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Clinical - Winter > 9 & 10 - Allergic Rhinitis > Flashcards

9 & 10 - Allergic Rhinitis Flashcards

1
Q

What causes allergic rhinitis? What does this result it?

A
  • Inhaled allergens

- Results in mucosal inflammation and airflow obstruction

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2
Q

What is allergic rhinitis characterized by?

A

Nasal sx of sneezing, pruritus, and discharge

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3
Q

What are some conditions that often occur w/ allergic rhinitis?

A
  • Asthma
  • Sinusitis
  • Otitis media
  • Conjunctivitis
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4
Q

What is allergic rhinitis classified as?

A

Major chronic respiratory disease

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5
Q

What are the major risk factors associated w/ allergic rhinitis?

A
  • Age (most prevalent in adolescents and young adults)
  • Family history
  • Repeated exposure to multiple offending allergen
  • Presence of other allergic conditions (asthma, atopic dermatitis)
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6
Q

What is the typical onset age of allergic rhinitis?

A

10 y/o

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7
Q

What is the pathophys of allergic rhinitis?

A

1) Sensitization - IgE produced binds to mast cells and basophils
2) Immediate reaction - recognition of allergen by IgE bound to mast cells and basophils causes degranulation, releasing preformed mediators (histamine, TNF, leukotrienes); happens w/in mins of re-exposure and lasts for 30-90 mins
3) Late reaction - migration of inflammatory cells, eosinophils, monocytes, macrophages, and basophils; occurs 4-8 h after exposure

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8
Q

What happens w/ repeated exposure to an allergen?

A

Inflammation “primes” the tissue, decreasing threshold of allergen required to produce an immediate response

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9
Q

What are common ocular sx of allergic rhinitis?

A
  • Red, irritated eyes w/ prominent conjunctival blood vessels
  • Itching or burning
  • Tearing
  • Stringy or watery discharge
  • Puffy eyelids, especially in morning
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10
Q

What are some facial features of allergic rhinitis?

A
  • Allergic gape (open mouth breathing secondary to nasal obstruction)
  • Allergic salute (children wiping runny nose w/ bottom of palm)
  • Allergic shiners (periorbital darkening secondary to venous congestion)
  • Dennie’s lines (wrinkles beneath lower eyelid)
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11
Q

What are some systemic sx of allergic rhinitis?

A
  • Cognitive impairment
  • Fatigue
  • Irritability
  • Malaise
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12
Q

What are the various characterizations of allergic rhinitis?

A
  • Seasonal, perennial (all year), or episodic
  • Intermittent or persistent
  • Mild or moderate to severe
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13
Q

What determines if allergic rhinitis is intermittent or persistent?

A

Persistent is more than 4 days per week and more than 4 weeks per year; intermittent is 4 or less

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14
Q

What determines if allergic rhinitis is mild or moderate to severe?

A
  • Mild = has sx, but doesn’t interfere w/ QOL

- Moderate to severe = sx interfere w/ QOL

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15
Q

What are differential diagnoses for allergic rhinitis?

A
  • Infectious rhinitis (viral, common cold)
  • Idiopathic non-allergic or vasomotor rhinitis (non-inflammatory)
  • Hormonal rhinitis (pregnancy, menstruation)
  • Non-allergic inflammatory rhinitis
  • Occupational rhinitis
  • Nasal polyps
  • Drug-induced rhinitis
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16
Q

What is vasomotor rhinitis? Symptoms?

A
  • Non-allergic rhinitis, w/ onset later in life

- Sx = nasal congestion, rhinorrhea, and postnasal drip

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17
Q

What are triggers for vasomotor rhinitis?

A
  • Temp
  • Exercise
  • Environmental changes
  • Cigarettes
  • Perfume
  • Emotional stress
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18
Q

What are some medications that can cause non-allergic rhinitis or drug-induced rhinitis?

A
  • Antihypertensive agents (prazosin, beta-blockers, ACE inhibitors)
  • Oral contraceptives
  • NSAIDs
  • Overuse of topical decongestants
  • Older antipsychotic agents
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19
Q

What are some red flags for allergic rhinitis?

A
  • Under 2 y/o
  • Wheezing and SOB
  • Tightness of chest
  • Painful ear or sinuses
  • Fever
  • Purulent nasal or ocular discharge
  • Allergen not identifiable
  • Impaired QOL
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20
Q

What are some non-pharms for allergic rhinitis?

A
  • Avoid allergen
  • Normal saline
  • Nasal breathing strips
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21
Q

What is the purpose of nasal saline?

A
  • Reduces nasal concentration of inflammatory mediators, possibly helping to prevent or eliminate congestion
  • Flush out mucous and allergens
  • Improve nasal airflow
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22
Q

How do nasal breathing strips work?

A

Improve nasal airflow in px suffering from congestion

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23
Q

What is the mechanism of antihistamines?

A
  • Competitive, reversible antagonist at H1 receptor

- Prevents histamine binding

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24
Q

What symptoms of allergic rhinitis can antihistamines reduce?

A
  • Sneezing
  • Rhinorrhea
  • Itch (nasal, palatal, ocular)
  • Nasal congestion and/or stuffiness (only desloratidine, cetirizine, and fexofenadine)
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25
Q

What is the tx of choice for mild sx of allergic rhinitis?

A

2nd gen antihistamines

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26
Q

What are the 1st gen antihistamine?

A
  • Chlorpheniramine
  • Diphenhydramine (benadryl)
  • Brompheniramine/ doxylamine/ triprolidine/ pyrilamine (Nyquil)
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27
Q

What are the 2nd gen antihistamines?

A
  • Loratidine
  • Cetirizine
  • Fexofenadine
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28
Q

What is the 3rd gen antihistamine?

A

Desloratidine

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29
Q

What are adverse effects of 1st gen antihistamines?

A
  • Dry mouth and eyes
  • Constipation
  • Sedation
  • Fatigue
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30
Q

What are drug interactions w/ 1st gen antihistamines?

A
  • Alcohol
  • Hypnotics
  • Sedatives
  • CNS depressants
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31
Q

What are adverse effects of 2nd gen antihistamines?

A
  • May cause drowsiness in some

- Headache

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32
Q

When should cetirizine be avoided?

A

If have hypersensitivity to hydroxyzine

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33
Q

When should antihistamines be taken?

A

Before exposure to allergen, b/c prevent actions of histamine (can’t reverse effects of histamine after it has been activated)

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34
Q

What should be done if antihistamines are ineffective?

A

As long as no adherence issues, px can switch to another class of antihistamine

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35
Q

Which antihistamines are available as IM dosage form?

A

1st gen

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36
Q

What are the general recommendations for antihistamines?

A
  • Start tx 10-14 days before onset of sx (for seasonal/intermittent allergies)
  • Continue throughout season and for 2-3 weeks after season
  • Take on daily basis for chronic sx
  • For infrequent exposure, take AH 2-5 hours before exposure
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37
Q

Which groups of px should avoid products w/ anti-cholinergic side effects (ex: 1st gen antihistamines)?

A
  • Glaucoma (will increase intraocular pressure)

- Arrhythmias (will increase heart rate)

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38
Q

Can antihistamines be used in hypertension?

A

Yes, as long as no other conditions

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39
Q

What are contraindications for 1st gen antihistamines?

A
  • Glaucoma
  • Severe bladder obstruction
  • Stenosing peptic ulcer
  • Hyperthyroidism
  • Cardiac disease (heart failure, ischemic heart disease)
  • Prostate disease
  • Chronic lung disease
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40
Q

What are the oral decongestants?

A
  • Phenylephrine

- Pseudoephedrine

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41
Q

What are the intranasal decongestants?

A
  • Oxymetazoline
  • Xylometazoline
  • Phenylephrine
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42
Q

How do decongestants work?

A
  • Vasodilate capillaries that cause congestion

- Vasoconstrict alpha receptors in nasal mucosa and decrease inflammation

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43
Q

Which decongestant is an alpha 1 agonist?

A

Phenylephrine

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44
Q

Which decongestants are alpha 2 agonists?

A
  • Oxymetazoline

- Xylometazoline

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45
Q

Would a decongestant improve nasal itching, sneezing, or runny nose?

A

No

46
Q

What is the onset of oral decongestants? What is the age limit?

A
  • 15-30 mins

- Used in px 6 y/o and older

47
Q

What are adverse effects of pseudoephedrine?

A
  • Irritability
  • Dizziness
  • Headaches
  • Insomnia
48
Q

What are contraindications to oral decongestants?

A
  • Heart disease, severe hypertension, coronary artery disease
  • Angle-closure glaucoma
  • Diabetes
  • Hyperthyroidism
  • Prostate enlargement
49
Q

Which drugs interact w/ oral decongestants?

A
  • MAOIs
  • TCAs
  • Methyldopa
50
Q

What is the onset of intranasal decongestants?

A

5-10 minutes

51
Q

What is the dosing for each intranasal decongestant?

A
  • Oxymetazoline = q12h
  • Phenylephrine = q4h
  • Xylometazoline = q8-10h
52
Q

What are side effects of intranasal decongestants?

A
  • Nasal burning
  • Stinging
  • Dryness
  • Mucosal ulceration
  • Rhinitis medicamentosa (rebound congestion)
53
Q

What is the age restriction for intranasal decongestants?

A

12 y/o and older

54
Q

What is the contralateral technique for intranasal decongestants?

A

Block one nostril and spray into nose w/ other hand

55
Q

When are ophthalmic decongestants used?

A

In combination w/ antihistamines to relieve conjunctivitis

56
Q

What is the mechanism of ophthalmic decongestants?

A

Vasoconstriction, resulting in decrease of eye redness

57
Q

What is a contraindication for ophthalmic decongestants?

A

Angle closure glaucoma

58
Q

What are side effects of ophthalmic decongestants?

A

Burning, stinging

59
Q

Do ophthalmic decongestants produce a rebound effect?

A

Yes, increases redness and swelling if used more than 10 days

60
Q

What are examples of ophthalmic decongestants?

A
  • Naphazoline
  • Phenylephrine
  • Tetrahydrazoline
  • Oxymetazoline
61
Q

What is an example of a mast cell stabilizer?

A

Sodium cromoglycate

62
Q

What dosage forms are mast cell stabilizers available as?

A
  • Intranasal spray

- Ocular drops

63
Q

What is the mechanism of mast cell stabilizers?

A
  • Inhibits degranulation of mast cells

- Doesn’t have antihistamine, anti-cholinergic, or anti-inflammatory effects

64
Q

What sx do mast cell stabilizers alleviate?

A

Runny nose, nasal itching, sneezing

65
Q

What are disadvantages to mast cell stabilizers?

A
  • Delayed onset of action (may take 4-7 days for improvement and 3-4 weeks for full benefit)
  • 2-4 sprays TID-QID
66
Q

Are mast cell stabilizers more effective than antihistamines?

A

No

67
Q

What is the mechanism of intranasal corticosteroids?

A
  • Decrease influx of inflammatory cells

- Inhibits release of cytokines, which leads to reduction of inflammation

68
Q

What is the onset of intranasal corticosteroids?

A
  • Onset w/in 6-8 hours

- Maximal effect in 7-14 days

69
Q

What are the most effective agents for allergic rhinitis?

A

Intranasal corticosteroids

70
Q

When are intranasal corticosteroids the first line therapy?

A

Moderate to severe or persistant allergic rhinitis

71
Q

Should intranasal corticosteroids be used prn or continuously?

A

More effective if used continuously

72
Q

Are combinations of oral antihistamines and intranasal steroids more effective than each alone?

A

No

73
Q

What are side effects of intranasal corticosteroids?

A
  • Burning
  • Stinging
  • Nosebleeds
  • Headache
  • Throat irritation
  • Nasal dryness
74
Q

What are the 2 OTC intranasal corticosteroids available?

A
  • Triamcinolone

- Fluticasone

75
Q

What is the schedule of triamcinolone nasal spray?

A
  • Schedule 3 for 12 y/o and older in packaging that contains no more than 120 sprays
  • Schedule 2 if contains more than 120 sprays
  • Schedule 1 if for children under 12 y/o
76
Q

What is the dosing of triamcinolone?

A
  • Initial = 2 sprays in each nostril once daily

- Once maximal benefit achieved, reduce dose to 1 spray in each nostril once daily for maintenance

77
Q

What is the schedule of fluticasone?

A
  • Schedule 3 for 18 y/o and older in packaging that contains no more than 120 sprays
  • Schedule 1 for children under 18 y/o
78
Q

What is the dosing of fluticasone?

A
  • Week 1 = 2 sprays in each nostril once daily
  • Week 2 to 3 months = 1 spray in each nostril once daily if sx controlled
  • After 3 months, confirm w/ HCP if continued use needed
79
Q

What drugs does fluticasone interact w/?

A
  • Ritonavir
  • Ketoconazole
  • ASA
80
Q

What are some contraindications for intranasal corticosteroids?

A
  • Immunodeficiency
  • HIV medications
  • Any signs or sx of infection in nasal cavity
  • Oral corticosteroid
  • Pregnant or breastfeeding
81
Q

What is the efficacy of intranasal antihistamines?

A
  • Similar efficacy to oral antihistamines for sx relief of rhinitis and conjunctivitis
  • Less effective than INS
82
Q

What are intranasal combination products? When are they indicated?

A
  • Intranasal combination of corticosteroid and antihistamine

- Indicated when no or incomplete resolution of sx w/ INS alone

83
Q

What is an example of an intranasal anticholinergic?

A

Ipratropium solution

84
Q

What is the mechanism of intranasal anticholinergics?

A

Prevents secretions of nasal mucosa

85
Q

What are side effects of intranasal anticholinergics?

A
  • Dryness of nasal mucosa
  • Nosebleeds (epistaxis)
  • Dry mouth or throat
  • Headache
86
Q

When are intranasal anticholinergics indicated?

A
  • Rhinorrhea only sx or refractory rhinorrhea

- Some types of vasomotor rhinitis

87
Q

When would oral steroids be used for allergic rhinitis?

A
  • Short time (5-10 days) in px w/ severe sx of allergic rhinitis
  • Used in combination w/ INS
88
Q

Which agent is recommended for persistent sx that affect quality of life?

A

Intranasal corticosteroids

89
Q

Which agent is recommended for mild intermittent sx?

A

Oral 2nd gen antihistamines

90
Q

What is immunotherapy? When is it indicated?

A
  • Giving the px some of the allergen so when the px is exposed to the allergen in the environment, the immune system won’t respond
  • Indicated for moderate or severe persistent allergic rhinitis when usual tx have failed, px doesn’t want medication long term, or px has allergic asthma
91
Q

What are the 2 types of immunotherapy available?

A
  • Subcutaneous injection, given at regular intervals at doctor’s office
  • Sublingual, first dose given at doctor’s office then px takes medication at home daily
92
Q

How long is immunotherapy taken? How long do the results last?

A
  • Taken for 3-5 years

- Results last 7-12 years

93
Q

What agents are recommended for allergic rhinitis in children over 2 y/o?

A
  • Most 2nd gen antihistamines
  • Fexofenadine can only be used in children over 12 y/o
  • Intranasal glucocorticosteroid can be prescribed in children over 4 y/o
94
Q

Why aren’t 1st gen antihistamines recommended for children?

A

Can cause hyperactivity

95
Q

Can mast cell stabilizers be used in children?

A

Yes

96
Q

Can decongestants be used in children under 6 y/o?

A

No, so normal saline can be used to help clear nose

97
Q

What is recommended for allergic rhinitis in pregnancy?

A

Loratidine or cetirizine

98
Q

Can intranasal corticosteroids be used in pregnancy?

A

Under physician supervision

99
Q

What type of rhinitis is common in elderly? What is the recommended tx?

A
  • Non-allergic rhinitis

- Intranasal ipratropium recommended for runny nose

100
Q

What can reduce the effectiveness of fexofenadine?

A

Grapefruit, orange, and apple juice

101
Q

When should a px be referred who is taking a systemic decongestant?

A

If congestion doesn’t improve after 5-7 days

102
Q

What is the monitoring for allergic rhinitis?

A
  • Symptomatic relief w/ initial OTC therapy in 3-4 days
  • Complete relief of sx may take 2-4 weeks (follow-up after 1 week)
  • Ophthalmic antihistamines should cause sx resolution w/in 72 hours
103
Q

What are some non-pharms for allergic conjunctivitis?

A
  • Avoid allergen

- Cold compresses for 10-15 min TID-QID to help redness and itching

104
Q

What are the pharm options for allergic conjunctivitis?

A
  • 1st line = ocular lubricants for sx relief
  • 2nd gen oral antihistamines to stop itching
  • 2nd line = ocular antihistamines, ocular decongestants, or decongestant/antihistamine combinations
105
Q

What is the dosing for ocular lubricants?

A

1 drop 2-6 times daily

106
Q

What is the mechanism of ocular lubricants?

A
  • Dilutes allergen and decreases allergen contact time w/ conjunctiva
  • Creates barrier against pollens
107
Q

Can mast cell stabilizers be used for allergic conjunctivitis?

A

Yes to prevent redness, itching, and eyelid edema

108
Q

What is the mechanism of ophthalmic decongestants?

A

Reduces eye redness and eyelid edema through vasoconstriction

109
Q

What are the 2 available OTC ophthalmic decongestants?

A
  • Phenylephrine

- Imidazolines

110
Q

What are some precautions w/ ophthalmic decongestants?

A
  • Risk of rebound ocular congestion w/ continued use (more than 10 days)
  • Contraindicated in angle-closure glaucoma
111
Q

What is the monitoring for allergic conjunctivitis?

A
  • Monitor daily for improvement of sx (itching, tearing, redness)
  • Refer if no improvement w/in 3 days or sx remain despite tx

Clinical - Winter (24 decks)

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