Allergic Rhinitis Flashcards
People that have allergic rhinitis will often likely have what?
asthma
What is allergic rhinitis?
- IgE airway condition that occurs due to inhaled allergens and results in mucosal inflammation and airway obstruction
- characterized by nasal symptoms of sneezing, pruritus and discharge
What is the impact of AR?
- fatigue, reduced concentration or loss of productivity
- can be quite significant for some
What are the key facts associated with AR?
- Age (most prevalent in adolescents and young adults, some people grow out of it- onset approx 10 y/o)
- Family history (30% chance for children with one atopic parent - 50% with 2 parents)
- repeated exposure to multiple offending allergens
- presence of other allergic conditions (asthma, atopic dermatitis)
What are the 3 stages of pathophys of allergic rhinitis?
- Sensitization
- 1st contact with inhaled aeroallergen
- IgE produced which binds to mast cells and basophils - Immediate Reaction
- recognition of allergen by IgE bound to mast cells and basophils
- degranulation (release of preformed mediators, histamine, TNF, new formed mediators, leukotrienes, prostaglandins D2 and kinins)
- result in symptoms of sneezing, rhinorrhea, congestion and pruritus
- happens within minutes of re-exposure
- lasts for 30-90 minutes - Late Reaction
- migration of inflammatory cells, eosinophils, monocytes, macrophages and basophils
- symptoms similar to immediate action, but congestion predominates
- occurs 4-8 hours after exposure
Over time, the persistent inflammation is thought to ____ the tissue, decreasing the threshold of allergen needed to produce an immediate response
prime
What are some common occupational allergies?
- seed dust
- woods
- cockroaches
- animal dander
- moulds
What are the common nasal symptoms that are seen with allergic rhinitis?
- frequent, paroxysmal sneezing
- itching of the nose and palate
- anterior watery rhinorrhea
- nasal congestion
What are the common ocular symptoms associated with allergic rhinitis?
- red, irritated eyes with prominent conjunctival blood vessels
- itching or burning that may be intense
- tearing
- stringy or watery discharge
- puffy eyelids- especially in the morning
What are the common facial features that are associated with allergic rhinitis?
- allergic gape (open-mouthed breathing secondary to nasal obstruction)
- allergic salute
- allergic shiners (periorbital darkening secondary to venous congestion)
- donnie’s lines (wrinkles beneath the lower eyelids)
What are some of the systemic symptoms of allergic rhinitis?
- cognitive impairment
- fatigue
- irritability
- malaise
What are some common perennial allergies?
- dust, mould
What is classified as intermittent allergic rhinitis?
< 4 days/week
< 4 weeks/year
What is classified as persistent allergic rhinitis?
> 4 days/week
>4weeks/year
What constitutes vasomotor rhinitis?
- a form of non-allergic rhinitis, which onset later on in life
- presentation: nasal congestion, rhinorrhea and postnasal drip (dripping in back of throat)
- patients usually 40-60 y/o
triggers: temperature, exercise, environmental changes, cigarettes, perfume, paint, smoke and emotional stress
True or false: vasomotor rhinitis is immune mediated. Antihistamines would work for vasomotor rhinitis
False
What are some common medications that can cause non allergic rhinitis?
- antihypertensive agents (prazosin, beta blockers, ACE inhibitors)
- oral contraceptives
- NSAIDS
- topical decongestants
- older antipsychotics agents
What are the red flags to be aware of with allergic rhinitis?
- age < 2 y/o
- wheezing and shortness of breath
- tightness in the chest
- painful ear or sinuses
- fever
- purulent nasal or ocular discharge
- allergen not identifiable
- failed medication - inadequate response to appropriate OTC rx after about 2 weeks
- poor quality of life/missing school or work
What are the general treatments of allergic rhinitis?
- non-pharmacological treatments (avoid the offending allergen- eliminate the allergen from the environment)
- pharmacotherapy
- immunotherapy
- education
What is normal saline used for?
- used to soothe irritated nasal tissues and moisturize the nasal mucosa
- used on a prn basis
Controlled clinical studies suggest that nasal irrigation might do what?
- reduce nasal concentration of inflammatory mediators, therefore possible helping to prevent or eliminate congestion
- flush out mucus and allergens
- improve nasal airflow
How do nasal breathing strips work?
- drug free option
- work by mechanical means to improve nasal airflow in patients suffering form congestion
- symptomatic relief
- considered a device
- NO EVIDENCE THAT IT WORKS
What are the treatment goals for allergic rhinitis?
- avoid or minimize the exposure to allergen
- alleviate symptoms associated with allergic rhinitis
- minimuse actual and potential adverse events associated with medication
What is the MOA for antihistamines?
- competitive, reversible antagonist at H1 receptor
- prevents histamine binding and action at the receptor site
- does not affect histamine synthesis or chemically inactivate histamine
- effective in reducing sneezing, rhinorrhea and itch (nasal, palatal and ocular) associated with AR
With the exception of desloratadine, these antihistamines are generally _________
not effective at relieving nasal congestion and stuffiness
Do antihistamines get rid of histamine that has already been released?
NO it does not - they just block histamine at the site of action - if the mast cells have already degranulated and have bound to their active site, they will have no further affect
Describe first generation antihistamines
non selective and sedating antihistamine
Describe second generation antihistamines
peripherally selective and non-sedating
____ generation antihistamines have a high amount of anticholinergic SE
First
What are the known first generation antihistamines?
- chlorpheniramine
- diphenhydramine
- brompheniramine /doxyalamine/pyrilamine/triprolidine
What are the known second generation antihistamines?
- loratadine
- cetirizine
- fexofenadine
What is the one known 3rd generation antihistamine?
- desloratidine
With ____ it is important to avoid all juices
fenofexadine
10% of patients that have ____ will have sedating SE
cetirizine
What is the dosing of Diphenhydramine?
Onset: 15-30 mins
Dosing: every 6-8 hours
Adverse effects: anticholinergic (dry mouth and eyes, constipation, urinary retention)
and CNS effects (sedation, fatigue, disease, impairment of cognition and performance)
Drug Interactions: alcohol, hypnotics, sedatives, CNS depressants
What is the dosing of Chlorpheniramine?
Onset: 30 minutes
Dosing: every 4-6 hours
Adverse effects: anticholinergic effects as well as CNS effects (sedation, fatigue, dizziness, impaired cognition and performance)
Drug interactions: alcohol, hypnotics, sedatives, CNS depressants
What is the dosing of cetirizine?
Onset: 20-60 minutes
Dosing: once daily
Adverse effects: minimal to no anticholinergic or CNS effects - may cause drowsiness in some headache
** avoid if hypersensitivity to hydroxyzine
What is the dosing of fexofenadine?
Onset: 1 hour
Dosing: OD ( 120 mg) or BID (60 mg)
Adverse effects: minimal to no anticholinergic or CNS effects, headache
** take with water, do not take straight with antacids
What is the dosing for loratadine?
Onset: 1-3 hours
Dosing: OD
Adverse effects: minimal to no anticholinergic or CNS effects - headache
What is the dosing for desloratadine?
Onset: 1.25 hours
Dosing: OD
Adverse effects: minimal to no anticholinergic or CNS effects, headache
Central effects of antihistamines depends on the drug’s ability to cross the ____
BBB
Antihistamines should be taken _____ before pollen season or onset of symptoms (for seasonal/intermittent allergies)
10-14 days
Should continue antihistamines throughout the season and for ______ afterwards
2-3 weeks
For infrequent exposure to allergens, such as visiting a house with a cat, the AH should be taken _____ before exposure to the allergen
2-5 hours
What are some of the causes of ineffectiveness of antihistamines?
- patient non-adherence
- increased antigen exposure
- worsening condition
- limited effectiveness of AH in severe disease
- develops similar symptoms due to unrelated disease
- suggest switching to another class of AH
What are the most common side effects of AH?
- Sedation: mild drowsiness to deep sleep
- CNS depression: disturbed coordination, dizziness, drowsiness and inability to concentrate
- may be increased with alcohol
- mucus secretion thickened - Anticholinergic effect: this is typically associated with the 1st generation AH
- dry mouth/dry eyes/dry nose, constipation, tachycardia, urinary retention, increase intraocular pressure
What are the contraindications of using a 1st generation AH?
- narrow angled glaucoma
- severe bladder obstruction
- stenosing peptic ulcer or pyloroduodenal obstruction
- hyperthyroidism
- cardiac disease
- prostate disease
- chronic lung disease
- Caution: patients with MAOIs
Can you take a first generation antihistamine with hypertension?
- YES
- it does not cause an increase in blood pressure, only HEART RATE
What is the action of decongestants?
- they sole the symptoms of congestion only, they do not treat the inflammatory cause of the allergic rhinitis
- cause vasoconstriction of the alpha receptors, inflammatory mediators do not flood the area as much so you do not get as much inflammation and congestion
What are the two used oral decongestants?
- phenylephrine
- pseudophedrine
Of the oral decongestants, which is the only one that is effective?
- pseudoephedrine
What are the most common intranasal decongestant?
- oxymetazoline
- xylometazoline
- phenylephrine
- naphazoline
What symptoms do decongestants treat?
- do not treat any of the other symptoms of allergic rhinitis - itchy watery eyes, watery nose, etc
Antihistamines have their full effect in about _____ days
3
Decongestants should be used for only about ___ days, and should only be used for short term symptom relief
3-7
How do decongestants work?
- decongestants cause vasoconstriction of the alpha receptors in the nasal mucosa and decreased inflammation
- sympathomimetics
Phenylephrine is a ___ adrenergic agonist
alpha 1
Oxymetazoline and xylometazoline are ____ adrenergic agonists
alpha 2
Pseudoephedrine is a ____ releaser
noradrenaline
Onset of action of an oral decongestant is ______
15 to 30 minutes
You can use oral decongestants in this over _____
6 years of age
What are the adverse effects of using an oral decongestant?
- irritability
- dizziness
- headaches
- tremor
- insomnia
- peripheral vasoconstriction
and tachycardiaor palpitation - may adversely affect blood sugar in diabetics
It is best to avoid using oral decongestants in those with what?
- patients with heart disease, angle-closure glaucoma, diabetes, hyperthyroidism. prostate enlargement are at risk of adverse effects with these agents
What are the absolute contraindications to using oral decongestants?
-patients with severe hypertension and coronary artery disease
What other drugs interact with oral decongestants?
- MAOI
- TCA
- methyldopa
What is the onset of action for all three intranasal decongestants?
5-10 minutes
What are the dosing differences of all three intranasal decongestants?
(oxymetazoline, phenylephrine, xylometazoline)
Oxymetazoline: Q12H
Phenylephrine: Q4H
Xylometazoline: Q8-10H
What are the side effects of intranasal decongestants?
nasal burning, stinging, dryness or mucosal ulceration
** can also cause rebound nasal congestion
What is the benefit of using a intranasal decongestant over a systemic one?
- topical products have fewer side effects
Explain rhinitis medicamentosa (RM)- rebound congestion form using intranasal decongestants
- prolonged use (>3-5 days)
- caused by the down regulation of alpha adrenergic receptors
- rebound swelling of nasal mucosa and drug induced rhinitis
- thought to be less risk with oxymetazoline and xylometazoline due to longer acting formulations
- use in adults and children over 12 years old
Intranasal decongestants treat nasal obstruction in _______
both allergic rhinitis and non-allergic rhinitis
Intranasal decongestants are used as prophylaxis in ____
air travel (15-30 minutes)
Local vasoconstriction occurs within ____ of administration
10 minutes
An ophalmic decongestant can be used for short term use in combination with an AH to relieve ____
conjunctivitis
What is the mechanism of action of ophthalmic decongestants?
vasoconstriction results in a decrease in eye redness
** does NOT actually treat the congestion - ONLY treats the red eye
Ophthalmic decongestants are contraindicated in what disease state?
- in patients with angle closure glaucoma
What are the side effects associated with ophthalmic decongestants?
- burning
- stinging
What is the rebound effect associated with ophthalmic decongestants?
- increased redness and swelling is used more than 10 days
What are the 4 medications that are typically in ophthalmic decongestants?
- naphazoline
- phenylephrine
- tetrahydrazoline
- oxymetazoline
What is the mechanism of action of mast cell stabilizers?
- inhibits degranulation of mast cells or intracellular events that follow the binding of the IgE to the mast cell
- does not have antihistamine, anticholinergic or antiinflmmatory effects
- alleviates runny nose, nasal itching and sneezing, but are NOT antihistamines
What are the disadvantages of using a mast cell stabilizer?
- delayed onset of action, may take 4-7 days for any improvement and full benefit will take 304 weeks if used after exposure to an allergen
What is the dosing of a mast cell stabilizer?
- 2-4 sprays TID-QID dosing
It is important to use mast cell stabilizers ____, 2-3 weeks before the start of allergy season
prophylactically
Mast cell stabilizers are considered to be ___ effective than antihistamines and intranasal corticosteroids
less
What is considered to be the most effective agent for AR?
- intranasal corticosteroids
What is the mechanism of action of intranasal corticosteroids?
- decreased influx of inflammatory cells and inhibiting release of cytokines which leads to a reduction of inflammation
Intranasal corticosteroids are more effective if used _____
continuously
Onset of action of intranasal corticosteroids is ________, but maximal effect takes place in ______ days
30 minutes
7-14 days
What are the side effects of using intranasal corticosteroids?
- burning, stinging, nosebleeds, headache, throat irritation and nasal dryness
Do intranasal corticosteroids have a negative effect on growth in children?
- no, they do not
Triamcinolone nasal spray is schedule ___, for over ___ years of age in packaging that contains no more than 120 sprays
3
12 y/o
Fluticasone propionate is schedule ____, for over ___ years of age in packaging containing no more than 120 sprays
3
18 y/o
Intranasal antihistamines have a similar efficacy to what?
oral antihistamines
What are the common side effects associated with intranasal antihistmines?
- bitter taste, headache, fatigue, irritation and epistaxis
A combination product that is both intranasal corticosteroid and antihistamine is known to resolve symptoms in those with what?
- moderate to sever AR
What is the mechanism of action of an intranasal anticholinergic?
- prevents secretions of the nasal mucosa
- dosing is bid to tid
What are the side effects of intranasal anticholinergics?
- dryness of nasal mucosa
- nosebleeds (episaxis)
- dry mouth and throat
- headache
What is the only benefit of using intranasal anticholinergics?
- excessive rhinorrhea. therefore use only when rhinorrhea symptom or refractory rhinorrhea
- helpful in vasomotor rhinitis
- ipratropium does not cross the BBB and is not systemically absorbed
Oral steroids should be used in combination with what?
- intranasal steroids
For persistent symptoms that affect quality of life, _____ are preferred
intranasal corticosteroids
For mild intermittent symptoms, oral _________ are preferred
second generation antihistamines
What is the process of immunotherapy?
- is the process of giving the patient some of the allergen, so that when the patients is exposure to the allergen in the environment, the immune system would not respond
- indicated for moderate or severe persistent allergic rhinitis when:
1. usual treatments have failed
2. patient does not want to use medications long term
3. patients with allergic rhinitis
What are the 2 types of immunotherapy?
- subcutaneous injection - given at regular intervals at the doctors office
- Sublingual - first dose must be taken at the doctor’s office, then patient can take medication at home daily (to make sure they do not have an anaphylactic reaction)
Subcutaneous may be more ____, but sublingual is _____
- effective
- safer
Generally immunotherapy is taken for _____ years and results may last _____ years
3-5 years
7-12 years
Do not use OTC products in patients under _____
2 y/o
What is the one exception of an antihistamine that cannot be used in children >2 and has to be used in those over 12?
- fenofexadine
What is the age limit for using an intranasal glucocorticosteroid?
- can be prescribed in children over 4 y/o
___ generation antihistamines are generally recommended for children with allergic rhinitis?
Second
Second generation agents are preferred fir children unless treating what?
- allergic skin reactions
- anaphylactic reaction
Disodium cromoglycate can also be used in children - true or false?
True
Why is rhinitis so common in pregnancy?
- increased estrogen and progesterone that causes vasomotor rhinitis - nasal congestion is non-allergic
- should try non-pharm methods (saline)
___ of women with AR will experience increased in symptoms during pregnancy (may worsen, stay the same or even improve)
33%
What is the recommended medications to use to treat allergic rhinitis in pregnancy?
- loratadine
- cetirizine
(do NOT give desloratidine- do not have enough studies) - sodium cromylglycate (was not absorbed systemically)
Actual allergic rhinitis is NOT common in elderly but non-allergic rhinitis is very common due to changes in the vasculature of the nose. What symptoms may it cause?
- congestion
- rhinitis
What medications can cause non-allergic rhinitis in the elderly?
- antihypertensives
- ASA/NSAIDS
_____ can be recommended to treat non-allergic rhinitis in the elderly
Intranasal ipratropium
The effectiveness of fexofenadine may be reduced by ____, ____, and _____ juice
- grapefruit
- orange
- apple
_____ may cause drowsiness in some patients. Alcohol may increase the sedative effect
Cetirizine
A slight increase in _____ may be noticed with systemic decongestants
heart rate
If congestion does not improve after ____ days after taking a decongestant, it is recommended to see the doctor
5-7
Decongestants should be taken in the ____ to avoid insomnia
morning
if needed to be taken, should take the evening dose 3-5 hours before bedtime to avoid insomnia
Mast cell stabilizers should be frequently administered on a ____ basis
TID
How many weeks will it take for mast cell stabilizers to reach its full effectiveness?
- 2-4 weeks
What are some side effects that can be experienced by a person taking mast cell stabilizers?
nasal dryness, nosebleeds and a sore throat
Symptomatic relief with initial nonprescription drug therapy is how long?
3 to 4 days
Complete relief of symptoms may take _____
2-4 weeks
The use of ophthalmic antihistamines should result in symptom resolution within ______
72 hours
