Oleh: Amelia Lorensia Fakultas Farmasi Universitas Surabaya 2017 ALLERGIC RHINITIS Oleh: Amelia Lorensia Fakultas Farmasi Universitas Surabaya 2017

Outline Definisi Allergic Rhinitis Tipe Allergic Rhinitis Hal yang harus diperhatikan Terapi Lama pengobatan Saat untuk merujuk ke dokter

ALLERGIC RHINITIS Nasal mucosa Gejala allergic rhinitis terjadi setelah respon inflamasi meliputi pelepasan histamin yang diawali dengan tersimpan pada nasal mucosa. Rhinitis means 'inflammation of the nose', whilst the term allergic describes 'a normal but exaggerated response to a substance'. Outline Patofisiologi

Outline Gejala

Patofisiologi Kliasifikasi

Laboratory Tests Nasal Smear. The doctor may take a nasal smear. The nasal secretion is examined microscopically for factors that might indicate a cause, such as increased numbers of white blood cells, indicating infection, or high counts of eosinophils. High eosinophil counts indicate an allergic condition, but low counts do not rule out allergic rhinitis. Tests for IgE. Blood tests for IgE immunoglobulin production may also be performed. One test is called the radioallergosorbent Test (RAST), used to detect increased levels of allergen-specific IgE in response to particular allergens. Blood tests for IgE may be less accurate than skin tests. They should be performed only on patients who cannot undergo skin testing or when skin test results are uncertain.

Imaging Tests In people with chronic rhinitis, the doctor may also check for sinusitis. Imaging tests may be useful if other tests are ambiguous. CT scans may be useful for some cases of suspected sinusitis or sinus polyps.

KLASIFIKASI ALLERGIC RHINITIS Mild : all of following : Normal sleep Normal daily activities, sport, leisure Normal wok & schol Symptoms not troublesome Moderate : One or more of the following : Abnormal sleep Impairment of daily activities, sport, leisure Problems caused at work or school Troublesome symptoms Intermittent : Terjadi <4 hari/minggu atau < 4 minggu Persistent : Terjadi >4 hari/minggu dan >4 minggu Outline Tipe

TIPE ALLERGIC RHINITIS Seasonal (hay fever) Perennial (intermittent or persistent) Occurs in response to specific allergens (pollen from tree, grasses, & weeds) present at predictable times of the year and typically cause more acute symptoms Occurs year round in response to nonseasonal allergens (e.g.,dust mites, animal dander, molds) and usually causes more subtle, chronic symptoms.

SEASONAL ALLERGIC RHINITIS Symptoms of Seasonal Allergic Rhinitis : Runny nose; congestion; sneezing Itching of the eyes, throat, nose, or roof of the mouth Watering or redness of the eyes Macam2 alergen, seperti: grass pollens, tree pollens, fungal mould spores. grass pollens tree pollens fungal mould spores Perennial

GRASS POLLENS

TREE POLLENS

FUNGAL MOULD SPORES

PERENNIAL ALLERGIC RHINITIS Terjadi ketika gejala muncul sepanjang tahun dan biasanya disebabkan house dust mite, animal dander dan feathers. Biasanya memburuk pada musim panas. house dust mite animal dander feathers Lanjut...

House dust mite Dust mites favour homes with high humidity levels and constant warm temperatures, and under these conditions mite populations explode, although there are some seasonal fluctuations. The mites are known to concentrate in high traffic areas in homes and on certain furniture items, especially beds, upholstered lounges, chairs, and in carpets with long fibres. They are attracted to these areas for food, and they feed on shed human skin scales and secretions, house dust, fungal spores, pollen grains, plant fibres, and insect scales. Dust mites dislike strong light and will take harbourage in the seams, ledges, and framework of furniture when exposed. Due to their light weight, dust mites can become airborne during activities such as bed making, and in this way can be distributed throughout the room or house.

Animal dander

Feathers

PERENNIAL ALLERGIC RHINITIS (lanjt..) Perennial rhinitis dapat dibedakan dengan seasonal rhinitis dengan menanyakan: Waktu Kejadian munculnya gejala Perennial Must know

HAL YANG HARUS DIPERHATIKAN... USIA DURASI GEJALA R P D Bahaya gejala/ berkaitan dengan kondisi Outline Terapi

1. USIA Gejala dapat dimulai pada semua usia, meskipun biasanya onset lebih sering terjadi pada anak2 dan dewasa muda (kondisi biasanya pada usia 20-30an) Biasanya px py riwayat keluarga. Kondisi sering membaik seiring bertambahnya usia Dewasa muda yang melakukan banyak aktivitas → hindari tx yang dapat menyebabkan drowsiness. Back

2. DURASI Gejala akan sering muncul pada rhinitis musiman pada saat jumlah pollen meningkat. Px dapat mengalami gejala yang mereka pikir adalah mild cold symptoms untuk jangka panjang, tanpa mereka ketahui bahwa sebenarnya adalah perennial rhinitis. Back

3. GEJALA Rhinorrhoea, runny nose Nasal congestion Nasal itching Eye symptoms Sneezing Back

4. RPD Walaupun dapat terjadi pada semua usia, tapi tidak adanya riwayat penyt. Keluarga bukan merupakan indikasi yang penting bahwa rhinitis bukan merupakan masalah. Back

5. BAHAYA GEJALA BERKAITAN DENGAN KONDISI Ketika berkaitan dengan gejala seperti tightness of the chest, wheezing, shortness of breath or coughing muncul → segera rujuk. : Bahaya serangan asma !!! Weezing Earache & facial pain Purulent conjunctivitis Must Know Terapi

TERAPI Antihistamin Dekongestan Nasal steroids Sodium cromoglicate Topikal antihistamin Outline Lama

Antihistamin Pilihan pertama untuk gejala mild, moderate, dan intermittent dari allergic rhinitis. Efektif untuk mengurangi sneezing & rhinorrhoea, tetapi kurang efektif untuk nasal decongestion. Sedatif Non sedatif Contoh: Promethazine Diphenhidramine Acrivastine (3x/hari) cetirzine (1x/hari) loratadine (1x/hari) KI : Anak2 <12 tahun Tx

Antihistamin (lanjt..) Konseling ??? Tx

Antihistamin (lanjt..) Alkohol Hypntic Sedative Efek sedatif ↑ Anxiolytics Ritonavir + non sedatif antihist → kadar ob non sedatif antihist ↑ Aprenavir/ cimetidine + loratadine → kadar ob aprenavir/ cimetidine ↑ Antihis py ef antagonis dengan betahistine Efek sedatif ↑ Tx

Antihistamin (lanjt..) Efek samping : drowsiness (terutama pd sedatif antihist) Mulut kering Blurred vision Konstipasi Retensi urin Ef samping meningkat pd px yang juga mengunakan obat dgn ef. antikolinergik (antidepressan trisklik, neuroleptics) Drowsiness refers to feeling abnormally sleepy during the day -- often with a strong tendency to actually fall asleep in inappropriate situations or at inappropriat Somnolence (or "drowsiness") is a state of near-sleep, a strong desire for sleep, or sleeping for unusually long periods (c.f. hypersomnia). It has two distinct meanings, referring both to the usual state preceding falling asleep, and the chronic condition referring to being in that state independent of a circadian rhythm. The disorder characterized by the latter condition is most commonly associated with users of prescription hypnotics, such as mirtazapine or zolpidem.e times. Tx

Antihistamin (lanjt..) Kontraindikasi: Narrow- (closed-) angle glaucoma →krn antihist dapat me↑ tek. intraokular Penyakit liver Hipertrofi prostatik Tx

Decongestants Btk sed : oral (pseudoefedrin) atau topikal Dapat juga dikombinasi dgn anntihistamin. Topikal decongestant dapat menyebabkan rebound congestion, terutama pada penggunaan jangka panjang. Tidak boleh digunakan >1 minggu. Pada bentuk sediaan eye drops? KI : Glaukoma, px yg menggunakan lensa kontak Tx

Nasal steroid Btk sed : Spray (beclometasone, fluticasone, triamcinlone) Digunakan untuk seasonal allergic rhinitis. Steroid spray digunakan untuk terapi moderate-severe gejala nasal yang terus menerus. Bekerja dengan mengurangi inflamasi yang terjadi karena aksi alergen Jika gejala muncul → px perlu untuk memahami bahwa kemungkinan perlu beberapa hari sebalum efek terapi secara penuh tercapai. Dapat digunakan pada usia >18 tahun, sampai 3 bulan. Tx

Nasal steroid (lanjt..) Efek samping: Kontraindikasi: Konseling ?? Dryness & irritation of the nose & throat Nosebleeds Kontraindikasi: Wanita hamil Glaukoma Konseling ?? Tx

Sodium cromoglicate Btk sed: nasal drops ato spray dan eye drops Dapat digunakan untuk profilaksis. Digunakan sekurang2nya 1 minggu sebelum hay fever season kemungkinan dimulai dan kemudian digunakan terus menerus. Berfunfsi sebagai penstabil sel mast Efek samping: nasal irriation Kontraindikasi: px yg menggunakan lensa kontak (karena pd eye drops → mengandung pengawet). Tx

Topikal Antihistamin Nasal treatment Eye treatment Cth :Azelastine, levocabastine BNF → tx harus dimulai 2-3 minggu sebelum hay fever season dimulai. Eye treatment Levocabastine Tx Lama

TIPS... Do not keep pets such as dog and cat at home. If you already have one and cannot give it away, try to avoid close contact. Keep it away from the living room and bedroom. Avoid fuzzy or furry toys or clothing. Do not carpet the floor. Change the linen and pillow case frequently (twice a week) and wash them in hot water (>60 degree Celsius). There are also special anti-dust mite cover for the mattress and pillow available commercially. Keep the house dry, clean and adequately ventilated. Clean the curtain and upholstery frequently. Avoid prolonged stay in dusty and polluted areas.

Indoor Protection against Allergens 1. Controlling Pets People who already have pets and are not allergic to them are probably at low risk for developing such allergies later on. When children are exposed to more than one dog or cat during their first year, they have a much lower risk for not only pet allergies but also seasonal allergies and asthma. (Pet exposure does not protect them from other allergens, notably dust mites and cockroaches). For children who have an existing allergy to pets: If possible, pets should be given away or kept outside. If this isn't possible, they should at least be confined to carpet-free areas outside the bedroom. Cats harbor significant allergens, which can even be carried on clothing. Dogs usually present fewer problems. Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, that remove allergens from skin and fur and are now available for both cats and dogs and are easier to use than wet shampoos.

Indoor Protection against Allergens (Lanjt..) Preventing Exposure to Cigarette and Cooking Smoke Parents who smoke should quit. Studies show that exposure to second-hand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children. 3. Controlling Dust Spray furniture polish is very effective for reducing both dust and allergens. Air cleaners, filters for air conditioners, and vacuum cleaners with High Efficiency Particulate Air (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. Vacuuming actually stirs up both mites and cat allergens. People with these types of allergies should avoid having carpets or rugs in their homes. For children with allergies, vacuuming should be performed when the child is not around.

Indoor Protection against Allergens (Lanjt..) 4. Bedding and Curtains Replace curtains with shades or blinds, and wash bedding using the highest temperature setting. Encase mattress and pillow in special dust mite proof covers (however, washing is very important since impermeable covers alone do not help prevent allergies). Wash pillow in water hotter than 150 F, or in cooler water with detergent and bleach. Wash sheets in blankets weekly and hot water. Avoid sleeping or lying on cushions or furniture that is cloth covered. Stuffed toys should be kept away from the bed and washed weekly as described above. Placing toys in a dryer or freezer may help but is not considered enough. Children should sleep as high off the floor as possible (avoid the bottom bunk of a bunk bed).

Indoor Protection against Allergens (Lanjt..) 5. Reducing Humidity in the House Living in a damp environment is counterproductive. Humidity levels should not exceed 30 - 50%. Fix all leaky faucets and pipes, and eliminate collections of water around the outside of the house. Dehumidify basements, but empty and clean humidifier daily with a vinegar solution. Clean often any moldy surfaces in basement or in other areas of the home. 6. Exterminating Pests (Cockroaches and Mice) Use professional exterminators to eliminate cockroaches. (One study reported that ridding a home of cockroaches and cleaning the house using standard housecleaning techniques failed to eliminate the cockroach allergens themselves.) Exterminate mice and attempt to remove all dust, which might contain mouse urine and dander. Keep food and garbage in closed containers. Keep food out of bedrooms.

Outdoor Protection against Allergens The following are some recommendations for avoiding allergens outside: Start taking allergy medications 1 - 2 weeks before ragweed season begins. Be sure to take allergy medications before going outside. If regular medications do not work, ask your doctor about allergy shots. Camping and hiking trips should not be scheduled during times of high pollen count (May and June for grass pollen and September to October for ragweed). Patients who are allergic should avoid barns, hay, raking leaves, and mowing grass. (A mask can be worn during outdoor chores to help reduce pollen exposure.) Sunglasses can help prevent pollen from getting into eyes. After being outdoors, clean off pollen residue by bathing, washing hair and clothes, and using a nasal salt water rinse.

Dietary Factors Some evidence suggests that people with allergic rhinitis and asthma may benefit from a diet rich in omega-3 fatty acids (found in fish, almonds, walnuts, pumpkin, and flax seeds) and fruits and vegetables (at least five servings a day). Some studies also suggest reducing sodium, trans fatty acids (hydrogenated fats found in commercial products and baked goods), and omega-6 fatty acids (found in most vegetable oils). Investigators are also studying probiotics -- so-called good bacteria, such as lactobacillus and bifidobacterium, which can be obtained in supplements.

LAMA PENGOBATAN Perbaikan gejala seharusnya terjadi dalam beberapa hari. Jika tidak ada perbaikan setelah 5 hari → rujuk ke dokter Outline Dokter !!

Saat untuk merujuk ke dokter Wheezing & shortness of breath Tightness of chest Painful ear Painful sinuses Purulent conjungtivitis Failed medication Nasal polyps occur in some people with perennial rhinitis; they are smooth, round, soft structures attached to the lining of the nose. They can cause obstruction of the nose, and loss of smell. Occasionally they need to be surgically removed due to extreme discomfort. Over time, people with perennial rhinitis may experience a reduced sense of smell, headaches, and recurrent infections. Other potential complications include infections of the middle ear and sinuses. Outline Thanx

Purulent conjungtivitis any inflammatory process that involves the conjunctiva; however, to most patients, conjunctivitis (often called pink eye) is a diagnosis in its own right. Most causes of conjunctivitis are benign, and the role of the emergency physician is to separate those few conditions requiring more vigorous treatment from the majority that can be handled satisfactorily in the ED. Purulent conjungtivitis

Allergic Rhinoconjunctivitis The presence of ocular itching, tearing, or redness and/or the presence of nasal itching, persistent rhinorrhea, nasal obstruction, or sneezing. There may be an identifiable season of the year or a particular exposure which will elicit symptoms. Symptoms should exceed 6 weeks or be present in a particular season at least 2 years in a row.

THANX Outline

DAFTAR PUSTAKA Blenkinsopp, A., Paxton, P., Blenkinsopp, J. (2009) Symptoms in The Pharmacy – A Guide to the Management of Common Illness. 6th ed, Oxford : Blackwell Publishing Ltd DiPiro J, Talbert R, Yee G, Matzke G, Wells B, Posey M, editors. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. McGrawHill: United States; 2005. 70