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アレルギー性鼻炎

著者: 藤枝重治 福井大学医学部 耳鼻咽喉科・頭頸部外科学

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2020/11/12
参考ガイドライン:
  1. 2020年版(改訂第9版)鼻アレルギー診療ガイドライン―通年性鼻炎と花粉症―
  1. Allergic Rhinitis and its Impact on Asthma (ARIA) Phase 4 (2018)
患者向け説明資料

概要・推奨   

  1. 診断には十分な問診を行うとともに、アレルゲンに対する特異的IgEを測定して、アレルギー性鼻炎の診断を確定して、治療に取り組むことを推奨する。
  1. アレルギー性鼻炎治療の第1選択薬は、第2世代抗ヒスタミン薬であり、現在は眠気などの有害事象が極めて少なく安全であることを患者に十分に説明して処方することが、患者のQOL向上につながる。
 
参考文献:
日本耳鼻咽喉科免疫アレルギー学会/鼻アレルギー診療ガイドライン作成委員会編:鼻アレルギー診療ガイドライン 2020年版(改訂第9版)、ライフ・サイエンス、2020;p2-108.
Allergol Int. 2020 May 27:S1323-8930(20)30050-2. doi: 10.1016/j.alit.2020.04.001. Online ahead of print.
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
藤枝重治 : 講演料(田辺三菱製薬,サノフィ,杏林製薬),研究費・助成金など(マルホ,田辺三菱製薬,ツムラ),奨学(奨励)寄付など(サノフィ,小野薬品)[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 2019年に施行した疫学情報が追加され、アレルギー性鼻炎の有病率は49.2%、スギ花粉症は38.8%であった。ともに2008年よりも増加した。(松原篤、坂下雅文、後藤穣、川島佳代子、松岡伴和、近藤悟、山田武千代、竹野幸夫、竹内万彦、浦島充佳、藤枝重治、大久保公裕:鼻アレルギーの全国疫学調査2019 (1998年,2008年との比較): 速報―耳鼻咽喉科医およびその家族を対象として―[https://www.jstage.jst.go.jp/article/jibiinkoka/123/6/123_485/_pdf/-char/ja])
  1. 発症のメカニズムに2型自然リンパ球(ILC2)が追加された。くしゃみ増強など鼻粘膜過敏症亢進メカニズムに最小持続炎症とプライミング効果が追加された。
  1. 薬物療法に生物学的製剤(抗IgE抗体)が追加された。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. アレルギー性鼻炎は、抗原に対するくしゃみ、鼻汁、鼻閉、鼻・目の痒みを示す反応である[1]
  1. わが国においてアレルギー性鼻炎は、通年性と季節性に分類される[1]
  1. 通年性は、ダニ、ペット、ゴキブリなど1年中存在する抗原に対する症状と定義される[1]
  1. 季節性は、スギを代表とする花粉抗原に対する季節限定の症状と定義される[1]
  1. 欧米では持続性と間欠性に分類される[2]
  1. 間欠性は週4日未満あるいは4週間未満、持続性は週4日以上あるいは4週間以上の症状を有すると定義される[2]
  1. 通年性は小児発症が、季節性は成人発症が多い。
  1. 季節性において咳、咽頭違和感、全身倦怠感、皮膚の痒み、後鼻漏、咽頭の痒みなど多彩な症状を示す。
問診・診察のポイント  
問診:
  1. どのようなときに症状が出現するかを聞き出すことが大切である。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
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文献 

著者: Kimihiro Okubo, Yuichi Kurono, Keiichi Ichimura, Tadao Enomoto, Yoshitaka Okamoto, Hideyuki Kawauchi, Harumi Suzaki, Shigeharu Fujieda, Keisuke Masuyama, Japanese Society of Allergology
雑誌名: Allergol Int. 2020 May 27;. doi: 10.1016/j.alit.2020.04.001. Epub 2020 May 27.
Abstract/Text Like asthma and atopic dermatitis, allergic rhinitis is an allergic disease, but of the three, it is the only type I allergic disease. Allergic rhinitis includes pollinosis, which is intractable and reduces quality of life (QOL) when it becomes severe. A guideline is needed to understand allergic rhinitis and to use this knowledge to develop a treatment plan. In Japan, the first guideline was prepared after a symposium held by the Japanese Society of Allergology in 1993. The current 8th edition was published in 2016, and is widely used today. To incorporate evidence based medicine (EBM) introduced from abroad, the most recent collection of evidence/literature was supplemented to the Practical Guideline for the Management of Allergic Rhinitis in Japan 2016. The revised guideline includes assessment of diagnosis/treatment and prescriptions for children and pregnant women, for broad clinical applications. An evidence-based step-by-step strategy for treatment is also described. In addition, the QOL concept and cost benefit analyses are also addressed. Along with Allergic Rhinitis and its Impact of Asthma (ARIA), this guideline is widely used for various clinical purposes, such as measures for patients with sinusitis, childhood allergic rhinitis, oral allergy syndrome, and anaphylaxis and for pregnant women. A Q&A section regarding allergic rhinitis in Japan was added to the end of this guideline.

Copyright © 2020 Japanese Society of Allergology. Production and hosting by Elsevier B.V. All rights reserved.
PMID 32473790  Allergol Int. 2020 May 27;. doi: 10.1016/j.alit.2020.04・・・
著者: Jean Bousquet, Peter W Hellings, Ioana Agache, Flore Amat, Isabella Annesi-Maesano, Ignacio J Ansotegui, Josep M Anto, Claus Bachert, Eric D Bateman, Anna Bedbrook, Kazi Bennoor, Mickael Bewick, Carsten Bindslev-Jensen, Sinthia Bosnic-Anticevich, Isabelle Bosse, Jan Brozek, Luisa Brussino, Giorgio W Canonica, Victoria Cardona, Thomas Casale, Alfonso M Cepeda Sarabia, Niels H Chavannes, Lorenzo Cecchi, Jaime Correia de Sousa, Elisio Costa, Alvaro A Cruz, Wienczyslawa Czarlewski, Giuseppe De Carlo, Giulia De Feo, Pascal Demoly, Philippe Devillier, Mark S Dykewicz, Yehia El-Gamal, Esben E Eller, Joao A Fonseca, Jean-François Fontaine, Wytske J Fokkens, Maria-Antonieta Guzmán, Tari Haahtela, Maddalena Illario, Juan-Carlos Ivancevich, Jocelyne Just, Igor Kaidashev, Musa Khaitov, Omer Kalayci, Thomas Keil, Ludger Klimek, Marek L Kowalski, Piotr Kuna, Violeta Kvedariene, Desiree Larenas-Linnemann, Daniel Laune, Lan T T Le, Karin Lodrup Carlsen, Olga Lourenço, Bassam Mahboub, Alpana Mair, Enrica Menditto, Branislava Milenkovic, Mario Morais-Almeida, Ralph Mösges, Joaquim Mullol, Ruth Murray, Robert Naclerio, Leyla Namazova-Baranova, Ettore Novellino, Robyn E O'Hehir, Ken Ohta, Yoshitaka Okamoto, Kimi Okubo, Gabrielle L Onorato, Susanna Palkonen, Petr Panzner, Nikos G Papadopoulos, Hae-Sim Park, Ema Paulino, Ruby Pawankar, Oliver Pfaar, Davor Plavec, Ted A Popov, Paul Potter, Emmanuel P Prokopakis, Menachem Rottem, Dermot Ryan, Johanna Salimäki, Boleslaw Samolinski, Mario Sanchez-Borges, Holger J Schunemann, Aziz Sheikh, Juan-Carlos Sisul, Rojin Rajabian-Söderlund, Talant Sooronbaev, Cristiana Stellato, Teresa To, Ana-Maria Todo-Bom, Peter-Valentin Tomazic, Sanna Toppila-Salmi, Antonio Valero, Arunas Valiulis, Erkka Valovirta, Maria-Teresa Ventura, Martin Wagenmann, De Yun Wang, Dana Wallace, Susan Waserman, Magnus Wickman, Arzu Yorgancioglu, Luo Zhang, Nanshan Zhong, Mihaela Zidarn, Torsten Zuberbier, Mobile Airways Sentinel Network (MASK) Study Group
雑誌名: J Allergy Clin Immunol. 2019 Mar;143(3):864-879. doi: 10.1016/j.jaci.2018.08.049. Epub 2018 Sep 29.
Abstract/Text Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline by using the best approach to integrated care pathways using mobile technology in patients with allergic rhinitis (AR) and asthma multimorbidity. The proposed next phase of ARIA is change management, with the aim of providing an active and healthy life to patients with rhinitis and to those with asthma multimorbidity across the lifecycle irrespective of their sex or socioeconomic status to reduce health and social inequities incurred by the disease. ARIA has followed the 8-step model of Kotter to assess and implement the effect of rhinitis on asthma multimorbidity and to propose multimorbid guidelines. A second change management strategy is proposed by ARIA Phase 4 to increase self-medication and shared decision making in rhinitis and asthma multimorbidity. An innovation of ARIA has been the development and validation of information technology evidence-based tools (Mobile Airways Sentinel Network [MASK]) that can inform patient decisions on the basis of a self-care plan proposed by the health care professional.

Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
PMID 30273709  J Allergy Clin Immunol. 2019 Mar;143(3):864-879. doi: 1・・・
著者: S Yonekura, Y Okamoto, K Okubo, T Okawa, M Gotoh, H Suzuki, T Kakuma, S Horiguchi, T Hanazawa, A Konno, M Okuda
雑誌名: J Investig Allergol Clin Immunol. 2009;19(3):195-203.
Abstract/Text BACKGROUND: In recent years, many countries have experienced an increase in the prevalence of allergic rhinitis. No effective approach is currently available to prevent the onset of symptoms in allergic individuals. Pranlukast, a leukotriene receptor antagonist with a good safety and efficacy record for the management of allergic inflammation, may be appropriate for early intervention in the management of pollinosis.
OBJECTIVE: To investigate the efficacy of pranlukast as an early intervention in the control of cedar pollinosis.
METHODS: In a double-blind comparative study, pranlukast (n = 102) or placebo (n = 91) was administered to cedar pollinosis patients immediately before the start of the dispersion season and continued for 4 weeks. Subsequently, pranlukast was administered to all patients for 2 weeks until the end of the cedar pollen dispersion season (mid-March). All patients were carefully monitored for severity of nasal symptoms, symptom scores, medication scores, symptom-medication scores, and quality of life (QOL).
RESULTS: Compared with placebo, therapy with pranlukast before and during the dispersion of cedar pollen in these patients significantly improved nasal symptoms (paroxysmal sneezing, rhinorrhea, and nasal congestion), symptom scores, and symptom-medication scores. The drug also significantly reduced deterioration of QOL, and improved nasal symptoms and QOL throughout the dispersion period.
CONCLUSION: Administering pranlukast immediately before the beginning of cedar pollen dispersion is effective in reducing symptoms of allergic rhinitis throughout the dispersion period.

PMID 19610262  J Investig Allergol Clin Immunol. 2009;19(3):195-203.
著者: Hideyuki Yamamoto, Takechiyo Yamada, Masafumi Sakashita, Seita Kubo, Dai Susuki, Takahiro Tokunaga, Kazuhiro Ogi, Yoko Terasawa, Shinji Yamashita, Yuichiro Kayano, Mikio Masada, Yuichi Kimura, Shigeharu Fujieda
雑誌名: Allergy Asthma Proc. 2012 Mar-Apr;33(2):e17-22. doi: 10.2500/aap.2012.33.3514.
Abstract/Text Cysteinyl leukotriene and leukotriene receptor occupancy have been linked to several processes in seasonal allergic rhinitis (SAR), including nasal congestion, rhinorrhea, and recruitment of inflammatory cells. We investigated whether add-on loratadine, an antihistamine, might be effective for SAR patients showing unsatisfactory control of symptoms with the leukotriene receptor antagonist (LTRA) montelukast alone. Patients with SAR caused by Japanese cedar pollen (SAR-JCP; mean age, 29.4 years) were given prophylactic montelukast for 1 month before peak JCP dispersal. Patients recorded the severity of the symptoms (sneezing, rhinorrhea, nasal congestion, and ocular symptoms) daily on visual analog scale (VAS). We selected patients with VAS scores of >50 for any of the symptoms just before the peak pollen season (March 2 to March 8) and designated them as "poorly controlled" patients. Then, in the peak JCP season (from March 9), we conducted a randomized, double-blind, placebo-controlled study to determine whether add-on loratadine might be effective for these "poorly controlled" patients. Montelukast alone was effective, as evaluated by improvement of the VAS scores, in 95 of the 137 patients (69.3%). Add-on loratadine significantly decreased the total scores for nasal symptoms (p < 0.05), sneezing (p < 0.05), and rhinorrhea (p < 0.05) when compared with placebo. The symptoms of SAR in two of three SAR-JP patients could be controlled (VAS score[s] under 50) by prophylactic treatment with montelukast alone under the condition of mild JCP dispersal. Furthermore, the effect of add-on antihistamine on sneezing and rhinorrhea was found in selected SAR-JCP patients.

PMID 22525385  Allergy Asthma Proc. 2012 Mar-Apr;33(2):e17-22. doi: 10・・・
著者: Takechiyo Yamada, Hideyuki Yamamoto, Seita Kubo, Masafumi Sakashita, Takahiro Tokunaga, Dai Susuki, Norihiko Narita, Kazuhiro Ogi, Masafumi Kanno, Shinji Yamashita, Yuko Terasawa, Yuichiro Kayano, Mikio Masada, Shigeharu Fujieda
雑誌名: Allergy Asthma Proc. 2012 Mar-Apr;33(2):e9-16. doi: 10.2500/aap.2012.33.3509.
Abstract/Text Intranasal corticosteroid therapy has exhibited effectiveness for improving nasal symptoms and quality of life (QOL) scores associated with seasonal allergic rhinitis. We prospectively investigated the efficacy of mometasone furoate nasal spray (MFNS) for improving the total nasal symptom score, QOL score, and sleep quality in subjects with perennial allergic rhinitis (PAR). Nasal airway conditions were also objectively assessed by measuring nasal nitric oxide (NO). Fifty-seven patients with PAR were randomized to MFNS or placebo for a 14-day, double-blind, crossover study. The subjects recorded their symptoms on nasal symptom forms and a visual analog scale. QOL and sleep quality were surveyed in accordance with the Japanese version of the Rhinoconjunctivitis Quality of Life Questionnaire (JRQLQ) and the Japanese version of the Epworth Sleepiness Scale. Nasal NO was measured during a single exhalation using a chemiluminescence analyzer. MFNS treatment achieved significant reductions versus placebo for total nasal symptoms (p < 0.001). There were significant decreases of the usual daily activity domain (p < 0.005), outdoor activities (p < 0.01), social function (p < 0.05), and the overall QOL score (p < 0.05) of JRQLQ with MFNS therapy versus placebo. A significant reduction of the sleepiness scale was also observed in the MFNS group with high sleep disturbance (p < 0.01). A significant decrease of nasal NO was found in the MFNS group (p < 0.01), especially among patients with severe nasal symptoms (p < 0.005). This prospective study indicated that MFNS therapy significantly improves nasal symptoms, QOL, sleep quality, and upper airway condition in Japanese subjects with PAR.

PMID 22525384  Allergy Asthma Proc. 2012 Mar-Apr;33(2):e9-16. doi: 10.・・・

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