Diagnosis and treatment of allergic rhinitis
Allergic rhinitis refers to chronic inflammation of the nasal mucosa following allergic or atopic individual exposure to allergens mediated by IgE-mediated release of mediators and involving multiple immunoreactive cells and cytokines. This lesson introduces the definition, classification, complications of allergic rhinitis and the causes of its increased incidence, and focuses on the diagnosis and treatment of allergic rhinitis.
I. The new WHO classification of allergic rhinitis
The new WHO classification of allergic rhinitis is intermittent, which means the number of days of symptoms per week is less than 4 days or the duration of the disease is less than 4 weeks; persistent, which means the number of days of symptoms per week is more than 4 days or the duration of the disease is more than 4 weeks; mild, which means normal sleep and daily activities of work and study are not affected; and moderate, which means the patient’s sleep and daily activities are affected.
Definition and classification of allergic rhinitis
Allergic rhinitis is a chronic inflammation of the nasal mucosa caused by IgE-mediated release of mediators and the involvement of a variety of immunologically active cells and cytokines after exposure to allergens in allergic individuals or atopic individuals. In order to suit the actual situation in China, the traditional classification is combined with the WHO recommended classification, which is divided into four types: seasonal intermittent, seasonal persistent, perennial intermittent and perennial persistent. Seasonal allergic rhinitis or hay fever has basically the same season of onset every year, and it corresponds to the pollination period of the allergenic pollen, with onset in the same season for at least two years. Perennial allergic rhinitis has allergic symptoms for more than half of the year. Mild to moderate is implemented in accordance with WHO regulations, changing the past rule of using the high or low score as the grading standard.
III. Reasons for the increase in the incidence of allergic rhinitis
Allergic rhinitis has a high incidence and an increasing trend. The reasons for the increase are: one is genetic factors, allergic rhinitis has a family history, and the incidence is different between those with a family history and those without; secondly, environmental factors, such as pets, pollen, dust mites, molds, etc.; again, passive exposure to allergens, such as passive smoking, particles from motor vehicle exhaust; the increased incidence is also related to the modern Western lifestyle and The first is air pollution, the second is food pollution, and the third is pollution of the mind, the stress of life and psychological tension can cause an increase in allergic rhinitis.
Allergic rhinitis is a global health problem, accounting for 10% to 25% of the world’s population, with nearly 500 million people worldwide suffering from allergic rhinitis. The prevalence in China is 6.32% and the incidence of telephone interviews is 11.1%. Seven scientists who have studied allergic rhinitis have won the Nobel Prize. According to the statistics of the United States in 2002, the direct and indirect losses caused by allergic rhinitis exceeded 12 billion dollars per year.
Fourth, the complications of allergic rhinitis
Allergic rhinitis can cause many complications, such as allergic conjunctivitis, nasal polyps, sinusitis, exudative otitis media, and life-threatening asthma. Patients with allergic rhinitis are more likely to develop asthma. 80% of asthma patients are caused by allergic rhinitis, while 40%-50% of allergic rhinitis can develop into asthma.
V. Diagnosis and differential diagnosis of allergic rhinitis
The diagnosis of allergic rhinitis is mainly based on medical history, symptoms and signs. The history is whether there is a family history or a history of asthma attacks; the symptoms are nasal itching, sneezing, nasal discharge must have three of the four; signs are nasal mucosa pallor, edema, polyps. The next step is to look for allergens. Again, laboratory tests, a large number of eosinophils and basophils in nasal secretions, increased eosinophils in peripheral venous blood, and increased eosinophils in conjunctival scrapings further support the diagnosis of allergic rhinitis. There is also pathology, with increased eosinophils, mast cells or basophils.
There are two ways to find allergens, in vivo and in vitro. In vivo includes punctures, spot patches, etc. The in vitro ones are blood sampling, excitation test of nasal mucosa or excitation test of conjunctiva. The purpose of allergen search is to avoid exposure to allergens and secondly to desensitize. Desensitization is most effective when one or two allergens are at ++++ or ++++.
The differential diagnosis of allergic rhinitis includes non-allergic eosinophilic rhinitis, aspirin intolerance triad, vasomotor rhinitis and cerebrospinal fluid nasal fistula, especially aspirin intolerance. Asthma attacks in people who take aspirin or Valium tablets, Anacin or drugs containing aspirin are aspirin intolerant, so people with allergic rhinitis or asthma try not to use drugs containing aspirin ingredients.
Abnormalities in the nasal structure, such as deviated nasal septum, scars, adhesions, nasal septum perforation, nasal foreign bodies, etc., can aggravate allergic rhinitis.
VI. Treatment of allergic rhinitis
The World Health Organization issued guidelines for the diagnosis and treatment of allergic rhinitis and formed the ARIA working group on allergic rhinitis and its impact on asthma, which came out with the first edition in 2001 and was revised in 2008.
The treatment strategy for allergic rhinitis consists of five aspects, the first of which is improving immunity, the second is patient education, the third is allergen avoidance, the fourth is anti-allergy, and the fifth is desensitization, with desensitization being the theoretical radical cure.
(i) Improving immunity
Improving one’s immunity includes physical exercise, acupuncture, tui na, massage, food therapy, and medicine.
(II) Education of patients
Many patients with allergic rhinitis are afraid of hormones and often refuse to use them or stop using them for a period of time, but hormone therapy is very effective. There are also patients who cannot insist on taking anti-allergy drugs and stop taking them when their symptoms disappear, and there are patients who are afraid of spending money, in addition to long-term use of a drug that causes drug resistance. So patient education is very important.
(iii) Avoid allergens
Such as cleaning, clean living environment, avoid eating allergic food, avoid contact with allergic environment.
(iv) Anti-allergy
The stepwise program of anti-allergic rhinitis treatment recommended by the World Health Organization gives a stepwise program according to different degrees of mildness, including medical medication and surgical procedures.
In 2008, the ARIA working group made a revision, and the main elements of the revision are that nasal hormones are the first-line drugs for the treatment of moderate to severe allergic rhinitis, antihistamines and H1 receptor blockers are available, and antagonists of leukotrienes are particularly important for patients with asthma with allergic rhinitis. Specific immunotherapy or vaccine therapy is the main treatment for allergic rhinitis, and sublingual specific immunotherapy is safe and effective.
Intranasal glucocorticoids provide comprehensive control of nasal symptoms. In comparison with intranasal chromone (disodium chromogranate), intranasal alkaline congestants, anticholinergics, antileukotrienes, oral H1 antihistamines, intranasal H1 antihistamines, and intranasal glucocorticoids, intranasal glucocorticoids are the most effective for nasal discharge, sneezing and runny nose, nasal congestion, nasal itching, and eye symptoms.
Intranasal glucocorticoids can block the symptoms of allergic rhinitis in three ways, affect the synthesis and release of inflammatory mediators, promote the synthesis of intracellular anti-inflammatory proteins, and relieve symptoms. Intranasal hormones can significantly improve the nasal symptoms of chronic sinusitis, especially nasal congestion.
There are three intranasal hormones available to control the symptoms of nasal congestion, the best being budesonide. The formulation of budesonide is special because besides the pure drug, its preservative is potassium sorbate, which does not affect cilia movement; budesonide also has a special esterification effect, after entering the nasal mucosa cells, it can play a role in the first direction and combine with long-chain fatty acids in the second direction, which can be stored and play a branched role after combining. The mechanism of budesonide is also special, because it can easily enter the cell membrane, and after passing through the cell membrane, it can enter the nucleus to play the anti-inflammatory effect. The effect of budesonide is significantly better than other intranasal hormones, and its effect on non-allergic rhinitis is obvious.
Budesonide not only treats allergic rhinitis, but also non-allergic rhinitis and vasomotor rhinitis. This intranasal hormone can significantly reduce the size of nasal polyps, facilitate surgery, and prevent recurrence of polyps. After 12 months of treatment with budesonide for chronic rhinosinusitis, their nasal mucosa largely returns to normal.
Allergic rhinitis in women with allergic rhinitis who are planning to become pregnant or have become pregnant when allergic rhinitis occurs, or when allergic rhinitis occurs during breastfeeding is a more difficult technical problem and should not be easily administered to pregnant women or women planning to become pregnant or breastfeeding. Budesonide is negative in animal tests and reproduction tests and is classified as a class B drug, called intranasal hormone of class B during pregnancy. A survey was done in Switzerland and found no effect on pregnant women with the hormone.
Nasal hormones have good safety, do not affect children’s development, do not affect adrenal cortical function with long-term use, and do not cause diabetes.
Glucocorticoids and budesonide do not contain anti-preservatives such as Freon, which are mild and non-irritating to the nasal mucosa. The preservative contained in budesonide is potassium mountain phosphate, which does not affect the movement of nasal cilia and can effectively accelerate the clearance rate of nasal cilia.
Intranasal hormones take effect very quickly, 3 hours. If you have long-term nasal congestion and chronic sinusitis, you should use the medication for a longer period of time and see the effect only after 1 month. Regarding the relief time of anti-allergy drugs, antihistamine nasal spray has a fast onset of action, but a short duration.
Leukotrienes are metabolites of arachidonic acid, consisting of leukotrienes C4, D4 and E4, which are important inflammatory mediators. Drugs in this class include montelukast sodium (cis-elastine), which is taken orally once a day, one tablet at a time.
(v) Desensitization therapy
Desensitization therapy is similar to injectable vaccine. In 1911, scholars in England first applied allergen infusion subcutaneously to treat hay fever, which was introduced to the United States after 1915, and was the first to standardize allergens in Europe in 1980, which was summarized by the World Health Organization in 1998. Desensitization, also known as immunotherapy, specific immunotherapy, and vaccine therapy, is based on the principle that a small amount of allergen extract is hit into the body intermittently and regularly, so that the patient develops specific tolerance and no more allergies occur. Depending on the route of administration, they can be divided into two categories: subcutaneous specific immunotherapy and non-injectable specific vaccines. Non-injectable vaccines include local specific vaccines and systemic specific vaccines, and local specific vaccines include sublingual specific vaccines, oral specific vaccines, intranasal specific vaccines, and intratracheal specific vaccines. Subcutaneous vaccines can be divided into two types according to the speed of injection, a conventional specific vaccine and an accelerated specific vaccine. The conventional specific vaccine is divided into an initial phase and a maintenance phase, with the initial phase taking approximately 6 months and the maintenance phase taking 1-3 years. Accelerated atopic vaccines are further divided into two types: the organism-specific vaccine vaccine, which can be shortened to 1-2 months, and the maintenance phase, which can be maintained for 1 year or 6 months; and the other is the shock atopic vaccine, which can be desensitized in about 3 months.
New advances include allergen-like vaccines, vaccines with allergen peptide fragments, vaccines with cytokines or immunostimulatory sequences, specific immunotherapy with the combined application of anti-IgE antibodies, and DNA vaccines for allergens. Indications for specific vaccine therapy include a history of allergic rhinitis with a clear allergen, typical symptoms, skin prick test ++, specific IgE class II or higher, and age 5 to 70 years, but some people can do it at age 4. Whether vaccines for allergic rhinitis can be used in newborns is under investigation. Contraindications to specific immunotherapy include a history of severe immunodeficiency or during malignancy, long-term use of adrenal hormones, long-term use of beta-blockers, severe asthma attacks, severe rhinitis, during pregnancy, and periods of high psychological expectations or psychological imbalance.
The standardization of allergen extracts was carried out earlier in foreign countries, and allergen preparations are highly standardized and expensive. In China, it was carried out later, and allergen extracts are crude extracts with low standardization, and China has a vast territory and many races, so the variety of foreign allergens is limited and not suitable for Chinese people. The State Food and Drug Administration of China has now approved vaccine treatment for mites, with one box available for 4 months in the initial phase and 7 months in the maintenance phase.
The process of injection is to first assess and inform, sign an informed consent form, then conduct a strict three-checking and seven-checking, prepare first aid equipment and drugs such as air compression pump (oxygen bag) or compression pump epinephrine, salbutamol, etc., stay for more than two hours after vaccination, check peak flow rate, inform precautions for 24 hours, agree on the next injection time, concentration, etc., enter the data into the database, and leave a 24-hour emergency telephone number.
From March 2006 to December 2008, we conducted 2,655 skin prick experiments, from which 198 patients with strong positive reactions were selected for vaccine treatment. 13 cases have completed the initial and maintenance phases of full desensitization treatment for 21-32 months, with complete disappearance of symptoms; another 13 cases have completed initial desensitization, with 6 cases of significant improvement in symptoms and no recurrence cases at present, and another The remaining 157 cases are still under desensitization treatment. 198 cases, 110 males and 88 females, aged 6-66 years, with a disease duration of 1 to 40 years, all had moderate to severe allergic rhinitis, with an initial stage of 11 months, a maximum of 1-2 years, and a maintenance stage of 1-1.5 years.
Among the 198 cases of desensitization, there were 37 cases of severe local skin redness and itchiness, 13 cases of eye redness and itchiness, 3 cases of generalized rash, 1 case of generalized rash with severe diarrhea, and a large head rash, which was relieved by oral antihistamines and dilution of the concentration before vaccination. 198 cases did not have bronchitis, anaphylaxis, aggravation of asthma or even death.
The Capital Ear Institute studied 115 pediatric patients, including 90 males and 25 females, 19 children aged 4-6 years, 81 children aged 7-12 years, and 15 children aged >12 years. The results of the study were: two cases ended, 26 cases in the initial phase, 84 cases in the maintenance phase, one case transferred, and two cases shed. 18 of the 84 cases were ≥2 years, 40 cases were 1-2 years, and 26 cases were 21-50 weeks. ROSS et al. summarized the results of 16 randomized blinded specific treatment trials over a 30-year period from 1966 to 1996, in which 51% of patients in the experimental group had reduced symptoms after treatment, compared with 27% in the control group.
A European case-control study found that vaccine treatment significantly improved symptoms after treatment and also prevented children from developing asthma, so vaccine treatment is effective in both children and adults. Vaccine therapy is more effective in stopping the onset of asthma at an early, young age and with mild symptoms. The safety of cluster immunotherapy and conventional immunotherapy is comparable. The effectiveness of shock vaccine therapy can reach 36%-38%, but its safety is not certain. Reasons for failure of vaccine therapy include acute asthma attacks, variety of allergens, lack of transportation, financial problems, poor compliance, insufficient information, and doubts about the effectiveness of treatment.
A certain dose of specific allergen is placed under the tongue and swallowed after 1-2 minutes, which is absorbed quickly and avoids degradation in the gastrointestinal tract, with an efficiency of 70%. It was first used in 1900, with better efficiency and safety, and is convenient and easy to use, and is now widely used in Europe, while China is currently in the initial stage.
The standardization of vaccines includes raw materials and production (collection, storage, extraction, purification), calibration methods, purity, potency, etc. The International World Health Organization considers vaccine treatment to be more cost-effective and worth promoting. Since the effect varies greatly due to different allergen types, purity, potency, and duration of treatment, and individual patients have severe allergic reactions, 8 million people received vaccine treatment in North American countries from 1990 to 2001, and 41 patients died, special emphasis should be placed on safety, indications and contraindications should be strictly mastered, emergency preparations should be made at all times, subcutaneous injection should be observed for at least 2 hours, puncture should be at least The patient should be observed for at least 30 minutes, the patient should be checked again before leaving and the maximum expiratory flow should be measured, if there is a 10% decrease salbutamol aerosol should be inhaled and oral fast-acting antihistamines should be administered.
Allergic rhinitis is divided into four types: seasonal intermittent, seasonal persistent, perennial intermittent and perennial persistent, and its incidence is high and increasing. The diagnosis is based on history, symptoms, signs, finding allergens, laboratory tests, pathology, etc. Treatment strategies include, improving immunity, patient education, allergen avoidance, anti-allergy, desensitization five aspects, desensitization is theoretically the radical cure.