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![Page 1: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/1.jpg)
Treatment of Sleep Associate disturbance in Allergy Diseases
Timothy J. CraigProfessor of Medicine and Pediatrics
Distinguished EducatorPenn State University
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Presentation Overview
• Allergic Rhinitis and Sleep Disturbance• Mechanisms of Sleep Disturbance in Allergic
Rhinitis• Impact of AR-associated Sleep Disturbances• Effects of Allergic Rhinitis Therapies on Sleep
and Quality of Life
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conflicts of interest with this presentation
• Merck- speaker, researcher, consultant• Astra-Zeneca- speaker• Teva- speaker• GSK- researcher
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Allergic Rhinitis Adversely Impacts Sleep in Adults and Children/Adolescents
96 93
79
0
20
40
60
80
100
120
40
36
32
28
0
10
20
30
40
50 N=476 Adults/Adolescents/Children with AR
Patie
nts
with
Mod
erat
e or
Sev
ere
Impa
ct (%
)
Sleep DailyActivities
School/WorkPerformance
Lifestyle
O’Connor and Punekar. J Allergy Clin Immunol. 2006;117:S322. Abstract 1244.Scadding and Punekar. EAACI Abstract Book. 2006;211. Abstract 741.
N=221 Adolescents/Children with AR
Patie
nts
with
Impa
ct (%
)
School/WorkPerformance
NormalActivities
Sleep
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Allergic Rhinitis Symptoms are Associated with Sleep Complaints
Leger et al. Arch Intern Med. 2006;166:1744.
17.2
27.125.4
19.6
12.8
20.518.3
23.3
40.3
63.2
46.8
28.7
42.841.6
0
10
20
30
40
50
60
70 Controls (n=502)
AR Patients (n=591)
Subj
ects
with
com
plai
nt (%
)
Difficulty FallingAsleep
NocturnalAwakening
EarlyAwakening
NonrestorativeSleep
Feeling ofLack of Sleep
Snoring ESS score>10
Prevalence of Sleep Complaints in Patients with Allergic Rhinitis and Controls
*P<0.001 vs controls.
* *
*
*
*
*
*
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Allergic Rhinitis (AR) Symptoms are Associated with Sleep Disorders
Leger et al. Arch Intern Med. 2006;166:1744.
Prevalence of Sleep Disorders in Patients with Allergic Rhinitis and Controls
*P≤0.003 vs controls.
24.3
0.5
10.4
16
32.6
3.8
23.2
35.8
0
5
10
15
20
25
30
35
40 Controls (n=502)
AR Patients (n=591)
Subj
ects
with
dis
orde
r (%
)
Insomnia SevereInsomnia
Sleep ApneaSyndrome
Hypersomnia
*
*
*
*
7.6 fold increase of OSA in AR
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Allergic Patients Experience More Apnea/Hypopnea than Non-allergic Controls
P<0.001
0
0.2
0.4
0.6
0.8
1.0
Allergic rhinitis group Control group
AH
I
Before allergy season
During allergy season
Stuck et al. J Allergy Clin Immunol. 2004;113:663.
Allergic patients had more apnea/hypopnea episodes than non-allergic controls
AHI=apnea/hypopnea index, determined as the total number of apnea and hypopneaepisodes (assessed by polysomnography) divided by hours of sleep.
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Patients with rhinitis had 10 times moremicroarousals (average of 50) than controls (n=14)
Lavie et al. Acta Otolaryngol. 1981;92;529.
Allergic Rhinitis is Associated with Increased Microarousals
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Lavie et al. Acta Otolaryngol. 1981;92;529.
Microarousals Correlate with Impaired Breathing
Microarousals in Allergic Rhinitis Correlate with Impaired Breathing
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Similarities between the twoObese man with severe OAS • Increase in IL-1• Increase in TNF• Increase in Il-6• Increase in T-helper 2
cytokines• Decrease in T-helper 1
cytokines
A young girl snoring and with rhinitis
• Increase in IL-1• Increase in TNF• Increase in Il-6• Increase in T-helper 2
cytokines• Decrease in T-helper 1
cytokines
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What is the Mechanism of Sleep Disturbance in Allergic Rhinitis?
1. Inflammatory components of the allergic response
2. Symptoms of allergic rhinitis3. Nasal congestion4. All three
Answer
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Impact of Poor Sleep
•Delayed onset•Sleep fragmentation
• Arousals/microarousals•Sleep Disordered
Breathing• Snoring• Obstructive Sleep Apnea
Impaired Social Functioning:• daytime fatigue/somnolence• Impaired performance• Impaired learning• Emotional/behavioral impact
Associated Diseases:•Hypertension•Cardiovascular disease•Stroke•Diabetes•Psychological disorders
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Treatment Options
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Treatment Options:Snoring Children
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The approach to the child with concerns for having OSA
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The affect of OSA and benefits of T+A on asthma
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The affect of OSA and benefits of T+A on poorly controlled asthma
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Kheirandish-Gozal. Pediatrics 2008
Sleep apnea in children treated with topical budesonide nasal spray
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Leukotrienes in tonsil tissue in children with sleep apnea (SA) and those with recurrent infection (RI)
LTC-4 LTB-4
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Adenoid reduction with 16 weeks of montelukast therapy
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Montelukast affect on sleep in children with sleep apnea compared with those receiving no therapy
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Treatment Options for Rhinitis Associated With Sleep disordered Breathing
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Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids
Oral antihistamines
Intranasal antihistamines
Oral decongestants
Intranasal decongestants
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
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Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines
Intranasal antihistamines
Oral decongestants
Intranasal decongestants
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 27: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/27.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines
Oral decongestants
Intranasal decongestants
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 28: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/28.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tiredness
Oral decongestants
Intranasal decongestants
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 29: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/29.jpg)
Oral decongestants compared to placebo and benefit on sleep and rhinitis
![Page 30: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/30.jpg)
Oral decongestants compared to placebo and benefit on sleep and rhinitis
![Page 31: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/31.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tried
Oral decongestants ++ - -/- 0
Intranasal decongestants
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 32: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/32.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tried
Oral decongestants ++ - -/- 0
Intranasal decongestants ++++ - - +
Intranasal cromones
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 33: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/33.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tried
Oral decongestants ++ - -/- 0
Intranasal decongestants ++++ - - +
Intranasal cromones + + +/+ -
Anticholinergics
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 34: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/34.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tried
Oral decongestants ++ - -/- 0
Intranasal decongestants ++++ - - +
Intranasal cromones + + +/+ -
Anticholinergics - ++ -/- -
Antileukotrienes
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 35: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/35.jpg)
Treatment Considerations in Allergic Rhinitis: ARIA Guidelines
Congestion RhinorrheaItching/
SneezingSleep
Intranasal steroids +++ +++ ++/+++ ++++
Oral antihistamines + ++ +++/++ +
Intranasal antihistamines + ++ ++/++ tried
Oral decongestants ++ - -/- 0
Intranasal decongestants ++++ - - +
Intranasal cromones + + +/+ -
Anticholinergics - ++ -/- -
Antileukotrienes ++ + -/- ++
Bousquet et al. Allergy. 2003;58:192. Bousquet et al. Allergy. 2002;57:841. Van Cauwenberge et al. Allergy. 2000;55:116.
![Page 36: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/36.jpg)
Effect of Therapies for Allergic Rhinitis on Sleep and Quality of Life: Summary
• Intranasal steroids provide significant relief of congestion and ocular symptoms and improve sleep in patients with allergic rhinitis
• Non-sedating antihistamines and leukotriene receptor antagonists provide modest improvements in congestion, ocular, and nighttime symptoms
• Decongestants effectively reduce congestion, but have minimal affect on sleep-disordered breathing
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Adverse Impact of Allergic Rhinitis on the Patient Quality of Life-Focus on Sleep: Conclusions
• Allergic rhinitis is associated with impaired sleep• Sleep impairment in allergic rhinitis can be caused by
– Inflammatory mediators– Nasal symptoms, primarily congestion and rhinorrhea– Ocular symptoms
• Impaired sleep adversely affects performance, productivity and social functioning, and increases the risk of associated diseases
• Intranasal steroids effectively target inflammation and relieve symptoms to provide improved sleep
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Thank you
• Stephanie Teets• Stan Golden• Josh Berlin• Sujani Kukumanu• Katherine Hughs• Casey Glass
• Joel Torretti• Faina Gurevich• Wenxin Wei• Jeff McCann• Chris Hanks• Carah Santos• Niti Sardana
![Page 39: Treatment of Sleep Associate disturbance in Allergy Diseases Timothy J. Craig Professor of Medicine and Pediatrics Distinguished Educator Penn State University.](https://reader035.fdocuments.in/reader035/viewer/2022062511/551443fc550346494e8b4ab0/html5/thumbnails/39.jpg)
Questions
Have a great day.