Phar 351 - Allergic Rhinitis

Front 1

Define: rhinitis

Back 1

Inflammation of membranes lining nose

Front 2

Define: allergic rhinitis

Back 2

Immunologically mediated rhinitis, initiated by an antigen-antibody reactions
Characterized by:
• Nasal congestion
• Rhinorrhea
• Sneezing
• Itchy nose
• Postnasal discharge
• Severity range from mild to debilitating

Front 3

Classification of allergic rhinitis:

Back 3

- Seasonal

- Perennial

- Perennial with seasonal exacerbation

- Episodic

Front 4

Classification of non-allergic rhinitis:

Back 4

- Vasomotor rhinitis
- Non-allergic rhinitis with Eosinophilia (NARES)

Front 5

Characteristics of vasomotor rhinitis:

Back 5

Sx: sneezing and watery rhinorrhea with or without nasal congestion or allergic basis can be found
Triggers: cold dry air, odors, emotions
- Cholinergic hyper-responsiveness may be the cause
- Anticholinergic tx (ipratroprium bromide intranasal spray) is effective

Front 6

Characteristics of non-allergic rhinitis with eosinophilia (NARES):

Back 6

- Similar Sx to allergic rhinitis but no
evidence of IgE-mediated hypersensitivity
- Eosinophils are abundant in nasal secretions
- Unknown cause
- Responds to intranasal CS

Front 7

Epidemiology or allergic rhinitis:

Back 7

- 10-30% of population

- 40% of children

- Usually before 20 y/o

- Decreased quality of life: decreased sleep, productivity, work and school attendance, concentration and mental functioning

Front 8

Predisposing factors to allergic rhinitis?

Back 8

- Family history of atopy (asthma, allergic rhinits, atopic dermatitis; increased risk if both parents affected)

- High socioeconomic class

- Allergen exposure

Front 9

Define: priming response

Back 9

With repeated exposure to allergens, the amount of allergen to induce an immediate response decreases

Front 10

Drugs associated with rhinitis:

Back 10

- ACE inhibitors
- Phosphodiesterase-5-selective inhibitors (Sildenafil- Erectile dysfunction)
- A- blockers (Prazosin, terazosin)
- ASA, NSAIDS
- Beta blockers
- Methyldopa
- OCs
- Overuse of topical decongestants (sympathomimetics)

Front 11

Allergens (and time period) for seasonal allergic rhinitis?

Back 11

- Seasonal exacerbation
- Tree pollens in spring (March, April)
- Grass pollens in summer (May, June, July)
- Weed pollens in summer and fall (Aug, Sept, Oct)
- Mold spores (Feb – Nov)

Front 12

Allergens for perennial allergic rhinitis?

Back 12

Environmental allergens such as :

- dust mites

- molds

- animal danders

- occupational allergens

- some perennial pollens

Front 13

Sx presentation patterns in patients?

Back 13

- Develop within 2- 3 years after sensitizing exposure
- Often escalate in severity then plateau or diminish
- May diminish with age

Front 14

Symptoms of allergic rhinitis?

Back 14

- Nasal congestion

- Clear rhinorrhea

- Sneezing and itching (nasal and palatia)

- Conjunctivitis (red, itchy eyes)

- Periorbital swelling

- Postnasal drip can cause coughing

- Systemic: fatigue, irritability, depression

Front 15

Physical examination findings?

Back 15

General: facial pallor, allergic shiners, mouth breathing, transverse crease on nose bridge (allergic salute)

- Dennie-Morgan lines and conjunctivitis

- Nasal mucosal swelling (bluish)

- Fluid in middle ear

Front 16

Diagnostic tests for allergic rhinitis?

Back 16

- Skin Tests
- Nasal cytology (for eosinophils & neutrophils)
- Serology (serum IgE increase 2 – 6 x normal in 30% – 40% patients)

Front 17

Advantages of skin tests?

Back 17

- Most sensitive, cost effective, and fast

- Identifies relevant allergens

- Only used in persistent or severe cases

Front 18

Disadvantages of skin tests?

Back 18

False negatives occur with anthihistamines, TCAs, Oral or TCS (must D/C before test)

Front 19

Seasonal, perennial, and common cold:

DURATION

Back 19

Seasonal: weeks - months

Perennial: continuous

Common cold: 1 week

Front 20

Seasonal, perennial, and common cold:

DISCHARGE

Back 20

Seasonal: watery

Perennial: not so copious

Common cold: mucopurulent

Front 21

Seasonal, perennial, and common cold:

SORE THROAT

Back 21

Seasonal: rare

Perennial: uncommon (irritated)

Common cold: sore throat + cough

Front 22

Seasonal, perennial, and common cold:

Itch/ sneeze

Back 22

Seasonal: itchy, sneezing

Perennial: less common

Common cold: mild sneeze, rarely itchy

Front 23

Allergic rhinitis complications?

Back 23

- Recurrent upper resp. infection (colds)

- Nasal polyps (sac-like growths of inflamed nasal mucosa)

- Loss of smell/ taste

- Facial and dental abnormalities

- Epistasis (nose bleeds)

- Sleep disorder

Front 24

Complications/ comorbidities of allergic rhinitis?

Back 24

- Asthma

- Sinusitis

- Otitis media with effusion (OME)

Front 25

Allergen avoidance methods for house dust mites?

Back 25

- Wash bedding and toys Q1-2 weeks in HOT water (>130F)

- Impermeable mattress and pillow covers are ineffective

- Reduce indoor humidity to 40-45%

- Minimize clutter; dust/ vacuum weekly

- Polished/ wipeable furniture and flooring

Front 26

Allergen avoidance methods for pets?

Back 26

- Keep out of bedroom/ home if possible

- Run HEPA air cleaner if indoor pet

- Bathe pet 2x/week

- Wash pet bedding weekly

Front 27

Allergen avoidance methods for pollen?

Back 27

- Close home and car windows and filter air (AC)

- Rinse of skin and hair before bed

- Dry laundry in dryer

- Plan outdoor activities in low pollen times

Front 28

Allergen avoidance methods for fungi/ molds?

Back 28

- Reduce indoor humidity (40 – 45% relative humidity)
- Repair any structural leaks for moisture
- Discard moldy furnishings
- Clean with fungicide (10% Cl bleach)

Front 29

Use and efficacy of nasal irrigation?

Back 29

Neti pot - administer saline solution/ flush nasal passageways

- Infection risk if naegleria fowleri (ameba) in tap water

- Evidence showing relief of symptoms, help as adjunct therapy, and tolerated by most patients

Front 30

MOA of oral antihistamines?

Back 30

Competitive blockers of H1 receptors. They do not prevent the release of histamine.

Front 31

Use and efficacy of oral antihistamines?

Back 31

Nasal response usually caused by histamine release; therefore need to take before exposure or continuously

- effective as PRN by maintenance is better

- Not responsive with chronic symptoms, high allergen exposure, or prolonged exposure

- Not very effective decongestant

- Can decrease non-nasal symptoms

Front 32

Why are first generation oral antihistamines (chlorphenarimine, diphenhydramine) often not used for allergic rhinitis?

Back 32

- sedation and anticholinergic effects

- GI disturbances

- Impair children's learning/ academic performance

- Cause fatal car accidents

Front 33

Characteristics of second generation (loratidine, desloratidine, fexofenadine (cetirizine)) antihistamines?

Back 33

- Large and lipophobic (doesn't cross BBB)

- Non-sedating (except cetirizine) at regular doses

- Not CNS depressant at regular doses

- Long acting (QD-BID dosing)

- Cost/day: $1.08-2.98

Front 34

Dosing regimen for cetirizine (Reactine)?

Back 34

5-10mg QD

Front 35

Dosing regimen for fexofenadine (Allegra)?

Back 35

60mg BID

Front 36

Dosing regimen for loratidine (Claritin)?

Back 36

10mg QD

Front 37

Dosing regimen for desloratidine (Aerius)?

Back 37

5mg qd

Front 38

Which second generation oral histamines have pregnancy category B, and C?

1. Cetirizine

2. Fexofenadine

3. Loratidine

4. Desloratidine

Back 38

B: 1 and 3

C: 2 and 4

Front 39

Use and efficacy for topical antihistamines?

Back 39

Levocabastine (Livostin 0.5%), BID

For nasal or ocular symptoms (eye drops or nasal spray)

- Equal or superior efficacy to oral antihistamines, faster onset

- Clinically significant effect on nasal congestion

Front 40

Side effect for topical antihistamines?

Back 40

Bad taste

Front 41

MOA of decongestants?

Back 41

Act on alpha -adrenergic receptors to cause vasoconstriction to reduce nasal congestion

- Effective to reduce severe obstructive congestion impairing absorption of intranasal steroids
- Can increase BP, stimulate CNS, interact with MAO inhibitors

Front 42

Name 4 topical decongestants.

Back 42

- Phenylephrine

- Oxymetazoline

- Xylometazoline

- Naphazoline (immidazolines = longer acting)

Front 43

Name 2 oral decongestants.

Back 43

- Phenylephrine

- Pseudophedrine

Front 44

Efficacy of combination products?

Back 44

Antihistamine (dries nasal secretion) + decongestant (reduce congestion)

- more effective in combo than alone

- convenient for short periods of time

Front 45

Disadvantages of combination products?

Back 45

Antihistamines + decongestant

- more insomnia and nervousness (even with sedating antihistamine)

- difficult to titrate dose when in combo

Front 46

Efficacy of topical corticosteroids vs. antihistamines?

Back 46

- More effective than antihistamines

- decrease all Sx (congestion, itching, sneezing, rhinorrhea, and similar effect on ocular symptoms compared to oral antihistamines)

- Use prophylactically and PRN

- Slow onset (3 days; max effect at 2 weeks)

Front 47

Which topical corticosteroids are used for allergic rhinitis?

Back 47

Budesonide, flunisolide, fluticasone, mometasone, triamcinolone

Front 48

Which hand is used during administration of topical intranasal steroid?

Back 48

If using on left nostril, use right hand to administer

- this directs spray away from septum to decrease risk of epistasis

Front 49

Which oral corticosteroids are used for allergic rhinitis?

Back 49

Prednisone 20-40 mg/d for 5 to 7 days
for very severe or intractable nasal symptoms or nasal polyposis.

Front 50

MOA and use of cromolyn?

Back 50

MOA: stabilizes mast cell membranes to prevent release of inflammatory mediator

Use: mild to moderate conditions (and prior to allergen exposure in episodic cases)

- steroids are superior in efficacy and compliance

Front 51

Dosing regimen of cromolyn?

Back 51

1 spray each nostril 6 times daily until adequate response obtained then decrease to bid or tid.

- delayed effect 4-7 days (or 2 weeks if severe or perennial cases)

- Cost: $15/4 weeks

Front 52

SEs of cromolyn?

Back 52

Safe with very few SEs: sneezing, stinging, nasal burning

Front 53

MOA and use of Ipratropium (Atrovent)?

Back 53

MOA: Blocks cholinergic receptors to decrease watery nasal secretions

Use: 1 spay per nostril TID-QID

- Lacking evidence for use in allergic rhinitis

Front 54

Use and efficacy of leukotriene receptor antagonists (Montelukast/ Zafirlukast)?

Back 54

- Similar efficacy to anithistamines (loratadine)
- Less effective than nasal CS
- Combined antihistamine + LTRA superior to either alone
- Weak as monotherapy to allergic rhinitis

Front 55

MOA and use of immunotherapy?

Back 55

Production of IgG blocking antibodies (block IgE from binding to antigen thereby inhibiting mast cell rupture)

- Use if non-responsive to pharmacotherapy or unable to tolerate SEs or avoid allergens

- Requires frequent injections

Front 56

Disadvantages of immunotherapy?

Back 56

- Requires frequent injections

- Risk of anaphylaxis (5% with high-potency extracts)

Front 57

Define: intermittent allergic rhinitis

Back 57

<4 days/week or <4 week in duration

Front 58

Define: persistent allergic rhinitis

Back 58

>4 days/week or >4 week duration

Front 59

Define: mild allergic rhinitis

Back 59

Normal sleep, daily activities, no troublesome symptoms

Front 60

Define: moderate/ severe allergic rhinitis

Back 60

One or more: decreased sleep, impaired daily activities, troublesome symptoms

Front 61

Treatment options for mild seasonal allergic rhinitis?

Back 61

- Treat with oral or nasal antihistamine

- For eye: topical antihistamine or cromones

Front 62

Treatment options for moderate seasonal allergic rhinitis?

Back 62

- Nasal CS

- For eye: topical antihistamine or cromones

Front 63

Treatment options for severe seasonal allergic rhinitis?

Back 63

- Nasal CS plus oral/ nasal antihistamine

Inadequate control: add further Sx treatment, or short-course oral CS, or consider immunotherapy

Front 64

For resistant cases of perennial allergic rhinitis, how is nasal blockage treated?

Back 64

- Short course topical decongestant or oral decongestant, or short course oral CS

- if resistant, surgical turbinate reduction

Front 65

For resistant cases of perennial allergic rhinitis, how is resistant rhinorrhoea treated?

Back 65

Nasal ipratropium bromide