September 21 to September 24

Charity Fox, MDClinical Associate Professor of Rheumatology/

ImmunologyDivision of Rheumatology/ ImmunologyThe Ohio State University Medical Center

Debora Ortega- Carr, MDDivision of Rheumatology/ ImmunologyThe Ohio State University Medical CenterMidwest Allergy Associates, Inc.

#1001 Recent Advances in the Treatment of Allergies

Debora Ortega- Carr, MDDivision of Rheumatology/ Immunology

The Ohio State University Medical CenterMidwest Allergy Associates, Inc.

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Profile Profile

Chad• 8 year old young male

• Symptoms - Nasal congestion - Sneezing - Cough - Skin itching• Family history is significant - Several brothers and father with allergic rhinitis

Chad• 8 year old young male

• Symptoms - Nasal congestion - Sneezing - Cough - Skin itching• Family history is significant - Several brothers and father with allergic rhinitis 2

Profile Profile

Chad• Evaluation showed sensitivities to: - Grass - Dogs - Dust mites

• Diagnosis: Allergic Rhinitis

Chad• Evaluation showed sensitivities to: - Grass - Dogs - Dust mites

• Diagnosis: Allergic Rhinitis

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Sources Of Allergens

Sources Of Allergens

Seasonal

• Pollens Trees Grasses

Weeds

• Molds

Seasonal

• Pollens Trees Grasses

Weeds

• Molds

Perennial• Animals Pets

Insects

House dust mites

• Indoor molds

• Occupational

Perennial• Animals Pets

Insects

House dust mites

• Indoor molds

• Occupational12

Appearance Of Seasonal Allergens

Appearance Of Seasonal Allergens

Pollens• Hardwood trees: Spring Mountain cedars: Late Fall/Winter Western red cedars: Late Winter• Grasses: Spring/ Summer• Ragweed: Summer/Fall

Molds• Outdoor: Spring/Summer/Fall

Pollens• Hardwood trees: Spring Mountain cedars: Late Fall/Winter Western red cedars: Late Winter• Grasses: Spring/ Summer• Ragweed: Summer/Fall

Molds• Outdoor: Spring/Summer/Fall 13

Treatment StrategiesTreatment Strategies

• Avoidance/Environmental Control

• Medications Nonpharmacologic - Saline nasal sprays

Pharmacologic - Antihistamines - Decongestants - Cromolyn sodium - Anticholinergic preparations - Corticosteroids

• Immunotherapy

• Avoidance/Environmental Control

• Medications Nonpharmacologic - Saline nasal sprays

Pharmacologic - Antihistamines - Decongestants - Cromolyn sodium - Anticholinergic preparations - Corticosteroids

• Immunotherapy 14

Summary Summary

Chad• Evaluation - Tested for several inhalant allergies - Found to be sensitive to dust mites, grass and dogs• Treatment - Immunotherapy - Topical nasal anti-inflammatory therapy - Responded well to therapy with significant symptoms improvement• Prognosis: Good

Chad• Evaluation - Tested for several inhalant allergies - Found to be sensitive to dust mites, grass and dogs• Treatment - Immunotherapy - Topical nasal anti-inflammatory therapy - Responded well to therapy with significant symptoms improvement• Prognosis: Good

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Charity Fox, MDClinical Associate Professor of Rheumatology/ Immunology

Division of Rheumatology/ ImmunologyThe Ohio State University Medical Center

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Profile Profile

Margherita• 42 year old woman

• Has had typical seasonal allergy symptoms for a number of years

• This year, more symptoms with increased difficulty breathing• No changes in environment • Positive family history of allergies

Margherita• 42 year old woman

• Has had typical seasonal allergy symptoms for a number of years

• This year, more symptoms with increased difficulty breathing• No changes in environment • Positive family history of allergies

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Profile Profile

Margherita• Physical Exam - Typical findings of seasonal allergic rhinitis - Pale, swollen nasal mucosa - Red eyes

• Skin Tests revealed: - Reactivity to grasses - PFT - borderline obstruction

• Diagnosis: Seasonal Allergic Rhinitis and Mild Allergic Asthma

Margherita• Physical Exam - Typical findings of seasonal allergic rhinitis - Pale, swollen nasal mucosa - Red eyes

• Skin Tests revealed: - Reactivity to grasses - PFT - borderline obstruction

• Diagnosis: Seasonal Allergic Rhinitis and Mild Allergic Asthma

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Areas Of New Knowledge

Areas Of New Knowledge

• Identifying Risk Factors

• Pharmacologic Therapy

• Immune Modulation

• Identifying Risk Factors

• Pharmacologic Therapy

• Immune Modulation

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Risk FactorsRisk Factors

• Genetic Predisposition - Multigenic System

Cytokine gene cluster on chromosome 5, Beta chain of IgE receptor on chromosome II, changes on chromosome 12, changes on chromosome 16

• Environmental Factors - Allergen exposure - Indoor air quality - Outdoor air pollution

• Diet - Neonatal exposure

• Infectious Disease - Role of early childhood infections

• Genetic Predisposition - Multigenic System

Cytokine gene cluster on chromosome 5, Beta chain of IgE receptor on chromosome II, changes on chromosome 12, changes on chromosome 16

• Environmental Factors - Allergen exposure - Indoor air quality - Outdoor air pollution

• Diet - Neonatal exposure

• Infectious Disease - Role of early childhood infections 20

Environmental Risk FactorsEnvironmental Risk Factors

• Allergen Exposure - High allergen count indoors, especially in bedroom - associated with great severity of allergic disease - Dust mite, cockroach, cat

• Rx - Early intervention with families and children with increase risk of atopy

• Requires - Identification of allergens - Education and support

• Allergen Exposure - High allergen count indoors, especially in bedroom - associated with great severity of allergic disease - Dust mite, cockroach, cat

• Rx - Early intervention with families and children with increase risk of atopy

• Requires - Identification of allergens - Education and support

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Environmental Risk FactorsEnvironmental Risk Factors

• Indoor air quality

- Tobacco

- Limited air exchange

• Indoor air quality

- Tobacco

- Limited air exchange

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Environmental Risk FactorsEnvironmental Risk Factors

• Outdoor Air Pollution - Fossil fuel combustion - Diesel exhaust particles - Ozone - Sulfur dioxide exposure - Respirable particulate matter

- Drive immune response toward IgE production and allergic inflammation

- Suggest - Monitor air quality - Refrain from exercising along roadways and on days with poor air quality - especially during pollen season

• Outdoor Air Pollution - Fossil fuel combustion - Diesel exhaust particles - Ozone - Sulfur dioxide exposure - Respirable particulate matter

- Drive immune response toward IgE production and allergic inflammation

- Suggest - Monitor air quality - Refrain from exercising along roadways and on days with poor air quality - especially during pollen season 23

Environmental Risk FactorsEnvironmental Risk Factors

• Diet - Neonatal or fetal exposure - Variable data regarding effects of material diet

- More consensus on the effect of early exposure to certain common food allergens (especially cow’s milk, peanuts, eggs)

- Suggest - Delayed introduction of food allergens to the diet

• Diet - Neonatal or fetal exposure - Variable data regarding effects of material diet

- More consensus on the effect of early exposure to certain common food allergens (especially cow’s milk, peanuts, eggs)

- Suggest - Delayed introduction of food allergens to the diet 24

Risk FactorsRisk Factors• Infections - “Hygiene Hypothesis” - Decreased incidence of bacterial infection in developed countries responsible for increased incidence of atopy

- Viral potentiation of allergic inflammation - Respiratory Syncytial Virus - Influenza virus - Rhinovirus

- Viral infections may induce long-term exacerbations of allergy

• Infections - “Hygiene Hypothesis” - Decreased incidence of bacterial infection in developed countries responsible for increased incidence of atopy

- Viral potentiation of allergic inflammation - Respiratory Syncytial Virus - Influenza virus - Rhinovirus

- Viral infections may induce long-term exacerbations of allergy 25

Pharmacologic TherapyPharmacologic Therapy

• New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - NIH Expert Panel Report on Asthma 1997

- WHO Position Paper on Allergen Immunotherapy 1998

• New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - NIH Expert Panel Report on Asthma 1997

- WHO Position Paper on Allergen Immunotherapy 1998 26

Pharmacologic TherapyPharmacologic Therapy

• New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - Comprehensive review of differential diagnosis and treatment of rhinitis

- Preferential use of non-sedating second generation antihistamines as first-line agents

- Uncontrolled rhinitis is comorbid condition for asthma, sinusitis, otis media

• New Guidelines - Practice Parameters for Diagnosis and Management of Rhinitis 1998 (AAAAI, ACAAI, JCAAI) - Comprehensive review of differential diagnosis and treatment of rhinitis

- Preferential use of non-sedating second generation antihistamines as first-line agents

- Uncontrolled rhinitis is comorbid condition for asthma, sinusitis, otis media

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Pharmacologic TherapyPharmacologic Therapy

• New Guidelines - NIH Expert Panel Report on Asthma 1997 - Antileukotriene agents became widely available only after publication

- WHO Position Paper on Allergen Immunotherapy 1998

• New Guidelines - NIH Expert Panel Report on Asthma 1997 - Antileukotriene agents became widely available only after publication

- WHO Position Paper on Allergen Immunotherapy 1998

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Pharmacologic TherapyPharmacologic Therapy

• Inhaled Corticosteroids and Bone Metabolism - Increased incidence of posterior cataracts - Suppression of HPA axis and systemic effects at higher doses

- Some evidence regarding inhaled corticosteroid effect on growth in moderate to high doses

- No evidence of osteoporosis in young adults

• Inhaled Corticosteroids and Bone Metabolism - Increased incidence of posterior cataracts - Suppression of HPA axis and systemic effects at higher doses

- Some evidence regarding inhaled corticosteroid effect on growth in moderate to high doses

- No evidence of osteoporosis in young adults 29

Immunotherapy (Immune Modulation)

Immunotherapy (Immune Modulation)

• Something old and something new

- Allergen Immunotherapy New understanding of long-term efficacy

• New therapies in clinical trials - Anti-IgE antibody therapy - T-cell epitope peptide therapy

• Something old and something new

- Allergen Immunotherapy New understanding of long-term efficacy

• New therapies in clinical trials - Anti-IgE antibody therapy - T-cell epitope peptide therapy

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Immunotherapy (Immune Modulation)

Immunotherapy (Immune Modulation)

• Allergen Immunotherapy - Decreased allergen-specific T-cell proliferation - Evidence of allergen-specific T-cell anergy - Changes in cytokine synthesis - decreases antigen-specific T-cell production of IL-4, altered IL-4: IFN-gamma ratios - Anergy persists for at least three years after cessation of allergy immunotherapy

• Allergen Immunotherapy - Decreased allergen-specific T-cell proliferation - Evidence of allergen-specific T-cell anergy - Changes in cytokine synthesis - decreases antigen-specific T-cell production of IL-4, altered IL-4: IFN-gamma ratios - Anergy persists for at least three years after cessation of allergy immunotherapy 32

New Methods Of Immune Modulation

New Methods Of Immune Modulation

• Anti-IgE Antibody Therapy

• T-cell Epitope Peptide Therapy

• Anti-IgE Antibody Therapy

• T-cell Epitope Peptide Therapy

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Summary Summary

Margherita• Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma

• Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler

• Prognosis: Expect her to continue to do well during allergy season

Margherita• Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma

• Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler

• Prognosis: Expect her to continue to do well during allergy season 36

#1002 Antidepressants Update

September 28 to October 1

Nicholas A. Votolato Pharm B. BCPPClinical Assistant Professor of PharmacyDepartment of Psychiatry and PharmacyThe Ohio State University Medical Center

Jeffery C. Hutzler, MD.Associate Professor of PsychiatryThe Ohio State University Medical CenterStaff PsychiatristThe Cleveland Clinic Foundation

NEXT WEEK

Summary Summary

Margherita• Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma

• Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler

• Prognosis: Expect her to continue to do well during allergy season

Margherita• Diagnosed with Seasonal Allergic Rhinitis and Mild Allergic Asthma

• Treatment - Non-sedating antihistamine - Decongestant - Broncodialator inhaler

• Prognosis: Expect her to continue to do well during allergy season 36