaces

Allergen Avoidance & Environmental Control


Pollenkalender

Pollen zijn moeilijk te vermijden!


050

100150200250300350400450500

18.0

3.98

26.0

3.98

03.0

4.98

11.0

4.98

19.0

4.98

27.0

4.98

05.0

5.98

13.0

5.98

21.0

5.98

29.0

5.98

06.0

6.98

14.0

6.98

22.0

6.98

30.0

6.98

08.0

7.98

16.0

7.98

24.0

7.98

01.0

8.98

09.0

8.98

0

0,5

1

1,5

2

2,5

Berk Gras mean 5-6 Cetirizine mean 5-6 FP

Eye symptomsred eyes, itching eyes

Pollen/m³/day VAS

Topical Corticosteroid vs oral antihistamine


050

100150200250300350400450500

18.0

3.98

26.0

3.98

03.0

4.98

11.0

4.98

19.0

4.98

27.0

4.98

05.0

5.98

13.0

5.98

21.0

5.98

29.0

5.98

06.0

6.98

14.0

6.98

22.0

6.98

30.0

6.98

08.0

7.98

16.0

7.98

24.0

7.98

01.0

8.98

09.0

8.98

00,511,522,533,544,55

Berk Gras mean 1-4 Cetirizine mean 1-4 FP

Total nasal symptomssneezing, rhinorrhoe, itching nose, obstructionPollen/m³/day VAS

Topical Corticosteroid vs oral antihistamine


33

*P<0.001 vs placebo.Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64. Pe

rcen

t cha

nge

in p

atie

nt-r

epor

ted

cong

estio

n sy

mpt

om s

core

from

bas

elin

e Days

**

**

* * **

* * * * * *

Nasal GCS – Pooled Analysis of 4 SAR TrialsPercent Change in Congestion Symptom Score (Patient-Reported)

Nasal GCS in Patients with SAR


Nasal GCS vs Oral H1 Receptor AntagonistsWeiner JM, et al. BMJ 1998; 317: 1624-9


sneezing rhinorrhea nasal nasal eye Asthma

obstruction itch symptoms

H1-antihistamines

oral ++ ++ 0 to + +++ ++ +

intranasal ++ ++ + ++ 0 +

intraocular 0 0 0 0 +++ 0

Nasal Corticoids +++ +++ +++ ++ ++ +

Anti-leukotrienes ++ ++ ++ ++ + ++

Cromones

intranasal + + + + 0 -

Intraocular 0 0 0 0 ++ -

Decongestants

intranasal 0 0 ++ 0 0 -

oral 0 0 + 0 0 -

Anti-cholinergics 0 +++ 0 0 0 -

Immunotherapy ++ ++ ++ ++ ++ +

Medications of allergic rhinitis - ARIA


Immunotherapie in de praktijk

• doeltreffend subcutane IT: bewezen

• juiste keuze patiënten!!!

Terug van weg geweest


Long-Term Efficacy of Grass-Pollen IT

Durham et al., NEJM 1999


Specific immunotherapy reduces the risk of developing asthma

In children with moderate/severe allergic rhinitis 3-year follow-up (N=151)

Möller C et al. J Allergy Clin Immunol 2002; 109: 251–256SIT Control

% o

f pat

ient

s

Odds ratio 2.52

0102030405060708090

100No asthma Asthma

N=19

N=40

N=32

N=60

N=40


Immunotherapie: duur van de behandeling

Effecten pas meetbaar na ½ tot 1 jaar

Indien dan geen duidelijk effect → therapie heroverwegen

Indien wel effect → minimaal 3 jaar therapie voortzetten→ liefst 5 jaar therapie voortzetten

Duur effect? - Mogelijk langer dan 15-20 jaar


Immunotherapie in de praktijk

• doeltreffend subcutane IT: bewezen

• juiste keuze patiënten

• effect op nieuwe sensibilisatie en astma

• veilig SCIT bij juiste voorzorgsmaatregelen

• steeds 30 min observatie

• steeds epipen en liefst reanimatie-trousse

• Toekomst: sublinguale Immunotherapie

kaf van het koren scheiden!

Terug van weg geweest


Rhinitis treatmentimproves asthmaEVIDENCE A

++ Anti-IgE mAbLeucotriene modifiersImmunotherapyNasal GCS

0 Antihistamines

Revised GINA 2006: Rhinitis treatment




Casus 3: vrouw 28 j, waterige neusloop,niezen,tranende ogen, tintelende lippen bij eten appel,nachtelijke hoest van maart tot mei


Allergienetwerk UZ-GentCentraal allergienummer: 09 332 67 08.

Sectoroverschrijdende zorg voor patiënten met allergieCoördinatie: Prof Dr Philippe Gevaert, Prof Dr Claus BachertCentraal contact voor afspraken: Mevr. Katrien Blomme 09/332 67 08

Neus-Keel-oorheelkunde: Prof Dr Philippe Gevaert - immunotherapie aeroallergenencontact: Mevr. Katrien Blomme 09/332 67 08

Longziekten: Prof Dr Guy Brusselle - immunotherapie wespen en bijencontact: 09/332 26 11

Huidziekten: Dr Hilde Lapeere - Dr Annelies Stockman diëtiste : Mevr. Sabina VereeckenContact: Myriam Francois 09/332 22 87

Dienst Kindergastro-enterologie: Prof . Dr. M. Van Winckel - Dr. S. Van Biervliet diëtiste : Mevr. Sabina Vereecken Contact: 09/332 24 30

Dienst Kinderlongziekten: Prof. Dr. F. De Baets - Dr. F. HaerynckContact: 09/332 24 30

Spoedgevallendienst/anafylaxie zorgpad: Prof Dr Peter De PaepeContact: 09/332 37 17

niezen: allergie of huis-tuin en keukensnottebel · sar: symptoms restricted to spring and/or...

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