Allergic rhinitis in children clinical guidelines. Allergic rhinitis in children. The complex of therapeutic measures includes

Sensitization

fluticasone propionate

fluticasone furoate

List of abbreviations

ALG- allergens

AR- allergic rhinitis

BA- bronchial asthma

GKS- glucocorticosteroids

CT- CT scan

Terms and Definitions

Allergens (AlG)- these are substances, predominantly of a protein nature, with a molecular weight of about 20 kD (from 5 to 100 kD) or low molecular weight compounds, haptens, which, upon first entering the body, predisposed to the development of allergies, cause sensitization, i.e. the formation of specific IgE antibodies, and in subsequent - the development of allergic reactions.

Allergen-specific immunotherapy (ASIT)- pathogenetic treatment of IgE-mediated allergic disease, in which the allergenic drug is administered according to a gradual dose increase scheme. Its goal is to reduce the symptoms associated with subsequent exposure to the causative allergen.

1. Brief information

1.1 Definition

Allergic rhinitis (AR)- IgE-mediated inflammatory disease of the nasal mucosa caused by exposure to a sensitizing (causal) allergen and manifested by at least two symptoms - sneezing, itching, rhinorrhea or nasal congestion.

1.2 Etiology and pathogenesis

Several approaches are used to classify allergens:

? on the way to the body(inhalation, enteral, contact, parenteral, transplacental);

? distribution in the environment(aeroallergens, indoor allergens, external allergens, industrial and occupational allergens and sensitizers);

? by origin(drug, food, insect or insect allergens);

? by diagnostic groups(household, epidermal, mold spores, pollen, insect, medicinal and food).

A special international nomenclature has been developed for the designation of allergens.

In our country, the most common is the classification that distinguishes the following diagnostic groups:

? non-infectious- household (aeroallergens of dwellings), epidermal, pollen, food, insect, medicinal allergens;

? infectious- fungal, bacterial allergens.

In foreign literature, there are internal(indoor) Alg - house dust, house dust mites, cockroaches, pets, fungi and external(outdoor) AlG - pollen and fungus.

Typical allergens in AR are, in particular, house dust mites, pollen from trees, cereals and weeds, animal allergens (cats, dogs), and molds. Cladosporium, Penicillium, Alternaria and etc.

An allergic reaction develops in a sensitized organism upon repeated contact with an allergen, accompanied by the development of allergic inflammation, tissue damage and the appearance of clinical symptoms of allergic diseases.

In the pathogenesis of allergic diseases, immediate type reactions (IgE-dependent, anaphylactic, atopic) are the main (but not always the only ones).

At the first contact with the allergen, specific proteins are formed - IgE antibodies, which are fixed on the surface of mast cells in various organs. This condition is called sensitization - increased sensitivity to a particular AlG.

Upon repeated contact of the sensitized organism with causative ALG, IgE-dependent inflammation develops in the nasal mucosa, causing the onset of symptoms. In most cases, one patient is simultaneously sensitized to several allergens belonging to different groups.

During the first minutes after exposure to AlG (the early phase of an allergic reaction), mast cells and basophils are activated, degranulation and release of inflammatory mediators (histamine, tryptase, prostaglandin D2, leukotrienes, platelet activating factor). As a result of the action of mediators, there is an increase in vascular permeability, hypersecretion of mucus, contraction of smooth muscles, the occurrence of acute symptoms of allergic diseases: itching of the eyes, skin, nose, hyperemia, swelling, sneezing, watery discharge from the nose.

4–6 hours later (late phase of the allergic reaction) after exposure to AlG, there is a change in blood flow, expression of cell adhesion molecules on endothelium and leukocytes, tissue infiltration by allergic inflammation cells - basophils, eosinophils, T lymphocytes, mast cells.

As a result, the formation of chronic allergic inflammation occurs, one of the clinical manifestations of which is nonspecific tissue hyperreactivity. The characteristic symptoms are nasal hyperreactivity and obstruction, hypo- and anosmia.

1.3 Epidemiology

AR is a widespread disease.

The median prevalence of AR symptoms is 8.5% (1.8–20.4%) in 6–7 year olds and 14.6% (1.4–33.3%) in 13–14 year olds (International Study Asthma and Allergy in Childhood: International Study of Asthma and Allergy in Childhood (ISAAC) Based on the results of a study conducted according to the GA2LEN (Global Allergy and Asthma European Network) protocol in 2008-2009 ., the prevalence of symptoms of allergic rhinitis in adolescents aged 15-18 was 34.2%, during an in-depth examination in 10.4% of cases, the diagnosis of AR was confirmed, which is approximately twice as high as official statistics.

The frequency of AR symptoms in the Russian Federation is 18-38%. Boys get sick more often. In the age group under 5 years, the prevalence of AR is the lowest, the rise in incidence is noted at early school age.

1.4 ICD-10 coding

J30.1- Allergic rhinitis caused by plant pollen

J30.2- Other seasonal allergic rhinitis

J30.3- Other allergic rhinitis

J30.4- Allergic rhinitis, unspecified

1.5 Examples of diagnoses

Allergic rhinitis, intermittent, mild course, remission

Allergic rhinitis, persistent, severe course, exacerbation

1.6 Classification

According to the traditional approach, AR is classified based on the duration and severity of rhinitis symptoms in the presence of sensitization.

Allergic rhinitis, depending on the nature of the pathogenetically significant allergen, may have seasonal(if sensitized to pollen or fungal allergens) or year-round character (with sensitization to household - house dust mites, cockroaches, and epidermal - animal dander, allergens). However, the distinction between seasonal and perennial rhinitis cannot always be made in all regions; as a result, this terminology has been revised and, based on the duration of symptoms, there are (according to the ARIA 2010 classification, as well as EAACI 2013):

intermittent ( seasonal or year-round, acute, occasional) AR(symptoms< 4 дней в неделю или < 4 нед. в году);

persistent(seasonal or year-round, chronic, long-term) AR(symptoms? 4 days a week or? 4 weeks a year).

This approach is useful for describing the manifestations of rhinitis and its impact on quality of life, as well as for determining a possible approach to treatment.

According to the severity of manifestations and the impact on the quality of life, AR is divided into:

AR light flow(minor symptoms; normal sleep; normal daily activities, sports, rest; does not interfere with school or professional activities);

AR moderate and severe course ( in the presence of painful symptoms leading to the appearance of at least one of such signs as sleep disturbance, disturbance of daily activity, inability to play sports, normal rest; violations of professional activity or study at school);

In addition, allocate exacerbation and remission allergic rhinitis.

2. Diagnostics

The diagnosis of AR is established on the basis of anamnesis data, characteristic clinical symptoms and the identification of causally significant allergens (during skin testing or determining the titer of specific antibodies of the IgE class in vitro if it is impossible to conduct skin tests).

(D = low confidence; very low confidence (expert consensus)

2.1 Complaints and medical history

The main complaints are usually the classic symptoms of allergic rhinitis:

rhinorrhea (clear, mucous discharge from the nasal passages);

sneezing - often paroxysmal;

itching, less often - a burning sensation in the nose (sometimes accompanied by itching of the palate and pharynx);

nasal obstruction, characteristic mouth breathing, sniffling, snoring, apnea, voice change and nasality.

The characteristic symptoms also include "allergic circles under the eyes" - darkening of the lower eyelid and periorbital region, especially in severe chronic course of the process.

Additional symptoms may include cough, decreased and lack of sense of smell; irritation, swelling, hyperemia of the skin above the upper lip and near the wings of the nose; nosebleeds due to forced blowing; sore throat, cough (manifestations of concomitant allergic pharyngitis, laryngitis); pain and crackling in the ears, especially when swallowing; hearing impairment (manifestations of allergic tubotitis).

Among the common non-specific symptoms observed in allergic rhinitis, note:

weakness, malaise, irritability;

headache, fatigue, impaired concentration;

sleep disturbance, depressed mood;

rarely - fever.

When collecting an anamnesis, they specify: the presence of allergic diseases in relatives; the nature, frequency, duration, severity of symptoms, the presence / absence of seasonal manifestations, response to therapy, the presence of other allergic diseases in the patient, provoking factors.

Comments: additional symptoms develop due to profuse secretion from the nose, impaired drainage of the paranasal sinuses and patency of the auditory (Eustachian) tubes. The nose is anatomically and functionally related to the eyes, paranasal sinuses, nasopharynx, middle ear, larynx, and lower respiratory tract, thus symptoms may include conjunctivitis, chronic cough, mouth breathing, nasal voice, and snoring with or without obstructive sleep apnea.

Concomitant pathology, symptoms

Allergic conjunctivitis is considered the most common comorbidity associated with AR. It is characterized by severe itching in the eyes, conjunctival hyperemia, lacrimation, and sometimes periorbital edema.

Chronic allergic inflammation of the upper respiratory tract can cause hypertrophy of the lymphoid tissue. A significant increase in the size of adenoids during the dusting season is observed in children with hay fever. In polysomnography, there is a pronounced correlation of sleep apnea syndrome with a history of nasal congestion and AR. Chronic middle ear exudate and Eustachian tube dysfunction have also been associated with rhinitis, potentially causing hearing loss. In the pathogenesis of ongoing allergic inflammation in the adenoid lymphatic tissue in children with atopy, local secretion of nonspecific and specific IgE to environmental allergens and staphylococcal enterotoxin antigens may play a role.

AR is often combined with asthma, being one of the determining risk factors for its occurrence. AR is one of the reasons for the development of exacerbation and reduction / lack of control of bronchial asthma: its symptoms often precede the manifestations of asthma. AR significantly increases the risk of emergency room visits for asthma.

At the same time, the presence of cough in allergic rhinitis sometimes pushes the doctor to a false diagnosis of bronchial asthma.

Being one of the “steps” of the atopic march, allergic rhinitis often accompanies atopic dermatitis, sometimes preceding, and sometimes ahead of, this form of allergy manifestation.

Allergic rhinitis due to pollen sensitization may be associated with food allergies (oral allergy syndrome). In this case, symptoms such as itching, burning and swelling of the mouth are due to cross-reactivity: sensitization to ragweed pollen can cause symptoms after eating melon; to birch pollen - after eating apples, etc.

Table 1- Manifestations of allergic rhinitis in children

2.2 Physical examination

Comments:in patients with AR, the mucous membrane is usually pale, cyanotic gray, and edematous. The nature of the secret is slimy and watery.

In chronic or severe acute AR, it is recommended to pay attention to the presence of a transverse fold on the back of the nose, which is formed in children as a result of "allergic salute" (rubbing the tip of the nose). Chronic nasal obstruction leads to the formation of a characteristic "allergic face" (dark circles under the eyes, impaired development of the facial skull, including malocclusion, arched palate, flattening of the molars).

2.3 Laboratory diagnostics

skin testing reveals causally significant allergens.

determination of specific antibodies of the IgE class (sIgE).

Comments: if it is impossible to conduct this study and / or there are contraindications (children under 2 years old, exacerbation of concomitant allergic pathology, taking medications that affect the test result, etc.)

This method is more expensive, and it is not necessary to cancel antihistamines before the study.

Allergic sensitization is diagnosed with a positive result of skin testing or the detection of antibodies of the IgE class specific to a certain allergen, while the quantitative characteristic of the studied parameter (papule size, sIgE concentration in blood serum) is extremely important.

The presence of AR is also possible in the absence of a noticeable general specific sensitization, which is due to the local formation of immunoglobulin E (IgE) in the nasal mucosa, the so-called. entopy. The question of whether this effect is observed in children remains open.

2.4 Instrumental diagnostics

Diagnosis of AR usually does not require instrumental methods.

Comments:this method is designed to detect eosinophils (performed during an exacerbation of the disease). Its practical use is limited, since the appearance of eosinophils in the nasal secretion is possible in other diseases (BA, nasal polyps in combination with or without asthma, non-allergic rhinitis with eosinophilic syndrome).

Comments: in the absence of dynamic control and confirmation of the presence of a causally significant allergen, these studies are uninformative.

Provocation tests with allergens in pediatric clinical practice are not standardized and are not recommended for use.

2.5 Differential diagnosis

Differential diagnosis of AR is carried out with the following forms of non-allergic rhinitis:

Vasomotor (idiopathic) rhinitis occurs in older children. Characterized by nasal congestion, aggravated by temperature changes, air humidity and strong odors, persistent rhinorrhea, sneezing, headaches, anosmia, sinusitis. Sensitization during the examination is not detected, heredity for allergic diseases is not burdened. Rhinoscopy reveals hyperemia and / or marbling of the mucous membrane, a viscous secret.

drug-induced rhinitis(including drug-induced rhinitis caused by prolonged use of decongestants. Permanent nasal obstruction is noted, with rhinoscopy, the mucous membrane is bright red. A positive response to therapy with intranasal glucocorticosteroids, which are necessary for the successful withdrawal of drugs that cause this disease, is characteristic).

Nonallergic rhinitis with eosinophilic syndrome(English NARES) is characterized by severe nasal eosinophilia (up to 80-90%), lack of sensitization and allergic history; sometimes becomes the first manifestation of intolerance to non-steroidal anti-inflammatory drugs. Symptoms include sneezing and itching, a tendency to form nasal polyps, a lack of an adequate response to antihistamine therapy, and a good effect with intranasal glucocorticosteroids.

When conducting a differential diagnostic search and / or if therapy is ineffective on the basis of symptoms, taking into account age characteristics (Table 2), additional studies are recommended

To rule out chronic rhinosinusitis and polyposis, a CT scan of the paranasal sinuses is recommended.

Comments: s Difficulty in nasal breathing (nasal congestion, nasal obstruction) may be the result of mucosal pathology and / or anatomical abnormalities (often - nasal septal curvature, less often - nasal vestibule stenosis with cleft lip, choanal atresia or piriformis stenosis). Nasal polyps that obstruct nasal breathing are grounds for excluding cystic fibrosis and/or primary ciliary dyskinesia, or, in the case of a unilateral polyp, an encephalocele. In rare cases, nasal obstruction may be due to malignancy.

To visualize polyps and exclude other causes of nasal breathing difficulties (presence of a foreign body, deviated nasal septum, etc.), nasopharyngeal endoscopy is recommended.

Comments: the color of discharge from the nose is an important diagnostic criterion that allows one to judge the character. Transparent discharge is observed in the initial stages of rhinitis of viral etiology, with AR and, in rare cases, leakage of cerebrospinal fluid (CSF). Viscous and often colored mucus is found in the nasal cavity with adenoid vegetations, recurrent adenoiditis and / or rhinosinusitis, as well as in the later stages of viral rhinosinusitis. Sinusitis in children is always associated with inflammation of the nasal cavity; thus, the term "rhinosinusitis" is preferred. Long-term, chronic severe rhinosinusitis may also be associated with primary ciliary dyskinesia, cystic fibrosis, and dysfunction of the humoral and/or cellular component of the immune system. Children with unilateral colored discharge should be examined for the presence of a foreign body.

To exclude primary ciliary dyskinesia, it is recommended to determine nasal mucociliary clearance and nasal NO concentration.

If obstructive sleep apnea is suspected, polysomnography is recommended.

Comments: AR is a common cause of nasal congestion accompanied by wide-mouthed breathing, snoring, and nasal discharge in preschool children. However, adenoid vegetations are also a fairly common pathology characterized by similar symptoms.

Comments:with symptoms of hearing loss after anterior rhinoscopy, otoscopy, tympanometry, acoustic impendancemetry are performed, if necessary, a consultation with an audiologist.

Olfactory disturbance- a typical symptom of rhinosinusitis; children with severe rhinosinusitis and nasal polyps may have hyposmia or anosmia, often without noticeable subjective symptoms. The rare Kallmann syndrome is characterized by anosmia due to hypoplasia of the olfactory bulb.

Nosebleeds possible with AR or with stagnation of blood in the vessels located in the Kisselbach zone. With excessively heavy nosebleeds, an endoscopic examination is indicated, it is necessary to exclude angiofibroma of the nasopharynx and coagulopathy (D– low degree of persuasiveness; very low level of certainty (expert consensus).

Cough is an important manifestation of rhinitis, due to the flow of mucus along the back of the pharynx and irritation of cough receptors in the nasal cavity, larynx and pharynx. If other manifestations of AR are not noted, and the effect of the therapy is absent, it is necessary to conduct a differential diagnosis with recurrent infections of the upper respiratory tract, whooping cough, foreign body and aspiration bronchiectasis, tuberculosis. In the absence of other symptoms of bronchial obstruction, the child is most likely to have bronchial asthma.

table 2- Differential diagnosis of rhinitis in children

* The etiology is often viral or bacterial, very rarely fungal. Against the background of an acute respiratory viral infection, nasal symptoms prevail on the 2-3rd day and disappear by the 5th. In young children, on average, up to 8 episodes of upper respiratory infection per year are possible, about 4 at school age.

3. Treatment

The main goal of therapy is to achieve disease control.

The complex of therapeutic measures includes:

limiting contact with pathogenetically significant allergens;

drug therapy;

allergen-specific immunotherapy;

education.

3.1 Conservative treatment

(Grade of confidence A-C; medium confidence (depending on the allergen)

Comments: It is not possible to completely avoid exposure to outdoor allergens, such as pollen. But even partial exclusion of contact with the causative allergen alleviates the symptoms of AR, reducing disease activity and the need for pharmacotherapy. However, all elimination measures should be personalized, cost-effective and effective only in the case of a thorough preliminary allergological examination (including an anamnesis to assess clinical significance, skin testing and / or determination of sIgE titer).

Indoor allergens (dust mites, pets, cockroaches and moulds) are considered major triggers and targeted for specific interventions. Complete elimination of allergens is usually not possible, and some interventions involve significant costs and inconvenience, often with only limited effectiveness. Outdoor allergens are even more difficult to manage, the only recommended approach may be to stay indoors for certain periods of time (for pollen sensitization).

pollen allergens. The seasonality of symptoms in spring is due to the dusting of trees (birch, alder, hazel, oak), in the first half of summer - cereals (hedgehog, timothy, rye), at the end of summer and autumn - weeds (wormwood, plantain, ragweed). During the flowering season, to eliminate allergens, it is recommended to keep windows and doors closed in the room and in the car, use indoor air conditioning systems, and limit the time spent outdoors. After a walk, it is advisable to take a shower or bath to remove pollen from the body and hair and prevent contamination of clothes and linen.

Mold spores. To eliminate allergens, it is necessary to thoroughly clean air humidifiers, steam extractors, apply fungicides, and maintain relative humidity in the room below 50%.

Allergens of house dust mites (species Dermatophagoides pteronyssinus and Dermatophagoides farinae). The use of special anti-mite bedding, allergen-proof mattress covers, helps to reduce the concentration of house dust mites, but does not lead to a significant reduction in the symptoms of allergic rhinitis.

Epidermal allergens (animal allergens - cats, dogs, horses, etc.). It is most effective to completely avoid contact with animals.

Food allergens (cause AR due to cross-reactivity with pollen sensitization).

Although fungal spores and house dust mite allergens are year-round allergens, their amount in the ambient air usually decreases during the winter months and increases during the spring and autumn.

It should be remembered that clinical improvement should be expected after a long time (weeks) after the elimination of allergens.

Pharmacotherapy

Antihistamines

1st generation antihistamines (chloropyramine - ATX code R06AC03, mebhydrolin - code ATX R06AX, clemastine - ATX code R06AA04) is not recommended for the treatment of AR in children.

(B - moderate degree of persuasiveness; average level of confidence).

Comments: 1st generation antihistamines have an unfavorable therapeutic profile, have pronounced sedative and anticholinergic side effects. Drugs in this group disrupt cognitive functions: concentration, memory and learning ability. Given the lack of second-generation antihistamines registered for use, children under the age of 6 months can be prescribed dimethindene for a short course (dosing regimen for patients from 1 month to 1 year, 3-10 drops per dose 3 times a day).

Antihistamines of the 2nd generation are recommended as basic therapy for AR, regardless of the severity (both on a regular course and on demand).

(

Comments: second-generation antihistamines (MPs) for both oral and intranasal administration are effective in AR Oral drugs are better tolerated, while intranasal drugs are characterized by a faster onset of effect.

Systemic antihistamines prevent and relieve AR symptoms such as itching, sneezing, and runny nose, but are less effective for nasal obstruction. There is no possibility of developing tachyphylaxis when taking second-generation antihistamines. However, second-generation systemic antihistamines may also be mildly sedating in some children.

Desloratadine (ATX code: R06AX27) is used in children from 1 year to 5 years, 1.25 mg (2.5 ml), from 6 to 11 years, 2.5 mg (5 ml) 1 time per day in the form of a syrup, over 12 years old - 5 mg (1 tablet or 10 ml of syrup) 1 time per day.

Levocetirizine (ATX code: R06AE09) for children over 6 years old - in a daily dose of 5 mg, for children aged 2 to 6 years - 2.5 mg / day in the form of drops.

Loratadine (ATX code: R06AX13) is used in children over 2 years of age. For children weighing less than 30 kg, the drug is prescribed 5 mg 1 time per day, for children weighing more than 30 kg - 10 mg 1 time per day.

Rupatadine (ATX code: R06AX28) is used in children over 12 years old, the recommended dose is 10 mg 1 time / day.

Fexofenadine (ATX code: R06AX26) is used in children aged 6–12 years, 30 mg 1 time per day, over 12 years old - 120–180 mg 1 time per day.

Cetirizine (ATX code: R06AE07) for children aged 6 to 12 months. 2.5 mg 1 time per day, children from 1 to 6 years old are prescribed 2.5 mg 2 times a day or 5 mg 1 time per day in the form of drops, children over 6 years old - 10 mg once or 5 mg 2 times a day.

Intranasal antihistamines are recommended in the treatment of both intermittent and persistent AR in children.

Comments:drugs of this pharmacological group are characterized by a faster onset of action compared to systemic antihistamines

Azelastine (ATX code: R01AC0) is used in children over 6 years of age as a nasal spray, 1 inhalation 2 times a day.

Levocabastine (ATX code: R01AC02) is prescribed for children over 6 years of age - 2 inhalations in each nasal passage during inspiration 2 times a day (maximum - 4 times a day).

Intranasal corticosteroids

Intranasal glucocorticosteroids (GCS) are recommended for the treatment of AR in children and adolescents over 2 years of age.

(A - a high degree of persuasiveness; highest level of confidence).

Comments:intranasal (GCS) actively affect the inflammatory component of AR, effectively reducing the severity of symptoms such as itching, sneezing, rhinorrhea and nasal congestion (and ocular symptoms. It has been shown that mometasone, fluticasone and ciclesonide begin to have an effect during the first day after the start of treatment. The use of intranasal corticosteroids improves the manifestations of concomitant asthma (A - a high degree of persuasiveness; highest level of confidence), and mometasone and fluticasone furoate are also effective in concomitant allergic conjunctivitis (B - moderate degree of persuasiveness; average level of confidence).

Nasal corticosteroids are well tolerated. Modern drugs for once daily use (in particular, mometasone, fluticasone, fluticasone furoate) are preferred because, having a lower systemic bioavailability (0.5%), unlike beclamethasone (33%), they do not reduce the growth rate (according to treatment data for one year (A - a high degree of persuasiveness; highest level of confidence).

As a possible adverse event (AE) of intranasal corticosteroids, if used incorrectly, perforation of the nasal septum and nosebleeds are noted, however, the lack of systematic data does not allow assessing the risk of developing AEs.

Beclomethasone (ATX code: R01AD01) is approved for use from the age of 6, prescribed 1 spray (50 mcg) in each nostril 2-4 times a day (maximum dose 200 mcg / day for children 6-12 years old and 400 mcg / day for children over 12 years of age).

Budesonide (ATX code: R01AD05) is approved for use in children from 6 years of age, prescribed 1 dose (50 mcg) in each half of the nose 1 time per day (maximum dose 200 mcg / day for children 6-12 years old and 400 mcg / day for children over 12 years of age).

Mometasone (ATX code: R01AD09) for the treatment of seasonal and year-round AR is used in children from 2 years of age, children aged 2–11 years are prescribed 1 inhalation (50 mcg) in each half of the nose 1 time per day, from 12 years old and adults - 2 inhalations in each nostril 1 time per day.

Fluticasone furoate (ATX code: R01AD12) is prescribed to children from 2 years of age, 1 spray (27.5 μg of fluticasone furoate in one spray) in each nostril 1 time per day (55 μg / day). In the absence of the desired effect at a dose of 1 spray in each nostril 1 time per day, it is possible to increase the dose to 2 sprays in each nostril 1 time per day (the maximum daily dose is 110 mcg). When adequate control of symptoms is achieved, it is recommended to reduce the dose to 1 spray in each nostril 1 time per day.

Fluticasone (ATX code: R01AD08) is approved for use in children from 4 years of age, children aged 4–11 years are prescribed 1 injection (50 mcg) in each half of the nose 1 time per day, adolescents from 12 years old - 2 injections (100 mcg) in each half of the nose 1 time per day.

To increase the effectiveness of intranasal corticosteroids, it is recommended to clear the nasal cavity of mucus before the administration of drugs, as well as the use of moisturizers.

Nasal glucocorticosteroids are recommended as first choice for moderate to severe AR, especially if nasal congestion is the main complaint, while second-generation antihistamines/montelukast may be preferred for mild AR.

To date, there is enough data to recommend nasal corticosteroids as more effective drugs for the treatment of AR than antihistamines and montelukast.

Systemic corticosteroids

(D = low confidence; very low confidence (expert consensus).

Comments:given the high risk of systemic side effects, the use of this group of drugs for the treatment of AR in children is very limited. School-age children with severe AR can only be prescribed a short course of prednisolone (ATX code: H02AB06) orally at 10–15 mg per day; duration of admission 3-7 days

Leukotriene receptor antagonists (ALTRs)

(A - a high degree of persuasiveness; highest level of confidence).

Comments: among leukotriene modifiers in children is used montelukast(ATX code: R03DC03). With concomitant bronchial asthma, the inclusion of montelukast in the treatment regimen allows, without increasing the load of corticosteroids, to effectively control the symptoms of AR.

In children aged 2-6 years, a tablet form is used at a dosage of 4 mg 1 time per day, from 6 to 14 years old chewable tablets 5 mg 1 time per day, from 15 years old - 10 mg per day.

Antihistamines and montelukast are recommended as an adjunct to nasal corticosteroid therapy.

(B – moderate degree of persuasiveness; medium level of certainty).

Comments: however, there are insufficient comparative data available to determine whether antihistamines are more effective than montelukast.

Nasal anticholinergics in the territory of the Russian Federation for this indication are not registered; children are not recommended for use.

Nasal decongestants

Topical decongestants (naphazolin (ATX code: R01AA08), oxymetazoline (ATX code: R01AA05), xylometazoline (ATX code: R01AA07)) is recommended for severe nasal obstruction in a short course (no more than 3-5 days).

(C – low degree of persuasiveness; low level of certainty).

Comments:longer use of this group of drugs leads to recurrent swelling of the nasal mucosa.

Nasal sodium cromoglycate

Comments:cromones are less effective than intranasal corticosteroids, antihistamines and montelukast in the treatment of AR(B – moderate degree of persuasiveness; medium level of certainty).Cromoglycic acid (ATX code: R01AC01) is registered for use in children over 5 years of age with mild AR in the form of a nasal spray, 1-2 inhalations in each nasal passage 4 times a day.

Other drugs

(A - a high degree of persuasiveness; highest level of confidence).

Comments:promote moisturizing and cleansing of the nasal mucosa, have proven effectiveness. Nasal lavage with saline or sterile seawater (ATX code: R01AX10) is an inexpensive treatment for rhinitis with limited but proven efficacy.

Anti-IgE Therapy: Not recommended for AR treatment alone.

Alternative therapies for the treatment of AR in children are not recommended.

If control is not achieved within 1.5–2 weeks, it is recommended to reconsider the diagnosis.

In children younger than 2 years of age, in the absence of the effect of antihistamines within a week before increasing therapy, it is recommended to reconsider the diagnosis.

For the seasonal form of the disease, regular treatment is recommended to start 2 weeks before the expected onset of symptoms.

In the absence of symptom control in severe AR, it is recommended to prescribe a short course of decongestants, if necessary, the possibility of emergency use of a short course of low-dose prednisolone (orally) is considered.

Immunotherapy

ASIT) is recommended for children with AR if there is clear evidence of an association between allergen exposure, disease symptoms, and an IgE-dependent mechanism. (B – moderate degree of persuasiveness; medium level of certainty).

Comments:ASIT induces clinical and immunological tolerance, has long-term efficacy and can prevent the progression of allergic diseases: it reduces the likelihood of developing bronchial asthma in patients with AR and conjunctivitis and expands the spectrum of sensitization. The positive impact of ASIT on the quality of life of the patient and his family members is shown.

ASIT should be carried out by a specialist allergist-immunologist. Treatment is carried out only in specialized allergological rooms of outpatient clinics and allergological departments of hospitals / day hospitals. The duration of therapy is usually 3-5 years. The selection of the drug and the route of administration is carried out by a specialist individually. Sublingual ASIT is more preferable for children, painless, convenient from the position of the route of administration and has a more favorable safety profile compared to the subcutaneous method. Premedication with antihistamines and ALTP may reduce the prevalence and severity of adverse effects of ASIT

Contraindications to allergen-specific immunotherapy are severe concomitant conditions: immunopathological processes and immunodeficiencies, acute and chronic recurrent diseases of internal organs, severe persistent bronchial asthma, poorly controlled by pharmacological drugs, contraindications to the appointment of adrenaline and its analogues, poor tolerability of the method.

Pharmacoeconomic models based on data from clinical trials and meta-analyses indicate that ASIT is cost effective.

3.2 Surgical treatment

Usually not required

3.3 Other treatment

(B - moderate degree of persuasiveness; average level of confidence).

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Allergic rhinitis, unspecified (J30.4), Pollen allergic rhinitis (J30.1), Other allergic rhinitis (J30.3), Other seasonal allergic rhinitis (J30.2)

Allergology, Allergology for children, Pediatrics

general information

Short description

Approved
Joint Commission on the quality of medical services
Ministry of Health of the Republic of Kazakhstan
dated September 15, 2017
Protocol No. 27

allergic rhinitis- allergic inflammation of the nasal mucosa, caused by contact with a causative allergen and manifested by rhinorrhea, nasal congestion, itching and sneezing with a duration of more than an hour during the day.

INTRODUCTION

Ratio of ICD-10 codes:

Protocol development date: 2013 (revised 2017).

Abbreviations used in the protocol:

Protocol Users: General practitioners, therapists, otorhinolaryngologists, pediatricians, allergists.

Evidence level scale:

Classification

Classification

:
The main features of the ARIA classification of AP take into account three main points:
1) duration of manifestations of AR;
2) severity of AR;
3) impact on the quality of life of AR.

1) Classification of AR by duration manifestations of AR :
Intermittent AR - the duration of symptoms is less than 4 days a week with a total duration of less than 4 weeks;
persistent AR - the duration of symptoms is more than 4 days a week with a total duration of more than 4 weeks.

2) Classification of AR according to the severity of manifestations and their impact on the quality of life:
Mild AR - there are clinical manifestations, but they do not disrupt daily activities (work, study) and do not affect sleep. The quality of life is little disturbed;
AR of moderate severity - there are clinical manifestations, they either disrupt daily activity (work, study), or disturb sleep. The quality of life is significantly reduced;
Severe AR - clinical manifestations are strong, they disrupt daily activities (work, study), and interfere with sleep. The quality of life is greatly impaired.

According to the phase of the disease:
3) Classification of AR by flow phase:
aggravation phase
remission phase.
It is not recommended to divide AR into seasonal and year-round forms, due to the multifactorial nature of AR and the need for its treatment and prevention even during the "off-season" period.

Diagnostics

METHODS, APPROACHES AND DIAGNOSIS PROCEDURES

Diagnostic criteria:

Differential Diagnosis

Differential Diagnosis:

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Treatment

Drugs (active substances) used in the treatment

Treatment (ambulatory)

TACTICS OF TREATMENT AT THE OUTPATIENT LEVEL
Treatment at the outpatient level is the main (and almost the only) method of dealing with allergic rhinitis. The tactics are reduced to minimizing symptoms (topical nasal and general), improving the patient's quality of life, preventing repeated exacerbations and complications from the upper and lower respiratory tract, including the development of bronchial asthma.

Hemedical treatment:
Protective regime (avoid contact with allergens, irritating agents, hypothermia, SARS, etc.);
Hypoallergenic diet
elimination (elimination) of causative and provoking factors;
reduction of contact with causative and provoking factors, in case of impossibility of complete elimination of the allergen;
· breathing exercises.
barrier agents and saline solutions in the form of nasal sprays. They are not medicines. They are used topically for preventive and restorative purposes.

Medical treatment(depending on the form, phase and severity), basic principles ( UD A):

Fixed assets:
Topical (intranasal) glucocorticosteroids(UD A):
Basic pathogenetic treatment of allergic rhinitis. The duration of continuous use can reach two years, but at the same time, alternating courses of prescribing drugs are shown (for example, every other day, or two to three times a week). Only this group of drugs provides comprehensive treatment and prevention of complications of AR (conjunctivitis, laryngitis, obstructive syndrome, bronchial asthma, etc.). They are used as monotherapy or in combination with antihistamine or antileukotriene drugs per os. The duration of the course is from 1 week to 6 months (if necessary, up to 12 months). Recommended for use in adults and children from 6 years of age.
Beclomethasone - 100-400 mcg / day (2-8 injections per day);
mometasone - 100-400 mcg / day (2-8 injections per day);
Fluticasone propionate - 100-400 mcg / day (2-8 injections per day);
Fluticasone furoate - 100-400 mcg / day (2-4 injections per day).

Antileukotriene drugs(leukotriene receptor antagonists) ( UDA):
Basic treatment of AR, especially when it is combined with broncho-obstructive manifestations and asthma, prevention of the development of asthma. As a rule, they are prescribed in combination with topical intranasal corticosteroids or as monotherapy (rarely). Assigned to children from 6 months of age (4 mg), from 6 years of age (5 mg), adolescents and adults (10 mg).
Montelukast - 4, 5 or 10 mg, depending on the age of the patient, 1 time per day, in the evening, for a long time (up to 3-6 months or longer, if clinically indicated).

2nd or 3rd generation antihistamines(UD A):
Basic treatment of allergic rhinitis. Apply in courses from several days to several months. They are used in combination with topical intranasal corticosteroids or as monotherapy (less often, especially in the presence of concomitant urticaria). Appointed 1 time per day, adults and children from 2 years old, only in oral form. The duration of the course of treatment is determined by the attending physician, usually does not exceed 3 months.
Loratadine 10 mg/day;
cetirizine 10 mg/day;
fexofenadine 120 mg and 180 mg/day;
ebastine 10-20 mg/day*;
Desloratadine 5 mg/day;
Levocetirizine 5 mg/day;
bilastine 20 mg/day.

Antihistamines 1st generation (UD A) - are used in acute course of moderate or severe degree in the first 3-5 days, followed by the transition to drugs of the 2nd or 3rd generation. They are used in children from birth, adolescents and adults, in oral or parenteral form.
Chloropyramine 5-75 mg/day;
hifenadine 25-75 mg/day*;
mebhydrolin 50-150 mg/day*;
· diphenhydramine 50-150 mg/day;
clemastine 1-3 mg/day;
promethazine 25-75 mg/day;
Dimethindene 1-6 mg/day*
Ketotifen 1-3 mg/day*

Sympathomimetic agents (UDA) - for the treatment of diseases of the nose (decongestants) are used only as a symptomatic remedy for temporary restoration of the patency of the nasal passages (for example, before taking topical steroids), as well as for mild allergic rhinitis. They are prescribed for children from 6 years of age and adults, no more than 4 doses per day and no more than 5-7 days, as there is a tendency to tachyphylaxis and other side effects.
naphazoline 0.05%, 0.1%*;
Oxymetazoline 0.05, 0.1%%;
xylometazoline 0.05, 0.1%;
Tetrizoline 0.05%, 0.1%*.

Additional funds:
Allergen specific immunotherapy ( UD A) :
It is carried out by an allergist after conducting SAD in vitro and in vivo and establishing causally significant allergens if their elimination is impossible and there are no contraindications. Only during a period of complete remission. SIT is possible in several ways - subcutaneous, oral, sublingual, intranasal. We use highly purified extracts of allergens intended for treatment, which have passed clinical trials and are approved for use in the Republic of Kazakhstan.

Membrane stabilizers*(UDD):
They are used mainly locally, with a preventive purpose, more indicated in childhood. The effectiveness of systemic use has not been confirmed.
· Cromoglycine acid 50-200 mg/day.
NB!* - drugs, at the time of the revision of the protocol, not included in the KNF, but registered in the Republic of Kazakhstan (status as of 06.2017, available from www.knf.kz)

Surgical intervention: No.

Further management:
Preventive actions:
Promoting knowledge about allergies, allergic rhinitis and bronchial asthma as the most common complication. Early detection of hypersensitivity, alertness in case of a burdened personal or family allergic history, detection and treatment of diseases of the upper respiratory tract, smoking cessation, ecology of work and life, healthy lifestyle.
observation of an allergist in dynamics;
education of patients in the school of allergy (asthma);
specific allergodiagnostics and elimination of causative allergens;
preventive hypoallergenic measures in housing and in the workplace;
exclusion of provoking factors, smoking;
wearing special filters or masks;
The use of systems for cleaning, ionization, ozonation, filtration, air humidification, vacuum cleaners with water filtration or "washing";

Treatment effectiveness indicators:
relief of clinical manifestations;
restoration of patency of the nasal passages;
restoration of nasal breathing, especially at night;
Improving the quality of life;
restoration of working capacity;
Reduction of sensitization during skin-allergic testing;
Decrease in the content of general and specific IgE (usually against the background of prolonged ASIT).

Hospitalization

Indications for planned hospitalization: No.

Indications for emergency hospitalization: No

Information

Sources and literature

1. Minutes of the meetings of the Joint Commission on the quality of medical services of the Ministry of Health of the Republic of Kazakhstan, 2017
   1. 1) Allergic rhinitis. consensus statement. EAACI position paper. // Allergy. 2000:55-116-134. 2) ARIA 2010. Allergic rhinitis and its impact on asthma. Annual Workshop Report. WHO. 2010. 3) Scientific and practical program "Program for the management of bronchial asthma and allergic rhinitis at the present stage in the Republic of Kazakhstan", Almaty, 2011, 27 p. 4) Allergology and immunology. National leadership. Ed. R.M. Khaitova, N.I. Ilina.- M.: GEOTAR Media, 2013 - 640 p. 5) Allergology. Federal clinical guidelines. Ed. R.M. Khaitova, N.I. Ilyina.- M., 2014.- 126 p. 6) Akdis C.A., Agache I. Global Atlas of allergy. - EAACI, 2014.- 398 p. 7) Federal clinical guidelines for the diagnosis and treatment of allergic rhinitis - Moscow, 2013 - 18 p. 8) Akpeisova R.B. Epidemiological and clinical and functional features of allergic rhinitis in combination with bronchial asthma. - abstract. cand. diss. - Almaty, 2009 - 28 p. 9) National register of medicines. Status as of June 2017. SCELSYMN MOH RK. Available from www.dari.kz 10) Global strategy for asthma management and prevention, 2012 (Update).- 2016.- 128 p. (available at www.ginasthma.com) 11) White book on allergy: Update 2013. Pavancar R. et al (eds) - World allergy organization, 2013 – 239 p.

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of developers:
1) Nurpeisov Tair Temyrlanovich - Doctor of Medical Sciences, Associate Professor, Head of the Republican Allergology Center of the RSE on REM "Research Institute of Cardiology and Internal Diseases", Almaty.
2) Zhanat Bakhytovna Ispayeva - Doctor of Medical Sciences, Professor, Head of the Allergology and Clinical Immunology Course, Kazakh National Medical University named after S.D. Asfendiyarova, President of the Kazakhstan Association of Allergists and Clinical Immunologists, member of EAACI.
3) Rozenson Rafail Iosifovich - Doctor of Medical Sciences, Professor of the Department of Children's Diseases No. 1, JSC "Astana Medical University".
4) Yukhnevich Ekaterina Alexandrovna - clinical pharmacologist, acting Associate Professor of the Department of Clinical Pharmacology, RSE on REM "Karaganda State Medical University".

Conflict of interests: no.

List of reviewers:
1) Gazalieva Meruert Arstanovna - Doctor of Medical Sciences, Head of the Department of Allergology and Immunology, RSE on REM "Karaganda State Medical University".

Conditions for revision of the protocol: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attached files

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1 RUSSIAN UNION OF PEDIATRICS RUSSIAN ASSOCIATION OF ALLERGOLOGISTS AND CLINICAL IMMUNOLOGISTS FEDERAL CLINICAL RECOMMENDATIONS FOR PROVIDING MEDICAL CARE TO CHILDREN WITH ALLERGIC RHINITIS Chief freelance specialist pediatrician of the Ministry of Health of Russia Academician of the Russian Academy of Sciences A.A. Baranov Chief Freelance Pediatric Allergist-Immunologist of the Ministry of Health of Russia Corresponding Member of the Russian Academy of Sciences L.S. Namazova-Baranova 2015

2 Table of contents Methodology .. 3 Definition ... 5 ICD code Epidemiology ..5 Classification Etiopathogenesis Clinical picture Concomitant pathology, symptoms ..8 Diagnosis .. 9 Differential diagnosis ..10 Treatment ..12 Management of children with AR Prevention ... 18 Forecast.19 2

3 FEDERAL CLINICAL RECOMMENDATIONS FOR PROVIDING MEDICAL CARE TO CHILDREN WITH ALLERGIC RINITIS These clinical guidelines were prepared jointly with the Russian Association of Allergologists and Clinical Immunologists, reviewed and approved at a meeting of the Executive Committee of the Professional Association of Pediatricians of the Union of Pediatricians of Russia at the XVII Congress of Pediatricians of Russia "Actual Problems of Pediatrics" on February 15 2014, updated. Approved at the XVIII Congress of Pediatricians of Russia "Actual problems of pediatrics" on February 14, 2015. Members of the working group: acad. RAS Baranov A.A., Corr. RAS Namazova-Baranova L.S., acad. RAS Khaitov R.M., prof., MD Ilyina N.I., Prof., MD Kurbacheva O.M., prof., d.m.s. Novik G.A., Prof., MD Petrovsky F.I., Ph.D. Vishneva E.A., Ph.D. Selimzyanova L.R., Ph.D. Alekseeva A.A. The authors confirm that there is no financial support/conflict of interest to be made public. METHODOLOGY Methods used to collect/select evidence: searches in electronic databases. Description of the methods used to assess the quality and strength of the evidence: The evidence base for the recommendations are publications included in the Cochrane Library, the EMBASE, MEDLINE and PubMed databases. Search depth - 5 years. Methods used to evaluate the quality and strength of evidence: expert consensus; assessment of significance in accordance with the rating scheme (the scheme is attached). Table 1 Rating scheme for assessing the level of evidence Levels Description of evidence 1++ High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias. 1+ Well-conducted meta-analyses, systematic, or RCTs with low risk of bias. 1- Meta-analyses, systematic, or RCTs with a high risk of bias. 2++ High quality systematic reviews of case-control or cohort studies. High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate likelihood of causation. 2+ Well-conducted case-control or cohort studies with an average risk of confounding or systematic effects 3

4 errors and the average probability of a causal relationship. 2- Case-control or cohort studies with a high risk of confounding effects or bias and a moderate likelihood of causation. 3 Non-analytic studies (eg: case reports, case series). 4 Expert opinion. Methods used to analyze the evidence: reviews of published meta-analyses; systematic reviews with tables of evidence. Description of the methods used to analyze the evidence When selecting publications as potential sources of evidence, the methodology used in each study is reviewed to ensure its validity. The outcome of the study affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendation. To minimize potential errors, each study was evaluated independently. Any differences in the estimates were discussed by the whole group of authors in full. If it was impossible to reach a consensus, an independent expert was involved. Evidence tables: completed by the authors of clinical guidelines. Methods used to formulate recommendations: expert consensus. Table 2 Rating scheme for estimating the strength of recommendations Strength Description A At least one meta-analysis, systematic review, or RCT rated 1++, directly applicable to the target population and demonstrating robust results rated as 1+, directly applicable to the target population and demonstrating overall sustainability of results. B A body of evidence that includes results from studies rated 2++ that are directly applicable to the target population and demonstrate overall consistency of results, or Extrapolated evidence from studies rated 1++ or 1+. C A body of evidence that includes results from studies rated 2+ that are directly applicable to the target population and demonstrate overall consistency of results, or Extrapolated evidence from studies rated 2++. D Level 3 or 4 evidence; or Extrapolated evidence from studies rated 2+. Good Practice Points GPPs The recommended good practice is based on the clinical experience of the authors of the developed guidelines. four

5 Economic analysis Cost analysis was not performed and publications on pharmacoeconomics were not analyzed. Recommendations validation method External peer review. Internal peer review. Description of the Guideline Validation Method These draft guidelines have been peer-reviewed by peer reviewers who were first asked to comment on the ease of understanding of the interpretation of the evidence underlying the guidelines. Comments were received from primary care physicians (allergists-immunologists) regarding the intelligibility of the presentation of these recommendations, as well as their assessment of the importance of the proposed recommendations as a tool for everyday practice. All comments received from the experts were carefully systematized and discussed by the members of the working group (the authors of the recommendations). Each item was discussed separately. Consultation and peer review The draft guidelines were peer-reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence base underlying the guidelines. Working group For the final revision and quality control, the recommendations were re-analyzed by the members of the working group, who came to the conclusion that all the comments and comments of the experts were taken into account, the risk of systematic errors in the development of recommendations was minimized. Key recommendations Strength of recommendations (A-D) based on appropriate levels of evidence (1+ +, 1+, 1-, 2++, 2+, 2-, 3, 4) and good practice points (GPPs) are provided in the presentation the text of the recommendations. Definition Allergic rhinitis (AR) is an IgE-mediated inflammatory disease of the nasal mucosa caused by exposure to a sensitizing (causally significant) allergen and is manifested by at least two symptoms - sneezing, itching, rhinorrhea or nasal congestion. ICD-10 code: J30.1 Pollen allergic rhinitis J30.2 Other seasonal allergic rhinitis J30.3 Other allergic rhinitis J30.4 Unspecified allergic rhinitis Epidemiology of AR is a widespread disease. The mean prevalence of AR symptoms is 8.5% (1.8-20.4%) in 6-7-year-olds and 14.6% (1.4-33.3%) in summer children (International Asthma and Allergy Study in Childhood : International Study of Asthma and Allergy in Childhood (ISAAC) Based on protocol 5 results

6 GA 2 LEN (Global Allergy and Asthma European Network) in years, the prevalence of symptoms of allergic rhinitis in adolescents was 34.2%, when conducting an in-depth examination in 10.4% of cases, the diagnosis of AR was confirmed that to a large extent prevails over the official statistics. Since similar studies, there has been an increase in the observed prevalence of AR worldwide. However, data for different centers vary greatly. The frequency of AR symptoms in the Russian Federation is 18 38%. Boys get sick more often. In the age group under 5 years, the prevalence of AR is the lowest, the rise in incidence is noted at early school age. Classification According to the traditional approach, AR is classified based on the duration and severity of rhinitis symptoms in the presence of sensitization. Typical allergens are, in particular, house dust mites, pollen of trees, cereals and weeds, animal allergens (cats, dogs), as well as mold fungi Cladosporium, Penicillium, Alternaria, etc. The presence of AR is possible even in the absence of a noticeable specific sensitization, which due to the local formation of immunoglobulin E (IgE) in the nasal mucosa, the so-called. entopy. The question of whether this effect is observed in children remains open. Allergic rhinitis, depending on the nature of a pathogenetically significant allergen, can be seasonal (with sensitization to pollen or fungal allergens) or year-round (with sensitization to household - house dust mites, cockroaches, and epidermal - animal dander, allergens). However, the distinction between seasonal and perennial rhinitis cannot always be made in all regions; as a result, this terminology has been revised and, based on the duration of symptoms, there are (according to the classification of ARIA 2008, 2010, and also EAACI 2013): intermittent (seasonal or year-round, acute, occasional) AR (symptoms< 4 дней в неделю или < 4 нед. в году); персистирующий (сезонный или круглогодичный, хронический, длительный) АР (симптомы 4 дней в неделю или 4 нед. в году). Такой подход удобен для описания проявлений ринита и его влияния на качество жизни, а также для определения возможного подхода к лечению. По степени выраженности проявлений и влиянию на качество жизни АР подразделяют на: АР легкого течения (незначительные симптомы; нормальный сон; нормальная повседневная активность, занятия спортом, отдых; не мешает учебе в школе или профессиональной деятельности); АР среднетяжелого и тяжелого течения (при наличии мучительных симптомов, приводящих к появлению хотя бы одного из таких признаков, как нарушение сна, нарушение повседневной активности, невозможность занятий спортом, нормального отдыха; нарушения профессиональной деятельности или учебы в школе); Кроме того, выделяют обострение и ремиссию аллергического ринита. Этиопатогенез Аллергены (АлГ) это вещества, преимущественно белковой природы, с молекулярной массой около 20 kd (от 5 до 100 kd) и ли низкомолекулярные соединения, гаптены, которые при первом поступлении в организм, предрасположенный к развитию аллергии, 6

7 cause sensitization, i.e. the formation of specific IgE antibodies, and in the subsequent development of allergic reactions. To systematize numerous allergens, several approaches have been proposed: by the way they enter the body (inhalation, enteral, contact, parenteral, transplacental); by distribution in the environment (aeroallergens, indoor allergens, external allergens, industrial and occupational allergens and sensitizers); by category (infectious, tissue, non-infectious, medicinal, chemical); by origin (medicinal, food, insect or insect allergens); by diagnostic groups (household, epidermal, mold spores, pollen, insect, medicinal and food). A special international nomenclature has been developed for the designation of allergens. In our country, the most common is the classification that distinguishes the following diagnostic groups: non-infectious household (aeroallergens of dwellings), epidermal, pollen, food, insect, medicinal allergens; infectious fungal, bacterial allergens. In foreign literature, internal (indoor) AlG of house dust, house dust mites, cockroaches, pets, fungi and external (outdoor) AlG of pollen and fungi are distinguished. An allergic reaction develops in a sensitized organism upon repeated contact with an allergen, accompanied by the development of allergic inflammation, tissue damage and the appearance of clinical symptoms of allergic diseases. In the pathogenesis of allergic diseases, immediate type reactions (IgE-dependent, anaphylactic, atopic) are the main (but not always the only ones). At the first contact with the allergen, specific IgE antibodies are formed, which are fixed on the surface of mast cells in various organs. This condition is called sensitization - increased sensitivity to a particular AlG. Upon repeated contact of a sensitized organism with causative ALG, IgE-dependent inflammation develops in the nasal mucosa, causing the development of symptoms. In most cases, one patient is simultaneously sensitized to several allergens belonging to different groups. During the first minutes after exposure to AlG (an early phase of an allergic reaction), mast cells and basophils are activated, degranulation and release of inflammatory mediators (histamine, tryptase, prostaglandin D2, leukotrienes, platelet activating factor). As a result of the action of mediators, there is an increase in vascular permeability, hypersecretion of mucus, contraction of smooth muscles, the occurrence of acute symptoms of allergic diseases: itching of the eyes, skin, nose, hyperemia, swelling, sneezing, watery discharge from the nose. After 4-6 hours (late phase of the allergic reaction) after exposure to AlG, there is a change in blood flow, expression of cell adhesion molecules on the endothelium and leukocytes, infiltration of tissues with allergic inflammation cells basophils, eosinophils, T lymphocytes, mast cells. As a result, the formation of chronic allergic inflammation occurs, one of the clinical manifestations of which is nonspecific tissue hyperreactivity. The characteristic symptoms are nasal hyperreactivity and obstruction, hypo- and anosmia. Clinical picture Main - classical symptoms of allergic rhinitis: - rhinorrhea (discharge from the nasal passages is transparent, mucous character); 7

8 - sneezing - often paroxysmal; - itching, less often - a burning sensation in the nose (sometimes accompanied by itching of the palate and pharynx); - nasal obstruction, characteristic mouth breathing, sniffling, snoring, apnea, voice change and nasality. The characteristic symptoms also include "allergic circles under the eyes" - darkening of the lower eyelid and periorbital region, especially in severe chronic course of the process. Additional symptoms develop due to profuse secretion from the nose, impaired drainage of the paranasal sinuses and patency of the auditory (Eustachian) tubes. Manifestations may include coughing, decreased and lack of sense of smell; irritation, swelling, hyperemia of the skin above the upper lip and near the wings of the nose; nosebleeds due to forced blowing; sore throat, cough (manifestations of concomitant allergic pharyngitis, laryngitis); pain and crackling in the ears, especially when swallowing; hearing impairment (manifestations of allergic tubotitis). Among the general non-specific symptoms observed in allergic rhinitis, note: - weakness, malaise, irritability; - headache, fatigue, impaired concentration; - sleep disturbance, depressed mood; - rarely - fever. Age Symptoms Main symptoms Possible additional symptoms sleep apnea, “allergic circles under the eyes” Ear ​​pain with pressure changes (for example, during flight) due to Eustachian tube dysfunction Hearing loss in chronic otitis media Cough Sleep disturbances fatigue, poor school performance, irritability Long-term and frequent respiratory tract infections. Poor asthma control Headache, facial pain, halitosis, cough, hypo- and anosmia in rhinosinusitis Comorbidities, symptoms The nose is anatomically and functionally related to the eyes, sinuses, nasopharynx, middle ear, larynx and lower airways thus, symptoms may include conjunctivitis, chronic cough, mouth breathing, nasal voice, and snoring with or without obstructive sleep apnea. Allergic conjunctivitis is considered the most common comorbidity associated with AR. It is characterized by severe itching in the eyes, conjunctival hyperemia, lacrimation, and sometimes periorbital edema. eight

9 Chronic allergic inflammation of the upper respiratory tract can cause hypertrophy of the lymphoid tissue. A significant increase in the size of adenoids during the dusting season is observed in children with hay fever. In polysomnography, there is a pronounced correlation of sleep apnea syndrome with a history of nasal congestion and AR. Chronic middle ear exudate and Eustachian tube dysfunction have also been associated with rhinitis, potentially causing hearing loss. In the pathogenesis of ongoing allergic inflammation in the adenoid lymphatic tissue in children with atopy, local secretion of nonspecific and specific IgE to environmental allergens and staphylococcal enterotoxin antigens may play a role. AR is often combined with asthma, being one of the determining risk factors for its occurrence. AR is one of the reasons for the development of exacerbation and reduction / lack of control of bronchial asthma: its symptoms often precede the manifestations of asthma. AR significantly increases the risk of emergency room visits for asthma. At the same time, the presence of cough in allergic rhinitis sometimes pushes the doctor to a false diagnosis of bronchial asthma. Being one of the “steps” of the atopic march, allergic rhinitis often accompanies atopic dermatitis, sometimes preceding, and sometimes ahead of, this form of allergy manifestation. Allergic rhinitis due to pollen sensitization may be associated with food allergies (oral allergy syndrome). In this case, symptoms such as itching, burning and swelling of the mouth are due to cross-reactivity: sensitization to ragweed pollen can cause symptoms after eating melon; to birch pollen - after eating apples, etc. Diagnosis Diagnosis of AR is established on the basis of history, characteristic clinical symptoms and the identification of causally significant allergens (by skin testing and or determining the titer of specific antibodies of the IgE class in vitro if skin testing is not possible) D. History and physical examination When taking anamnesis, specify the presence of allergic diseases in relatives; the nature, frequency, duration, severity of symptoms, the presence / absence of seasonal manifestations, response to therapy, the presence of other allergic diseases in the patient, provoking factors. It is necessary to carry out rhinoscopy (examination of the nasal passages, the mucous membrane of the nasal cavity, secretion, turbinates and septum). In patients with AR, the mucous membrane is usually pale, cyanotic gray, and edematous. The nature of the secret is slimy and watery. In chronic or severe acute AR, a transverse fold is found on the back of the nose, which is formed in children as a result of an "allergic salute" (rubbing the tip of the nose). Chronic nasal obstruction leads to the formation of a characteristic "allergic face" (dark circles under the eyes, impaired development of the facial skull, including malocclusion, arched palate, flattening of the molars). Identification of sensitizing allergens Skin testing allows you to identify causally significant allergens. If it is impossible to conduct this study and / or there are contraindications (children under 2 years of age, exacerbation of concomitant allergic pathology, taking medications that affect the test result, etc.), specific antibodies of the IgE class (sige) are determined. This method is more expensive, and it is not necessary to cancel antihistamines before the study. 9

10 Allergic sensitization is diagnosed with a positive result of skin testing or detection of IgE class antibodies specific to a certain allergen, while the quantitative characteristic of the studied parameter (papule size, serum concentration of sige) is extremely important. Additional research methods To exclude other diagnoses during the differential diagnostic search and / or if therapy is ineffective, it is recommended to conduct additional studies D: CT scan of the paranasal sinuses to exclude chronic rhinosinusitis and polyposis D. Endoscopy of the nasopharynx to visualize polyps D and exclude other causes of nasal breathing difficulty ( the presence of a foreign body, curvature of the nasal septum, etc.). Determination of nasal mucociliary clearance and nasal concentration of NO to rule out primary ciliary dyskinesia C. To rule out bronchial asthma, it is required to determine indicators of respiratory function and test with a bronchodilator for the reversibility of bronchial obstruction. In doubtful cases, a test with physical activity is carried out. If obstructive sleep apnea is suspected, polysomnography is performed. With symptoms of hearing loss after anterior rhinoscopy, otoscopy, under the supervision of an ENT doctor, additional studies are carried out: tympanometry, acoustic impendancemetry, if necessary, consultation with an audiologist. Additional methods not recommended for routine use: Cytological examination of swabs from the nasal cavity, a method designed to detect eosinophils (performed during an exacerbation of the disease). The practical application of the method is limited, since the appearance of eosinophils in the nasal secretion is possible in other diseases (BA, nasal polyps in combination with asthma or without it, non-allergic rhinitis with eosinophilic syndrome). Determination of the content of eosinophils and the concentration of total IgE in the blood has a low diagnostic value. Provocative tests with allergens in pediatric clinical practice have an extremely limited use C, they are performed only by specialists (allergologists-immunologists) in specialized medical institutions of an allergological profile. Differential diagnosis Differential diagnosis of allergic rhinitis is carried out on the basis of symptoms, taking into account age characteristics D (Table 4). They need special attention if the treatment does not have an effect on the symptoms. Nasal congestion Difficulty in nasal breathing (nasal congestion, nasal obstruction) may be the result of mucosal pathology and / or anatomical abnormalities (often - nasal septal curvature, less often - stenosis of the vestibule of the nose with a cleft lip, choanal atresia or pyriform stenosis). AR is a common cause of nasal congestion accompanied by wide-mouthed breathing, snoring, and nasal discharge in preschool children. However, adenoid vegetations are also a fairly common pathology characterized by similar symptoms. Nasal polyps that obstruct nasal breathing are grounds for ruling out cystic fibrosis and/or primary 10

11 ciliary dyskinesia, or, in the case of a unilateral polyp, encephalocele D. In rare cases, nasal obstruction may be due to malignancy. Color of discharge from the nasal passages The color of discharge from the nose is an important diagnostic criterion that allows one to judge the nature of the pathology D. Transparent discharge is observed in the initial stages of rhinitis of viral etiology, with AR and, in rare cases, leakage of cerebrospinal fluid (CSF). Viscous and often colored mucus is found in the nasal cavity with adenoid vegetations, recurrent adenoiditis and / or rhinosinusitis, as well as in the later stages of viral rhinosinusitis. Sinusitis in children is always associated with inflammation of the nasal cavity; thus, the term "rhinosinusitis" is preferred. Long-term, chronic severe rhinosinusitis may also be associated with primary ciliary dyskinesia, cystic fibrosis, and dysfunction of the humoral and/or cellular component of the immune system D. Children with unilateral stained discharge should be evaluated for the presence of a foreign body D. Smell impairment Smell impairment is a typical symptom of rhinosinusitis; children with severe rhinosinusitis and nasal polyps may have hyposmia or anosmia, often without noticeable subjective symptoms. The rare Kallmann syndrome is characterized by anosmia due to hypoplasia of the olfactory bulb. Nosebleeds Mild manifestations are possible with AR or with stagnation of blood in the vessels located in the Kisselbach zone. In case of excessive nasal bleeding, an endoscopic examination is indicated, it is necessary to exclude angiofibroma of the nasopharynx and coagulopathy D. Cough Cough is an important manifestation of rhinitis, caused by mucus flow down the back of the pharynx and irritation of cough receptors in the nasal cavity, larynx and pharynx. If other manifestations of AR are not noted, and the effect of the therapy is absent, it is necessary to conduct a differential diagnosis with recurrent infections of the upper respiratory tract, whooping cough, foreign body and aspiration bronchiectasis, tuberculosis. In the absence of other symptoms of bronchial obstruction, the child is most likely to have bronchial asthma. Table 4 Differential diagnosis of rhinitis in children D Diagnosis Preschool School Adolescent Infectious rhinitis Rhinosinusitis Deviated septum Choanal atresia or stenosis Immunodeficiency states Encephalocele Adenoid vegetations Nasal congestion, rhinorrhea, sneezing cough Nasal congestion in the absence of other symptoms of allergic rhinitis Nasal congestion without other signs of allergic rhinitis Mucopurulent discharge (persistent process) Unilateral nasal polyp Breathing through the mouth, mucopurulent discharge, snoring in the absence of other signs of allergic rhinitis 11

12 Foreign body Cystic fibrosis Primary ciliary dyskinesia Coagulopathy Systemic autoimmune diseases (Wegener's granulomatosis) CSF leakage Unilateral process accompanied by colored discharge, fetid odor Bilateral nasal polyps, poor sense of smell; chronic bronchitis, stool disorders, developmental delay Persistent mucopurulent discharge that does not stop between “colds”, bilateral stagnation of mucus and discharge at the bottom of the nasal septum, symptoms from birth Recurrent nosebleeds with minimal trauma Rhinorrhea, purulent hemorrhagic discharge, ulcerative necrotic lesion mucous membrane of the nose and mouth, possible perforation of the nasal septum, eustacheitis. Polyarthralgia, myalgia Colorless discharge from the nose, often a history of trauma * The etiology is often viral or bacterial, very rarely fungal. Against the background of an acute respiratory viral infection, nasal symptoms prevail on the 23rd day and disappear by the 5th. In young children, on average, up to 8 episodes of upper respiratory infection per year, about 4 at school age. In addition, the differential diagnosis is carried out with the following forms of non-allergic rhinitis (Table 5): Vasomotor (idiopathic) rhinitis occurs in older children. Characterized by nasal congestion, aggravated by temperature changes, air humidity and strong odors, persistent rhinorrhea, sneezing, headaches, anosmia, sinusitis. Sensitization during the examination is not detected, heredity for allergic diseases is not burdened. Rhinoscopy reveals hyperemia and / or marbling of the mucous membrane, a viscous secret. AR Drug-induced rhinitis (including drug-induced rhinitis caused by prolonged use of decongestants. Permanent nasal obstruction is noted, with rhinoscopy, the mucous membrane is bright red. A positive response to therapy with intranasal glucocorticosteroids, which are necessary for the successful withdrawal of drugs that cause this, is characteristic disease). Non-allergic rhinitis with eosinophilic syndrome (eng l. NARES) is characterized by severe nasal eosinophilia (up to 80-90%), lack of sensitization and allergic history; sometimes becomes the first manifestation of intolerance to non-steroidal anti-inflammatory drugs. Symptoms include sneezing and itching, a tendency to form nasal polyps, a lack of an adequate response to antihistamine therapy, and a good effect with intranasal glucocorticosteroids. Table 5 Causes of rhinitis symptoms in children Exposure to a sensitizing allergen Infectious rhinitis Non-allergic, non-infectious rhinitis Infectious etiology: viral, bacterial, very rarely protozoa/fungi o Exposure to irritants (eg, tobacco smoke) o Hormonal causes (hypothyroidism, pregnancy) o Drugs induced (taking β blockers, non-steroidal anti-inflammatory drugs, contraceptives) 12

13 o Vasomotor (idiopathic) rhinitis Treatment The main goal of therapy is to relieve the symptoms of the disease. The complex of therapeutic measures includes: - limiting contact with pathogenetically significant allergens; - drug therapy; - specific immunotherapy; - education. Limiting exposure to allergens It is not possible to completely avoid exposure to outdoor allergens, such as pollen. But even partial exclusion of contact with the causative allergen alleviates the symptoms of AR, reducing disease activity and the need for pharmacotherapy. However, all elimination measures should be personalized, cost-effective and effective only in the case of a thorough preliminary allergological examination (including an anamnesis to assess clinical significance, skin testing and / or determination of sige titer). Indoor allergens (dust mites, pets, cockroaches and moulds) are considered major triggers and targeted for specific interventions. Complete elimination of allergens is usually not possible, and some interventions involve significant costs and inconvenience, often with only limited effectiveness. Outdoor allergens are even more difficult to manage, the only recommended approach may be to stay indoors for certain periods of time (for pollen sensitization). pollen allergens. The seasonality of symptoms in spring is due to the dusting of trees (birch, alder, hazel, oak), in the first half of summer - cereals (hedgehog, timothy, rye), at the end of summer and autumn - weeds (wormwood, plantain, ragweed). During the flowering season, to eliminate allergens, it is recommended to keep windows and doors closed in the room and in the car, use indoor air conditioning systems, and limit the time spent outdoors. After a walk, it is advisable to take a shower or bath to remove pollen from the body and prevent soiling of linen. Mold spores. To eliminate allergens, it is necessary to thoroughly clean air humidifiers, steam extractors, apply fungicides, and maintain relative humidity in the room below 50%. Allergens of house dust mites (species Dermatophagoides pteronyssinus and Dermatophagoides farinae). The use of special anti-mite bedding, allergen-proof mattress covers, helps to reduce the concentration of house dust mites, but does not lead to a significant reduction in the symptoms of allergic rhinitis. Epidermal allergens (animal allergens - cats, dogs, horses, etc.). It is most effective to completely avoid contact with animals. Food allergens (cause AR due to cross-reactivity with pollen sensitization). Although fungal spores and house dust mite allergens are year-round allergens, their amount in the ambient air usually decreases during the winter months and increases during the spring and autumn. It should be remembered that clinical improvement should be expected after a long time (weeks) after elimination of allergens 13

14 Pharmacotherapy Antihistamines Antihistamines of the 1st generation (chloropyramine - code ATX R06AC03, mebhydrolin - code ATX R06AX, clemastine - code ATX R06AA04) have an unfavorable therapeutic profile, they should not be used for the treatment of AR due to the presence of pronounced sedative and anticholinergic side effects. effects B. Drugs of this group violate cognitive functions: concentration, memory and learning ability. Second-generation antihistamines are the basic therapy for AR, regardless of severity. Antihistamines of the second generation, both for oral and intranasal administration, are effective in AR A. Oral drugs are better tolerated, while intranasal drugs are characterized by a faster onset of effect. Systemic antihistamines prevent and relieve AR symptoms such as itching, sneezing, and runny nose, but are less effective for nasal obstruction. There is no possibility of developing tachyphylaxis when taking second-generation antihistamines. Cetirizine (ATX code: R06AE07) for children aged 6 to 12 months. 2.5 mg 1 time per day, children from 1 to 6 years old are prescribed 2.5 mg 2 times a day or 5 mg 1 time per day in the form of drops, children over 6 years old, 10 mg once or 5 mg 2 times a day. Levocetirizine (ATX code: R06AE09) for children over 6 years of age at a daily dose of 5 mg, for children aged 2 to 6 years 2.5 mg / day in the form of drops. Desloratadine (ATX code: R06AX27) is used in children from 1 year to 5 years, 1.25 mg (2.5 ml), from 6 to 11 years, 2.5 mg (5 ml) 1 time per day in the form of a syrup, over 12 years old 5 mg (1 tablet or 10 ml of syrup) 1 time per day. Loratadine (ATX code: R06AX13) is used in children over 2 years of age. For children weighing less than 30 kg, the drug is prescribed 5 mg 1 time per day, for children weighing more than 30 kg, 10 mg 1 time per day. Fexofenadine (ATX code: R06AX26) is used in children 6-12 years old, 30 mg 1 time per day, older than 12 years, mg 1 time per day. Rupatadine fumarate (ATX code: R06AX28) is used in children over 12 years old, the recommended dose is 10 mg 1 time / day. Intranasal antihistamines are effective in the treatment of both intermittent and persistent AR. Azelastine (ATX code: R01AC0) is used in children over 6 years of age as a nasal spray, 1 inhalation 2 times a day. Levocabastin (ATX code: R01AC02) is prescribed for children over 6 years of age, 2 inhalations in each nasal passage during inspiration, 2 times a day (maximum 4 times a day). Second-generation systemic antihistamines may also be mildly sedating in some children. Intranasal corticosteroids Intranasal glucocorticosteroids (GCS) actively act on the inflammatory component of AR, effectively reducing the severity of symptoms such as itching, sneezing, rhinorrhea and nasal congestion, as well as eye symptoms. Recommended for children and 14

15 adolescents aged 2 years and older A. It was shown that mometasone, fluticasone and ciclesonide begin to have an effect during the first day after the start of treatment. The use of intranasal corticosteroids improves the manifestations of concomitant asthma A, and mometasone and fluticasone furoate are also effective in concomitant allergic conjunctivitis B. Nasal corticosteroids are well tolerated. Modern drugs for use once a day (in particular, mometasone, fluticasone propionate, fluticasone furoate) are preferred, because, having a lower systemic bioavailability (0.5%), unlike beclamethasone (33%), they do not reduce the rate growth (according to treatment for one year A). As a possible undesirable effect (NE) of intranasal corticosteroids, if used incorrectly, perforation of the nasal septum and nosebleeds are noted, however, the lack of systematic data does not allow us to assess the risk of developing NE. To increase the effectiveness of intranasal corticosteroids, it is recommended to clear the nasal cavity of mucus before the administration of drugs, as well as the use of moisturizers. Mometasone furoate (ATX code: R01AD09) for the treatment of seasonal and year-round AR is used in children from 2 years of age, is prescribed to children 2-11 years old, 1 inhalation (50 mcg) in each half of the nose 1 time per day, from 12 years old and adults 2 inhalations in each nostril 1 time per day. Fluticasone furoate (ATX code: R01AD12) is prescribed to children from 2 years of age, 1 spray (27.5 μg of flutic azone furoate in one spray) in each nostril 1 time per day (55 μg / day). In the absence of the desired effect at a dose of 1 spray in each nostril 1 time per day, it is possible to increase the dose to 2 sprays in each nostril 1 time per day (maximum daily dose of 110 mcg). When adequate control of symptoms is achieved, it is recommended to reduce the dose to 1 spray in each nostril 1 time per day. Fluticasone propionate (ATX code: R01AD08) is approved for use in children from 4 years of age, children aged 4-11 years are prescribed 1 injection (50 mcg) in each half of the nose 1 time per day, adolescents from 12 years old, 2 injections (100 mcg) per day. each half of the nose 1 time per day. Beclomethasone (ATX code: R01AD01) is approved for use from the age of 6, prescribed 1 spray (50 mcg) in each nostril 2-4 times a day (maximum dose 200 mcg / day for children 6-12 years old and 400 mcg / day for children over 12 years of age). Budesonide (ATX code: R01AD05) is approved for use in children from 6 years of age, prescribed 1 dose (50 mcg) in each half of the nose 1 time per day, (maximum dose 200 mcg / day for children 6-12 years old and 400 mcg / days for children over 12 years of age). Systemic corticosteroids Given the high risk of systemic side effects, the use of this group of drugs for the treatment of AR in children is very limited. School-age children with severe AR can only be prescribed a short course of prednisolone (ATX code: H02AB06) orally, mg per day; duration of administration 3-7 days D. Leukotriene receptor antagonists (ALTR) Among the leukotriene modifiers, montelukast (ATX code: R03DC03) is used in children worldwide. Monotherapy with montelukast is effective in both intermittent and persistent AR A. 15

16 In children with concomitant bronchial asthma, the inclusion of montelukast in the treatment regimen allows, without increasing the load of corticosteroids, to effectively control the symptoms of AR. Montelukast practically does not cause undesirable effects. In children aged 2-6 years, a tablet form is used at a dosage of 4 mg 1 time per day, from 6 to 14 years old chewable tablets 5 mg 1 time per day, from 15 years old 10 mg per day. Nasal anticholinergics In the territory of the Russian Federation for this indication are not registered; do not apply to children. Nasal decongestants Topical decongestants (naphazoline (ATX code: R01AA08), oxymetazoline (ATX code: R01AA05), xylometazoline (ATX code: R01AA07)) are used for severe nasal obstruction for only a few consecutive days (3-5). Longer use leads to recurrent swelling of the nasal mucosa C. Nasal sodium cromoglycate Cromones are less effective than intranasal corticosteroids, antihistamines and montelukast in the treatment of AR. Cromoglycic acid (ATX code: R01AC01) is registered for use in children over 5 years of age with mild AR in the form of a nasal spray, 1-2 inhalations in each nasal passage 4 times a day. However, the use several times a day and the rather low efficacy, compared with other groups of drugs, complicates compliance. Other Medications Moisturizers Moisturize and cleanse the nasal mucosa with proven efficacy A. Nasal irrigation with saline or sterile seawater (ATX code: R01AX10) is an inexpensive treatment for rhinitis with limited but proven efficacy. Anti-IgE Therapy Omalizumab (ATX code: R03DX05) has been shown to be effective in treating both asthma and associated allergic rhinitis in patients with severe and moderate persistent uncontrolled asthma and AR. However, this drug is not used only for the treatment of AR. Alternative therapies There is no convincing evidence for the effectiveness of alternative therapies for AR. Principles of drug therapy Summarizing the above information on the pharmacotherapeutic groups of drugs used to treat AR in children, it is important to note some principles of therapy. To date, there is sufficient evidence to suggest that nasal corticosteroids are more effective for the treatment of AR than antihistamines and montelukast B. Symptoms of nasal congestion are better relieved by nasal corticosteroids B. Antihistamines and montelukast are equally well established as an additional agent in therapy 16

17 nasal corticosteroids B. However, there are insufficient comparative data available to determine whether antihistamines are more effective than montelukast. It is safe to say that topical corticosteroids, antihistamines, and montelukast are more effective for the treatment of AR than nasal cromones B. Nasal corticosteroids are suitable for use as first-line therapy in moderate to severe AR, especially if nasal congestion is the main complaint , while second-generation antihistamines/montelukast may be preferred in mild AR. Antihistamines for oral administration may be better tolerated, while intranasal drugs of this pharmacological group are characterized by a faster onset of action. If control is not achieved within 1 to 2 weeks, the diagnosis should be reassessed. For the seasonal form of the disease, regular treatment should begin 2 weeks before the expected onset of symptoms. If the age is less than 2 years and there is no effect of antihistamines within a week before the intensification of therapy, the diagnosis should be reconsidered. In the absence of control over symptoms, severe course of AR, a short course of decongestants is prescribed, if necessary, the possibility of emergency use of a short course of prednisolone in low doses (orally) is considered. Step up with insufficient control Elimination of triggers Moisturizers 3. Addition of an antihistamine drug / ALTP to GCS 2. Nasal GCS 1. Antihistamine drugs: systemic and local ASIT Step down with good control Figure. 1. Principles of treatment of allergic rhinitis in children. (1), (2) and (3) stages of therapy within a therapeutic approach based on the severity of rhinitis symptoms. Immunotherapy Allergen-specific immunotherapy (ASI) is a pathogenetic treatment of an IgE-mediated allergic disease, in which an allergenic drug is administered according to a gradual dose increase scheme. Its goal is to reduce the symptoms associated with subsequent exposure to the causative allergen. ASIT is indicated when there is clear evidence of an association between allergen exposure, disease symptoms, and an IgE-dependent mechanism. ASIT induces clinical and immunological tolerance, has long-term efficacy and can prevent the progression of allergic diseases: it reduces the likelihood of developing bronchial asthma in patients with AR and 17

18 conjunctivitis and broadening the spectrum of sensitization. The positive impact of ASIT on the quality of life of the patient and his family members is shown. ASIT should be carried out by a specialist allergist-immunologist. Treatment is carried out only in specialized allergological rooms of outpatient clinics and allergological departments of hospitals / day hospitals. The duration of therapy is usually 3 to 5 years. The selection of the drug and the route of administration is carried out by a specialist individually. Sublingual ASIT is more preferable for children, painless, convenient from the position of the route of administration and has a more favorable safety profile compared to the subcutaneous method. Premedication with antihistamines and ALTR may reduce the prevalence and severity of adverse effects in ASIT. Contraindications to allergen-specific immunotherapy are severe concomitant conditions: immunopathological processes and immunodeficiencies, acute and chronic recurrent diseases of internal organs, severe persistent bronchial asthma, poorly controlled by pharmacological drugs, contraindications to the appointment of adrenaline and its analogues, poor tolerability of the method. Pharmacoeconomic models based on data from clinical trials and meta-analyses indicate that ASIT is cost effective. Education Education of patients and their families is an ongoing process. The purpose of such interaction of the patient and his parents / guardian with a medical specialist is to achieve compliance and adherence to the prescribed therapy plan. In the process of training, the medical specialist should present the information necessary for the patient and his family members about the nature of the disease, elimination measures, drugs to relieve symptoms and specific immunotherapy, and draw up a personalized written plan. It is important to convince the patient and his parents / guardian of the safety of medicines, regularly monitor the technique of using nasal preparations; inform about the nature of rhinitis, its concomitant diseases and complications, as well as the benefits of effective therapy. Primary training must be supplemented with other educational activities (classes in an allergy school). One of the promising alternatives is the use of educational computer programs and Internet resources, especially for older children and adolescents B. Management of children with AR Children with allergic rhinitis are observed on an outpatient basis by an allergologist-immunologist (multiplicity of 1 time in 3-6 months without exacerbation) . A comprehensive examination with dynamic monitoring of the condition, determining changes in the spectrum and the degree of sensitization, consultations of other specialists are carried out for children 1 time in 6-12 months, depending on the severity and nature of the course of the process, according to indications, on an outpatient basis / in a day hospital. With the development of irreversible forms of turbinate hypertrophy, true hyperplasia of the pharyngeal tonsil, significant nasal breathing and / or hearing impairment, as well as with anomalies of the intranasal anatomy and pathology of the paranasal sinuses, according to indications, surgical treatment is performed in a round-the-clock hospital. Prevention Primary prevention is carried out primarily in children at risk with aggravated heredity for atopic diseases. Primary prevention 18

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UNION OF PEDIATRICS OF RUSSIA RUSSIAN ASSOCIATION OF ALLERGOLOGISTS AND CLINICAL

IMMUNOLOGISTS

Chief freelance specialist pediatrician of the Ministry of Health of Russia Academician of the Russian Academy of Sciences A.A. Baranov

Chief Freelance Pediatric Allergist-Immunologist of the Ministry of Health of Russia Corresponding Member of the Russian Academy of Sciences L.S. Namazova-Baranova

Methodology………………………………………………………………………………. …………………………………………………………………...5 ICD-10 code……………………………………………… ………………………………………………...5 Epidemiology………………………………………………………………………… ………….……….5 Classification…………………………………………………………………………………...……..6 Etiopathogenesis…………………………………………………………………..…….…………………..6 Clinical picture…………………… …………………….……………………………….…......7 Concomitant pathology, symptoms…………………………………………… ………….…….8 Diagnostics…..…………………………………………………………………………………………………9 Differential diagnostics ……………………………………………………………………..10 Treatment………………………………………………………… …………………………………….…….12 Management of children with AR…………………………………………………….…………… …....18 Prevention………………………………………………………………………………………...18 Forecast…………… …………………………………………………………………………………….19

These clinical guidelines were prepared jointly with the Russian Association of Allergologists and Clinical Immunologists, reviewed and approved at a meeting of the Executive Committee of the Professional Association of Pediatricians of the Union of Pediatricians of Russia at the XVII Congress of Pediatricians of Russia "Actual Problems of Pediatrics" on February 15, 2014, updated. Approved at the XVIII Congress of Pediatricians of Russia "Actual problems of pediatrics" on February 14, 2015.

Members of the working group: acad. RAS Baranov A.A., Corr. RAS Namazova-Baranova L.S., acad. RAS Khaitov R.M., prof., MD Ilyina N.I., Prof., MD Kurbacheva O.M., prof., d.m.s. Novik G.A., Prof., MD Petrovsky F.I., Ph.D. Vishneva E.A., Ph.D. Selimzyanova L.R., Ph.D. Alekseeva A.A.

METHODOLOGY Methods used to collect/select evidence : search in electronic databases.

Description of the methods used to assess the quality and strength of the evidence : The evidence base for recommendations are publications included in the Cochrane Library, the EMBASE, MEDLINE and PubMed databases. Search depth - 5 years.

Methods used to assess the quality and strength of evidence:

expert consensus;

Methods used to analyze the evidence:

systematic reviews with tables of evidence.

Description of the methods used to analyze the evidence

When selecting publications as potential sources of evidence, the methodology used in each study is reviewed to ensure its validity. The outcome of the study affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendation.

To minimize potential errors, each study was evaluated independently. Any differences in the estimates were discussed by the whole group of authors in full. If it was impossible to reach a consensus, an independent expert was involved.

Evidence tables: filled in by the authors of clinical guidelines.

Methods used to formulate recommendations : expert consensus.

A At least one meta-analysis, systematic review, or RCTs rated as

A group of evidence that includes results from studies rated as 1+ that are directly applicable to the target population and demonstrate overall consistency of results.

B Evidence group including study results rated as 2++,

Extrapolated evidence from studies rated 1++ or 1+.

C Evidence group including results of studies rated as 2+,

directly applicable to the target population and demonstrating overall sustainability of results, or

Extrapolated evidence from studies rated 2++.

D Level 3 or 4 evidence;

or Extrapolated evidence from studies rated 2+.

Economic analysis

Cost analysis was not performed and publications on pharmacoeconomics were not analyzed.

External peer review.

Internal peer review.

These draft guidelines have been peer-reviewed by peer reviewers, who were primarily asked to comment on the ease of understanding of the interpretation of the evidence underlying the recommendations.

Comments were received from primary care physicians (allergists-immunologists) regarding the intelligibility of the presentation of these recommendations, as well as their assessment of the importance of the proposed recommendations as a tool for everyday practice.

All comments received from the experts were carefully systematized and discussed by the members of the working group (the authors of the recommendations). Each item was discussed separately.

Consultation and expert assessment

Working group

For the final revision and quality control, the recommendations were re-analyzed by the members of the working group, who came to the conclusion that all the comments and comments of the experts were taken into account, the risk of systematic errors in the development of recommendations was minimized.

Strength of recommendations (A-D) based on appropriate levels of evidence (1++, 1+,1-, 2++, 2+, 2-, 3, 4) and good practice points (GPPs) are given in the text recommendations.

Definition

Allergic rhinitis (AR) - An IgE-mediated inflammatory disease of the nasal mucosa caused by exposure to a sensitizing (causal) allergen and manifesting itself with at least two symptoms - sneezing, itching, rhinorrhea, or nasal congestion.

ICD-10 code:

J30.1 Allergic rhinitis due to plant pollen

J30.2 - Other seasonal allergic rhinitis

J30.3 Other allergic rhinitis

J30.4 Allergic rhinitis, unspecified

Epidemiology

AR is a widespread disease.

The median prevalence of AR symptoms is 8.5% (1.8–20.4%) in 6–7 year olds and 14.6% (1.4–33.3%) in 13–14 year olds (International Study Asthma and Allergy in Childhood: International Study of Asthma and Allergy in Childhood (ISAAC).

GA2 LEN (Global Allergy and Asthma European Network - Global Allergy and Asthma Network in Europe) in 2008-2009, the prevalence of symptoms of allergic rhinitis in adolescents aged 15-18 was 34.2%, during an in-depth examination in 10.4% of cases, the diagnosis of AR was confirmed, which largely prevails over official statistics.

Since similar studies, there has been an increase in the observed prevalence of AR worldwide. However, data for different centers vary greatly.

The frequency of AR symptoms in the Russian Federation is 18–38%. Boys get sick more often. In the age group under 5 years, the prevalence of AR is the lowest, the rise in incidence is noted at early school age.

Classification

According to the traditional approach, AR is classified based on the duration and severity of rhinitis symptoms in the presence of sensitization.

Typical allergens are, in particular, house dust mites, pollen from trees, cereals and weeds, animal allergens (cats, dogs), as well as molds Cladosporium, Penicillium, Alternaria, etc.

The presence of AR is also possible in the absence of a noticeable specific sensitization, which is due to the local formation of immunoglobulin E (IgE) in the nasal mucosa, the so-called. entopy. The question of whether this effect is observed in children remains open.

Allergic rhinitis, depending on the nature of a pathogenetically significant allergen, can be seasonal (with sensitization to pollen or fungal allergens) or year-round (with sensitization to household - house dust mites, cockroaches, and epidermal - animal dander, allergens). However, the distinction between seasonal and perennial rhinitis cannot always be made in all regions; as a result, this terminology has been revised and, based on the duration of symptoms, there are (according to the classification of ARIA 2008, 2010, and also EAACI 2013):

intermittent ( seasonal or year-round, acute, occasional) AR (symptoms< 4 дней в неделю или < 4 нед. в году);

persistent (seasonal or year-round, chronic, long-term) AR (symptoms ≥ 4 days per week or ≥ 4 weeks per year).

This approach is useful for describing the manifestations of rhinitis and its impact on quality of life, as well as for determining a possible approach to treatment.

According to the severity of manifestations and the impact on the quality of life, AR is divided into:

Mild AR (minor symptoms; normal sleep; normal daily activities, sports, rest; does not interfere with school or professional activities);

AR medium severe and severe course ( in the presence of painful symptoms leading to the appearance of at least one of such signs as sleep disturbance,

violation of daily activity, the impossibility of playing sports, normal rest; violations of professional activity or study at school);

In addition, exacerbation and remission of allergic rhinitis are distinguished.

Etiopathogenesis

Allergens (AlG) are substances, predominantly of a protein nature, with a molecular weight of about 20 kD (from 5 to 100 kD) or low molecular weight compounds, haptens, which, when first introduced into an organism predisposed to the development of allergies,

cause sensitization, i.e. the formation of specific IgE antibodies, and in subsequent - the development of allergic reactions.

To systematize numerous allergens, several approaches have been proposed:

on the way of entering the body (inhalation, enteral, contact, parenteral, transplacental);

by distribution in the environment (aeroallergens, indoor allergens, external allergens, industrial and occupational allergens and sensitizers);

by origin (medicinal, food, insect or insect allergens);

by diagnostic groups (household, epidermal, mold spores, pollen, insect, medicinal and food).

A special international nomenclature has been developed for the designation of allergens.

In our country, the most common is the classification that distinguishes the following diagnostic groups:

non-infectious - household (aeroallergens of dwellings), epidermal, pollen, food, insect, medicinal allergens;

infectious - fungal, bacterial allergens.

In foreign literature, internal (indoor) AlG - house dust, house dust mites, cockroaches, pets, fungi and external (outdoor) AlG - pollen and fungi are distinguished.

An allergic reaction develops in a sensitized organism upon repeated contact with an allergen, accompanied by the development of allergic inflammation, tissue damage and the appearance of clinical symptoms of allergic diseases.

AT pathogenesis of allergic diseases, immediate type reactions(IgE-dependent, anaphylactic, atopic) are the main (but not always the only) ones. At the first contact with the allergen, specific proteins are formed - IgE antibodies, which are fixed on the surface of mast cells in various organs. This condition is called sensitization - increased sensitivity to a particular AlG.

Upon repeated contact of a sensitized organism with causative ALG, IgE-dependent inflammation develops in the nasal mucosa, causing the development of symptoms. In most cases, one patient is simultaneously sensitized to several allergens belonging to different groups.

AT during the first minutes after exposure to AlG (an early phase of an allergic reaction), mast cells and basophils are activated, degranulation and release of inflammatory mediators (histamine, tryptase, prostaglandin D2, leukotrienes, platelet activating factor). As a result of the action of mediators, there is an increase in vascular permeability, hypersecretion of mucus, contraction of smooth muscles, the occurrence of acute symptoms of allergic diseases: itching of the eyes, skin, nose, hyperemia, swelling, sneezing, watery discharge from the nose.

4–6 hours later (late phase of the allergic reaction) after exposure to AlG, there is a change in blood flow, expression of cell adhesion molecules on endothelium and leukocytes, tissue infiltration by allergic inflammation cells - basophils, eosinophils, T lymphocytes, mast cells.

AT As a result, the formation of chronic allergic inflammation occurs, one of the clinical manifestations of which is nonspecific tissue hyperreactivity. The characteristic symptoms are nasal hyperreactivity and obstruction, hypo- and anosmia.

Clinical picture

The main - classic symptoms of allergic rhinitis:

Rhinorrhea (a clear, mucous discharge from the nasal passages);

- sneezing - often paroxysmal;

- itching, less often - a burning sensation in the nose (sometimes accompanied by itching of the palate and pharynx);

- nasal obstruction, characteristic mouth breathing, sniffling, snoring, apnea, voice change and nasality.

The characteristic symptoms also include "allergic circles under the eyes" - darkening of the lower eyelid and periorbital region, especially in severe chronic course of the process.

D additional symptoms develop due to abundant secretion from

nose, impaired drainage of the paranasal sinuses and patency of the auditory (Eustachian) tubes. Symptoms may include cough, decrease and lack of smell; irritation, swelling, hyperemia of the skin above the upper lip and near the wings of the nose; nosebleeds due to forced blowing; sore throat, cough (manifestations of concomitant allergic pharyngitis, laryngitis); pain and crackling in the ears, especially when swallowing; hearing impairment (manifestations of allergic tubotitis).

Among the common non-specific symptoms observed in allergic rhinitis, note:

- weakness, malaise, irritability;

- headache, fatigue, impaired concentration;

- sleep disturbance, depressed mood;

- rarely - fever.

Table 3 Manifestations of allergic rhinitis in children

Symptoms

Main symptoms

Possible

additional

symptoms

Rhinorrhea - clear discharge

Itching - rubbing of the nose, "allergic gesture", "allergic nasal fold", sometimes accompanied by itching of the palate and pharynx

sneezing stuffy nose- mouth breathing, snoring, sleep apnea, "allergic circles under the eyes"

Ear pain with pressure change

(for example, during flight) due to dysfunction of the Eustachian tubes Hearing loss in chronic otitis media

Sleep disturbances - fatigue, poor school performance, irritability

Prolonged and frequent infections respiratory tract.Poor ace control tmy

Headache, facial pain, bad breath,

cough, hypo- and anosmia with rhinosinusitis

Concomitant pathology, symptoms

The nose is anatomically and functionally related to the eyes, paranasal sinuses, nasopharynx, middle ear, larynx, and lower respiratory tract, thus symptoms may include conjunctivitis, chronic cough, mouth breathing, nasal voice, and snoring with or without obstructive sleep apnea.

allergic conjunctivitis is considered the most common comorbidity associated with AR. It is characterized by severe itching in the eyes, conjunctival hyperemia, lacrimation, and sometimes periorbital edema.

Chronic allergic inflammation of the upper respiratory tract can cause hypertrophy of lymphoid tissue. A significant increase in the size of adenoids during the dusting season is observed in children with hay fever. Polysomnography showed a strong correlation sleep apnea syndrome with a history of nasal congestion and AR. Also associated with rhinitis chronic middle ear exudate and eustachian tube dysfunction potentially causing hearing loss. In the pathogenesis of ongoing allergic inflammation in the adenoid lymphatic tissue in children with atopy, local secretion of nonspecific and specific IgE to environmental allergens and staphylococcal enterotoxin antigens may play a role.

AR is often combined with asthma, being one of the determining risk factors for its occurrence. AR is one of the reasons for the development of exacerbation and reduction / lack of control of bronchial asthma: its symptoms often precede the manifestations of asthma. AR significantly increases the risk of emergency room visits for asthma.

At the same time, the presence of cough in allergic rhinitis sometimes pushes the doctor to a false diagnosis of bronchial asthma.

Being one of the “steps” of the atopic march, allergic rhinitis often accompanies atopic dermatitis, sometimes preceding, and periodically ahead of, this form of allergy manifestation.

Allergic rhinitis due to pollen sensitization may be associated with food allergy (oral allergy syndrome). In this case, symptoms such as itching, burning and swelling of the mouth are due to cross-reactivity: sensitization to ragweed pollen can cause symptoms after eating melon; to birch pollen - after eating apples, etc.

Diagnostics

The diagnosis of AR is established on the basis of anamnesis data, characteristic clinical symptoms and the identification of causally significant allergens (during skin testing or determining the titer of specific antibodies of the IgE class in vitro if skin tests are not possible) D .

History and physical examination

When collecting an anamnesis, the presence of allergic diseases in relatives is clarified; the nature, frequency, duration, severity of symptoms, the presence / absence of seasonal manifestations, response to therapy, the presence of other allergic diseases in the patient, provoking factors.

It is necessary to carry out rhinoscopy (examination of the nasal passages, the mucous membrane of the nasal cavity, secretion, turbinates and septum). In patients with AR, the mucous membrane is usually pale, cyanotic gray, and edematous. The nature of the secret is slimy and watery.

In chronic or severe acute AR, a transverse fold is found on the back of the nose, which is formed in children as a result of an "allergic salute" (rubbing the tip of the nose). Chronic nasal obstruction leads to the formation of a characteristic "allergic face" (dark circles under the eyes, impaired development of the facial skull, including malocclusion, arched palate, flattening of the molars).

Identification of sensitizing allergens

Skin testing reveals causative allergens.

If it is impossible to conduct this study and / or there are contraindications (children under 2 years old, exacerbation of concomitant allergic pathology, taking medications that affect the test result, etc.), specific antibodies of the IgE class (sIgE) are determined. This method is more expensive, and it is not necessary to cancel antihistamines before the study.

Allergic sensitization is diagnosed with a positive result of skin testing or the detection of antibodies of the IgE class specific to a certain allergen, while the quantitative characteristic of the studied parameter (papule size, sIgE concentration in blood serum) is extremely important.

Additional research methods

To exclude other diagnoses when conducting a differential diagnostic search and / or if therapy is ineffective, additional studies are recommended D:

CT scan of the paranasal sinuses to rule out chronic rhinosinusitis and polyposis D.

Endoscopy of the nasopharynx to visualize polyps D and exclude other causes of difficulty in nasal breathing (presence of a foreign body, deviated septum, etc.).

Determination of nasal mucociliary clearance and nasal NO concentration to rule out primary ciliary dyskinesiaC.

To exclude bronchial asthma, it is required to determine the parameters of the function of external respiration and a test with a bronchodilator for the reversibility of bronchial obstruction. In doubtful cases, a test with physical activity is carried out.

If obstructive sleep apnea is suspected, polysomnography is performed.

With symptoms of hearing loss after anterior rhinoscopy, otoscopy, under the supervision of an ENT doctor, additional studies are carried out: tympanometry, acoustic impendancemetry, if necessary, a consultation with an audiologist.

Cytological examination of smears from the nasal cavity is a method designed to detect eosinophils (performed during an exacerbation of the disease). The practical application of the method is limited, since the appearance of eosinophils in the nasal secretion is possible in other diseases (BA, nasal polyps in combination with asthma or without it, non-allergic rhinitis with eosinophilic syndrome).

Determination of the content of eosinophils and the concentration of total IgE in the blood has a low diagnostic value.

Provocative tests with allergens in children's clinical practice have an extremely limited application, they are performed only by specialists (allergologists-immunologists) in specialized medical institutions of an allergological profile.

Differential Diagnosis

Differential diagnosis of allergic rhinitis is carried out on the basis of symptoms, taking into account age characteristics D (Table 4). They need special attention if the treatment does not have an effect on the symptoms.

Nasal congestion

Difficulty in nasal breathing (nasal congestion, nasal obstruction) may be the result of mucosal pathology and / or anatomical abnormalities (often - nasal septal curvature, less often - nasal vestibule stenosis with cleft lip, choanal atresia or piriformis stenosis). AR is a common cause of nasal congestion accompanied by wide-mouthed breathing, snoring, and nasal discharge in preschool children. However, adenoid vegetations are also a fairly common pathology characterized by similar symptoms. Nasal polyps that obstruct nasal breathing are grounds for excluding cystic fibrosis and/or primary

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other allergic rhinitis (J30.3)

Allergology for children, Pediatrics, Pulmonology for children

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013

allergic rhinitis- an inflammatory disease of the nasal mucosa, characterized by IgE-mediated inflammation of the mucous membranes of the nasal cavity, accompanied by the presence of the following symptoms: discharge (rhinorrhea) from the nose, sneezing, itching in the nose, nasal congestion (International Consensus EAACI, 2000)

Protocol name: Allergic rhinitis in children.

Protocol code:

Code (codes) according to ICD-10:
J30. Vasomotor and allergic rhinitis.
J30.0 Vasomotor rhinitis.
J30.1 - Allergic rhinitis due to plant pollen
J30.2 - Other seasonal allergic rhinitis
J30.3 Other allergic rhinitis
J30.4 Allergic rhinitis, unspecified

Abbreviations used in the protocol:
AR - allergic rhinitis
GCS - glucocorticosteroids
BA - bronchial asthma
IgE - immunoglobulin E
AC-IgE - allergen-specific immunoglobulin E
SAD - specific allergodiagnostics
ASIT - allergen-specific immunotherapy
WHO - World Health Organization (WHO)
EAACI - European Academy of Allergology and Clinical Immunology
RNPAC - Republican Scientific and Practical Allergological Center

Protocol development date: 2013

Protocol Users: healthcare professionals involved in providing medical care to patients with allergic rhinitis; pediatricians; general practitioners, family, allergists, doctors of allergological departments, pediatric and other hospitals.

Indication of no conflict of interest: missing.

Classification

WHO classification (ARIA, 2007):
with the flow:
1. Intermittent (less than 4 days a week or less than 4 weeks).
2. Persistent (more than 4 days a week or more than 4 weeks).
by gravity:
1. Light (all of the following: normal sleep, no disruption of life, sports and work regimen).
2. Moderate and severe (one or more of the following: disruption of sleep, activity, sports and work, debilitating symptoms).

Classification
By age of occurrence:
1. sharp;
2. chronic.

With the flow:
1. seasonal;
2. year-round;

By the duration of the persistence of symptoms;
1. intermittent allergic rhinitis;
2. persistent allergic rhinitis.

According to the severity are distinguished:
1. light;
2. moderate (moderate);
3. severe allergic rhinitis.

Diagnostics

PeReven morenl basic diagnostic measures:

Main
1. Complete blood count.
2. Determination of the content of total IgE in serum or plasma.
3. Specific allergodiagnostics in vivo and in vitro.
4. Cytological analysis of a swab (wash, scraping) from the nose.

Additional
1. X-ray and computed tomography of the sinuses (according to indications).
2. Consultation of an ENT doctor (according to indications).
2.

Diagnostic criteria:

Complaints and anamnesis:
Nasal congestion (obstruction) - complete, partial or alternate, at different times of the day, depending on the etiology and regimen.
Nasal discharge (rhinorrhea) is usually watery or mucous.
Itching in the nose, burning sensation, pressure in the nose.
Sneezing - paroxysmal, not bringing relief.
There may be additional complaints - headache, weakness, irritability, watery eyes (due to sneezing), sore throat, dry cough (due to irritation of the lower respiratory tract, sputum), feeling short of breath, etc.
In the allergological history, it is necessary to pay attention to the prescription of the disease, seasonality, daily cyclicity, connection with specific and non-specific (heat, cold, pungent odors, stuffiness, etc.) provoking factors, occupational hazards, the effect of medications (local and systemic). Depending on the duration, frequency and rigidity of symptoms, the disease is classified according to the form, course, severity and stage.

Physical examination:
During a general examination, redness and irritation of the skin of the nose and nasolabial triangle (due to rhinorrhea), dark circles under the eyes (due to venous stasis and poor sleep quality), the so-called. "allergic salute" (rubbing the tip of the nose with the palm of your hand), complete or partial absence of nasal breathing, changes in the timbre of the voice, "adenoid face" (with the development of year-round rhinitis from childhood - a sleepy facial expression with puffiness and an open mouth).
With rhinoscopy, edematous pale pink or stagnant nasal turbinates, mucous discharge are visible.

Laboratory research:
Cytological examination of discharge from the nose with Wright or Hansel stain (smear, washout or scraping) - eosinophilia (more than 10%).
Specific allergodiagnostics in vivo and in vitro.

YingWithtRmental research:
Rhinomanometry - partial or complete patency of the nasal passages, a sharp increase in the resistance of the nasal passages (symmetrical or with a predominance of one side).
Radiography - no signs of organic lesions of the nose and paranasal sinuses, swelling of the nasal mucosa.
Specific allergodiagnostics in vivo - skin tests and in vitro.

Differential Diagnosis

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Treatment

Treatment goals:
Stop the symptoms, restore the patency of the nasal passages and nasal breathing (especially at night), improve the quality of life, restore working capacity.

Treatment tactics:

Hemedical treatment:
- elimination (elimination) of causative and provoking factors;
- reduction of contact with causative and provoking factors, in case of impossibility of complete elimination of the allergen;
- breathing exercises.

Medical treatment:
1. Antibacterial drugs are not indicated;
2. Local antiseptics are not indicated;
3. Immunostimulants are not shown;
4. Systemic corticosteroids are not shown;
5. Surgical treatment is contraindicated.

Topical (intranasal) glucocorticosteroids. Basic pathogenetic treatment of allergic rhinitis. Apply in courses from 2 weeks to 6 months. Only this group of drugs provides comprehensive treatment and prevention of complications of AR (conjunctivitis, laryngitis, obstructive syndrome, bronchial asthma, etc.). They are used as monotherapy or in combination with antihistamine or antileukotriene drugs per os.
Betamethasone (100-400 mcg/day)
Mometasone (100-400 mcg/day)
Fluticasone (100-400 mcg/day)

Antileukotriene drugs(leukotriene receptor antagonists). Basic treatment of AR, obstructive disorders, prevention of asthma development. Used in combination with topical intranasal corticosteroids or as monotherapy (rarely).
Montelukast 4, 5 or 10 mg, depending on the age of the patient, once a day, for a long time (3-6 months).

2nd or 3rd generation antihistamines. Basic treatment of allergic rhinitis - apply courses from 10 days to several months. Used as monotherapy or in combination with topical intranasal corticosteroids.
Loratadine 10 mg/day
Cetirizine 10 mg/day.
Fexofenadine 30, 60, 120, 180 mg/day.
Ebastin 10 mg / day.
Desloratadine 5 mg/day
Levocetirizine 5 mg/day.

In the presence of rhinoconjunctival syndrome - olopatadine

Sympathomimetic agents for the treatment of nasal diseases (decongestants) are used as a symptomatic remedy for temporary restoration of nasal passages patency (for example, before taking topical steroids), as well as for mild allergic rhinitis for no more than a week (there is a tendency to tachyphylaxis)
Naphazoline 0.05%
Oxymetazoline 0.05%
Xylometazoline 0.05%
Tetrizoline 0.05%

Membrane stabilizers. They are used mainly locally, with a preventive purpose.
Cromoglycic acid 50-200 mg / day.

Nonspecific hyposensitization.
Possible with seasonal allergic rhinitis in the absence of contraindications.

Specific immunotherapy:
It is carried out by an allergist after conducting SAD in vitro and in vivo and establishing causally significant allergens if their elimination is impossible and there are no contraindications. Only during a period of complete remission. SIT is possible in several ways - subcutaneous, oral, sublingual, intranasal. We use highly purified extracts of allergens intended for treatment, which have passed clinical trials and are registered in the country of origin (there are none registered in the Republic of Kazakhstan at the moment).

Other types of treatment: no.

Surgical intervention: no.

Prevention

Primary Prevention:
Promotion of knowledge about allergic rhinitis among the population and medical workers; early detection of hypersensitivity; alertness in the case of an existing aggravated family and personal allergic history, identification and treatment of chronic diseases of the upper respiratory tract; rejection of pets; primary and regular medical examinations; to give up smoking; changing living and working conditions; healthy lifestyle.

1. Observation of an allergist in dynamics.
2. Patient education at the Allergy School.
3. Identification of etiological factors (allergens) with their maximum elimination.
4. Preventive treatment of housing and place of work.
5. Exclusion of contacts with provoking factors (household chemicals, cosmetics, antibiotics, dust, etc.)
6. Courses of preventive therapy for seasonal allergic rhinitis.
7. Treatment of foci of chronic infection.

Further management:
After relief of exacerbation symptoms, follow-up with an allergist is necessary for specific in vitro and in vivo allergy diagnostics and specific immunotherapy.
In the case of a year-round course, a quarterly examination with anterior rhinoscopy, control of the level of total IgE in the blood serum and peak flowmetry is necessary.
With seasonal allergic rhinitis - medical examination 1-2 times a year with the above methods of examination.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. References: 1. ARIA 2010. Allergic rhinitis and its impact on asthma. Annual Workshop Report. WHO. 2010. 2. Global strategy for asthma management and prevention, 2012 (Update).- 2012.- 128 p. (Available at www.ginasthma.com) 3. Gushchin I. S., Ilyina N. I., Polner S. A. Allergic rhinitis: A guide for physicians. SSC - Institute of Immunology, RAAKI. M., 2002. 68 p. 4. Ilyina N. I., Polner S. A. Perennial allergic rhinitis// Consilium medicum. 2001. V. 3. No. 8. S. 384-393. 5. Luss L.V. Allergic rhinitis: problems, diagnosis, therapy // The attending physician. M., 2002 № 4. S. 24-28 6. Clinical immunology and allergology. Ed. G. Lolor Jr., T. Fisher, D. Adelman (Translated from English) - M., Practice, 2000. - 806 p. 7. Akpeisova R.B. "Epidemiological and clinical and functional features of allergic rhinitis in combination with bronchial asthma". Abstract cand. diss. - Almaty. - 2009. - 28 p.

Information

List of protocol developers:
1. Ispaeva Zh.B. - head. Department of the module "Allergology" KazNMU named after S.D. Asfendiyarov
2. Rozenson R.I. - prof. Department of Pediatric Diseases No. 1 JSC "Astana Medical University"

Reviewers: Nurpeisov T.T. - Doctor of Medical Sciences, Chief Freelance Allergist of the Ministry of Health of the Republic of Kazakhstan

Indication of the conditions for revising the protocol: The protocol is reviewed at least once every 5 years, or upon receipt of new data on the diagnosis and treatment of the relevant disease, condition or syndrome.

Attached files

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