Practical tips on allergic rhinitis鼻敏感實用錦囊

Dr. Philip H. Li Division of Rheumatology and Clinical Immunology,Queen Mary Hospital

李曦醫生瑪麗醫院風濕及臨床免疫科

“One in every five people

have symptoms of allergic rhinitis每五個人，就有一人有鼻敏感的病徵

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Questions & Answers問與答

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1. What is allergic rhinitis?甚麼是鼻敏感？

2. Do I have allergic rhinitis?我有鼻敏感嗎？

3. What causes allergic rhinitis?引起鼻敏感的成因？

4. How are allergy tests useful?過敏測試的作用

5. Management and appropriate treatment for allergic rhinitis鼻敏感的處理和合適的治療方法

6. Can allergic rhinitis be cured?鼻敏感可以根治嗎？

What is allergic rhinitis?甚麼是鼻敏感?

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Allergic rhinitis (“Hay fever”)過敏性鼻炎 (「花粉症」)

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● “Allergic” = inappropriate responses of the immune system to a normally harmless substance「過敏性」 =免疫系統對正常無害物質的不適當反應

● “Rhinitis” = inflammation of the mucous membrane inside the nose「鼻炎」 =鼻子內的粘膜發炎

(Many other non-allergic types: hormonal, infectious, occupational, vasomotor etc.)(許多其他非過敏的類型：荷爾蒙的、傳染性的、職業性的、血管收縮等)

● Symptoms: nasal discharge, itching, sneezing and nasal blockage症狀：鼻涕、發癢、打噴嚏和鼻塞

● The most common immunological disease known to mankind人類最常見的免疫疾病○ But still and generally poorly managed但仍然認識不足，而且通常也處理得不好

Rhinitis in Hong Kong鼻敏感在香港

6Allergy. 2009 Jan;64(1):123-48.

1 in 5-6 of all

Primary One

students!!

5至6個小一學生就有1個

● Increasing in Western countries在西方國家中逐漸增加○ Prevalence of 26% in UK Adults英國成年人患病率為26%

● Significant detrimental effects on physical and emotional functioning身體機能和情緒的顯著影響○ Absence from school and work不能上學和上班

○ Reduced productivity and performance降低工作能力和工作表現

○ Impairs quality of life, especially sleep影響生活質素，尤其是睡眠質素

○ Aggravates asthma, rhinosinusitis, and middle ear disease使哮喘、鼻竇炎和中耳疾病惡化

● 40% of patients have asthma40%鼻敏感患者同時患有哮喘○ Increases risk of developing asthma and worsening of asthma symptoms增加患上哮喘的機會和哮喘症狀惡化的風險

A growing problem日漸嚴重的問題

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Hong Kong Med J. 2010 Oct;16(5):354-61.

Allergy services in Hong Kong香港的過敏服務

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Asian Pac J Allergy Immunol. 2017 Dec 10 United States 1:65,546

~1 : 2,800,000Allergist : Head of population (adult)過敏症專科醫生：成人人口

Other limiting factors: costs (tests and medications),其他限制因素： 成本 (測試和藥物)

availability of testing/treatment facilities,測試/醫療設備的可用性

patient / physician awareness ...... 患者/醫生的意識

~1 : 560,000Allergist : Rhinitis patients過敏症專科醫生：鼻敏感患者

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Do I have allergic rhinitis?我有鼻敏感嗎?

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Management of allergic rhinitis鼻敏感的處理

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First第一

History taking歷史考慮

Reviewing the clinical history查看臨床病史

Delineate type and severity推算類型和嚴重程度

Examination檢查

Physical examination, 身體檢查

+/- endoscopy+/-內窺鏡檢查

Second第二

Investigations研究

Skin prick testing皮膚點刺測試

Blood tests for sIgE免疫球蛋白E血液測試

Third第三

Treatment治療

Avoidance measurements防避措施

Medications藥物Immunotherapy脫敏治療

Last最後

Best to seek a medical consult建議徵詢醫學意見

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● Any two of: nasal discharge, itching, sneezing and blockage/congestion其中兩種：鼻涕、發癢、打噴嚏和鼻塞

± Redness, watering or itchiness of eyes (“rhinoconjunctivitis”) in 50% of patients± 50%患者眼睛發紅、流眼水或眼睛痕癢 (鼻結膜炎)

● Typically通常會 –○ Both nose and eye symptoms are symmetrical 鼻和眼睛症狀相同出現

○ Nasal congestion alternates between both sides兩邊鼻輪流出現鼻塞

○ Usually clear-to-white secretions通常出現透明至白色的分泌物

○ Reduction in sense of smell嗅覺減弱

○ Cough and bad breath咳嗽和口臭

○ Temporal variations and specific triggers 隨時間變化和特定情況引發

👤

What type of rhinitis do I have?我有哪種鼻敏感？

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● Non-allergic非過敏的vs.

● Allergic過敏的○ Intermittent vs. persistent間歇的對持久的

○ Mild vs. moderate-severe輕度對中度至重度

○ Seasonal vs. Perennial季節性的對常年的(summer, spring or early autumn)(夏季、春季或初秋)

→ Impact on appropriate management and treatment strategies妥善的處理和治療方法的影響

www.euforea.eu/about-us/aria.html

What causes allergic rhinitis?引起鼻敏感的成因?

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An ’oversensitive’ immune response過度敏感的免疫反應

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敏化作用

免疫球蛋白E抗體

重新暴露於抗原

組胺

白三烯

肥大细胞

Common allergens常見致敏原

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Perennial常年的

Seasonal季節性的

House dust mite塵蟎

Animal dander動物皮屑

Grass pollen花粉（草）

Tree pollen花粉（樹木）

How are allergy tests useful?過敏測試的作用?

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Management of allergic rhinitis鼻敏感的處理

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First第一

History taking歷史考慮

Reviewing the clinical history查看臨床病史

Delineate type and severity推算類型和嚴重程度

Examination檢查

Physical examination, 身體檢查

+/- endoscopy+/-內窺鏡檢查

Second第二

Investigations研究

Skin prick testing皮膚點刺測試

Blood tests for sIgE免疫球蛋白E血液測試

Third第三

Treatment治療

Avoidance measurements防避措施

Medications藥物Immunotherapy脫敏治療

Last最後

Identifying the allergen辨識致敏原

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● Testing for specific immunoglobulin E (IgE) responses to allergens檢測特異免疫球蛋白E (IgE) 對致敏原的反應1. Allergen skin prick tests, or

致敏原皮膚點刺測試2. Blood tests for specific IgE

特異免疫球蛋白 E 的血液測試(Beware: Other tests are mostly still experimental and/or unproven!)(注意：其他測試仍是實驗性質，效果未經證實！)

Skin prick test皮膚點刺測試

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Tested allergen測試的致敏原

https://www.allergy-clinic.co.uk/our-clinics/allergy-testing/

Specific immunoglobulin E (IgE)特異免疫球蛋白E (IgE)

21Middleton's Allergy Essentials, by Drs. Robyn E. O'Hehir, Stephen T. Holgate, and Aziz Sheikh

當你的血液與一系致敏原在化驗所混合時，血液測試會量度過敏抗體或免疫球蛋白E的水平

抗體(免疫球蛋白E)

Management and appropriate treatment for allergic rhinitis鼻敏感的處理和合適的治療方法

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Management of allergic rhinitis鼻敏感的處理

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First第一

History taking歷史考慮

Reviewing the clinical history查看臨床病史

Delineate type and severity推算類型和嚴重程度

Examination檢查

Physical examination, 身體檢查

+/- endoscopy+/-內窺鏡檢查

Second第二

Investigations研究

Skin prick testing皮膚點刺測試

Blood tests for sIgE免疫球蛋白E血液測試

Third第三

Treatment治療

Avoidance measurements防避措施

Medications藥物Immunotherapy脫敏治療

Last最後

Allergenavoidance!避開致敏原！… one of the easiest and important steps after determining specific allergen sensitivities !

…確定對特定致敏原過敏後最簡單和重要的步驟之一！ 24

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● Found in most indoor places with relative humidity levels >45%多數在相對濕度大於 45%的室內環境中發現

● Most people are allergic to dust mite faecal particles多數人對塵蟎糞便過敏

● Highest concentrations in carpeting, pillows, mattresses, and upholstered furniture多數藏於地毯、枕頭、床墊和有軟墊的家具

House dust mite allergy家居塵蟎過敏

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House dust mite allergy家居塵蟎過敏

● Limited data on effective avoidance measures可能有效的防預措施（未被證實的）

○ Encase mattress, pillow and duvet in allergen-impermeable fabric以致敏原不能穿過的物料包住床墊、枕頭和羽絨被

○ Remove carpet, clutter, soft toys, and upholstered furniture清除地毯、雜物、絨毛玩具和有軟墊的家具

○ Use of acaricides on carpets and soft furnishing 在地毯和絨毛軟家具上使用殺蟎劑

○ Wash sheets, pillowcases, and blankets in hot/warm water weekly每週用熱水或溫水中清洗床單、枕套和毛毯

○ Control humidity to <50% relative humidity at normal temperatures在正常溫度下，控制相對濕度於50％以下

Pet dander allergy 寵物皮屑過敏

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● Majority of patients allergic to cats, dogs (or both)多數患者對貓和/或狗過敏

● Other pets also possible (reptiles, birds, insects, rodents, monkeys etc.)其他寵物也是可能的 (爬蟲類、鳥類、昆蟲、囓齒動物、猴子等)

● Most effective measure = not to keep animals in the house最有效的措施 =不要在家中養寵物

● Restricting the animal to one part of the house is not effective局限動物在家中的活動範圍是無效的

Pet dander allergy 寵物皮屑過敏

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● HEPA filters alone do not seem useful只靠高效率空氣微粒子 (HEPA) 過濾器似乎效用不大

● Cat and dog allergens remain airborne for extended periods of time貓和狗的致敏原會長時間停留在空氣中○ Even when cats are removed, allergens persist for many weeks or

months即使把貓移離家中，致敏原也會持續數週或數月

○ Allergen can be transferred on clothing and can easily be detected in schools and in houses even without a cat致敏原可以依附到衣服上，被帶到沒有貓的學校和家中

Pollen allergy花粉過敏

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● Outdoor allergens, especially pollens and molds, are difficult to avoid室外致敏原是難以避免的，尤其是花粉和霉菌

● Know your allergen and its seasons!了解你的致敏原及其出現的季節！

! Start avoidance and treatment measures before start of specific season! 在特定季節開始之前實行預防措施

● Stay indoors when possible and keeping windows closed盡可能留在室內並保持窗戶關閉

● Minimizing outdoor activity when pollen is highest (early morning/evening)當花粉最多時 (清晨和晚上) ，盡量減少戶外活動

● Avoiding going out during/after thunderstorms 避免於雷暴期間或後外出

● Showering before bed to remove allergens from hair and skin to reduce contamination of the bedding在睡前洗澡以去除頭髮和皮膚上的致敏原，減少床上用品受污染

樹 草 雜草

Saline irrigation鹽水沖洗

● Cheap, safe and easy經濟、安全和簡單

● Small beneficial effect in symptom reduction and may reduce need for medications減少症狀的效果不大，可能減少對藥物的需求

Adjunct therapies輔助治療

Carbon dioxide washing二氧化碳沖洗

● 10-second burst of pressurized carbon dioxide10秒的壓縮二氧化碳噴霧

● Reduces all symptoms of rhinitis within minutes 在幾分鐘內減弱所有鼻敏感症狀

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👍

“Most patients will require medications,

in addition to allergen avoidance大多數患者除了避免致敏原外，還需要藥物輔助

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Mild: Anti-histamines輕度：抗組織胺藥

● Oral (intranasal or ocular also available)口服 (用於鼻或眼也可)

● Second-generation anti-histamines第二代抗組織胺藥

● ! First-generation not recommended(sedation, cognitive impairment, dementia)!不建議第一代（鎮靜、認知障礙和癡呆）

● Improves all symptoms of rhinitis改善鼻炎的所有症狀

● Used regularly rather than “as needed” in persistent disease持續使用而非需要時使用

Step-wise approach循序漸進的方法

Moderate-Severe: Intranasal steroids (INS)中、嚴重：鼻用類固醇 (INS)● Anti-inflammatory treatment消炎藥

● Superior to anti-histamines and leukotriene receptor antagonists較抗組胺藥和白三烯素受體拮抗劑強

● Reduces nasal congestion減輕鼻塞

● Onset of action is 6-8 hours使用後6至8小時開始有效

● Improvement may take few days and maximal effect may take weeks可能需要幾天時間才能改善，可能需要數週才能逹最大效果

● Start treatment two weeks prior to a known allergen season在已知的致敏原季節前兩週開始治療

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Facts about intranasal steroids認識鼻內類固醇

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● Most effective single medication最有效的單一藥物

● Best initial therapy for moderate-severe disease對中度至嚴重病症的最佳初期治療

● Systemic absorption is negligible 身體吸收的份量是微不足道的○ No/limited hypothalamic-pituitary-

adrenal suppression at recommended doses在建議劑量下，沒有或很少抑制下視丘-腦垂腺-腎上腺軸的運作

● No effect on bone density or glaucoma對骨質密度或青光眼沒有影響

● Local irritation, sore throat and epistaxis affect around 10%約10％機會引發局部發炎、喉嚨痛和流鼻血影響

● Usually resolves with proper technique通常用適當的技術來解決

Clin Exp Allergy. 2008 Jan;38(1):19-42www.bsaci.org/_literature_121182/How_to_use_a_nasal_spray.

Clin Exp Allergy. 2008 Jan;38(1):19-42www.bsaci.org/_literature_121182/How_to_use_a_nasal_sprayhttp://www.drrahmatorlummc.com/littlesarea.htm.

ACTIVATE DEVICE AND DO NOT SNIFF

Step-wise approach: additional therapies循序漸進的的方法：其他療法

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Ipratropium異丙托溴銨

● Improves nasal discharge only (not other symptoms)只改善流鼻水 (非其他症狀)

● Less effective than INS效用低於鼻內類固醇

● Regular use may be effective as an “add-on” for persistent discharge定期使用可能有效舒緩長期流鼻水問題

● May cause dry nose and nose bleeding可能會導致鼻乾及流鼻血

Montelukast孟魯司特

● Similar to anti-histamines類似於抗組織胺劑

● Less consistent response效果不太一致

● Preferable in patients with concomitant asthma and nasal polyps適合同時患哮喘和鼻息肉的患者

● Some reports of neuropsychiatric side effects一些報告顯示有神經精神性的副作用

Topical decongestants減充血噴鼻劑

● Rapid relief of nasal congestion (minutes)迅速緩解鼻塞(分鐘)

● e.g. oxymetazoline例如：羥甲唑啉

● Greater impact than INS效用高於鼻內類固醇

● Short course only (<10 days)短期使用 (少於10日)

● Risk of rebound nasal congestion 反彈性鼻塞的風險(“rhinitis medicamentosa”)(「藥物性鼻炎」)

Can allergic rhinitis be cured?鼻敏感可以根治嗎?

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The final frontier ?

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De-sensitization (Immunotherapy)去敏化 (脫敏治療)

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● Alters the immune system‘s reaction to allergens and induces tolerance改變免疫系統對致敏原的反應並增強其接受能力

● Requires accurate identification of underlying allergic trigger需要準確識別過敏的主因

● Effective in both seasonal and perennial allergic rhinitis (and asthma)對季節性和常年性鼻敏感 (和哮喘)有效○ Subcutaneous immunotherapy (SCIT)皮下注射免疫療法 (SCIT)

○ Sublingual immunotherapy (SLIT)舌下免疫療法 (SLIT)

De-sensitization (Immunotherapy)去敏化 (脫敏治療)

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● Duration usually ~3 years, effects persist up to 12 years治療時間通常約3年，效果可持續最長12年

● Grass pollen: ↓30% in symptoms and ↓ 40% in rescue medication草花粉：↓ 30％的症狀和↓ 40％的藥物

● Dust mite: ↓58% in symptoms and ↓ 20% in rescue medication塵蟎：↓ 58％的症狀和↓ 20％的藥物

● Additional benefits:額外的好處：

○ ↓ risk of developing asthma among patients with allergic rhinitis↓鼻敏感患者出現哮喘的風險

○ ↓ development of new sensitivities↓出現新的過敏

An urgent need to re-calibrate our concept of “cost”迫切需要重新定義我們對「成本」的概念

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Quality of life生活質素

Doctor visits & hospital

admissions看醫生和入院

Prevention of asthma & new

sensitivities 預防哮喘和新的

過敏

Drug costs藥的成本

School/Work Productivity上班/上學的生產力

Expertise 專門技術

Sleep睡眠

Take home messages重要訊息

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Allergic rhinitis is …鼻敏感是…● a syndrome of nasal discharge, itching, sneezing and nasal blockage鼻涕、發癢、打噴嚏和鼻塞是典型特徵

● inflammation of the nose due to an “oversensitive” immune system鼻發炎是由於免疫系統「過分敏感」所引起的

● commonly triggered by house dust mites, pollen and pet allergies通常由家居塵蟎、花粉和寵物致敏原引起

Take home messages重要訊息

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Allergic rhinitis is …鼻敏感是…● detrimental effects on physical and emotional functioning對身體功能和情緒帶來有害的影響

● a growing concern worldwide and very common in Hong Kong越來越受到世界的關注，而在香港也很普遍

● and treatable…! Requiring:可以治療......！需要：○ identification of specific allergens for appropriate management識別致敏原並配合適當處理

○ evaluation of cost-effectiveness of therapies and even “cure”評估治療的成本效益

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Thanks!