allergic rhinitis Flashcards
presenting symptoms
- sneezing
- clear rhinorrhea
- itchy noses, eyes, palate
- nasal congestion
- malaise/fatigue (especially in children)
- post nasal drip (frequent throat clearing, cough)
SCHOLAR-MAC considerations
- history: are there patterns?
- does it usually happen at a particular time/place (i.e. seasonal, indoor vs. outdoor)
- onset: days vs weeks vs longer?
- aggravating/remitting: do specific exposures make it worse and then it goes away when exposure is over?
physical findings
- clear rhinorrhea
- pale or bluish discoloration and swelling of nasal mucosa
- conjunctivitis/watery ocular discharge
- frequent throating clearing
- “allergic shiners”: bags under the eyes that are pooling of venous blood
- “allergic crease”
- “allergic salute”
- “allergic gape”
classification of AR
- by temporal pattern
- by frequency of symptoms
- by severity of symptoms
temporal pattern
- seasonal, perennial (continually recurring), episodic
- may be difficult to determine
frequency of symptoms*
- intermittent (IAR): <4 days per week OR <4 weeks per year
- persistent (PER): >4 days per week AND >4 weeks per year
severity of symptoms*
- mild: not interfering with QOL
- moderate to severe: interfere with QOL
- examples: asthma exacerbation, sleep disturbance, impaired daily activities, leisure and/or sport, impaired school/work performance
exclusions for self-care
- children <12 years old* (due to under-diagnosed asthma concerns)
- pregnant or lactating women*
- symptoms of non-allergic rhinitis
- symptoms of otitis media, sinusitis, bronchitis, or other infection
- symptoms of undiagnosed or uncontrolled asthma, COPD, or other lower respiratory disorder
- severe or unacceptable side effects to treatment
general avoidance
- avoidance of smoking
- minimize use of wood-burning stoves and fireplaces
- HEPA filters: remove pollen, mold spores, cat allergens (but not fecal particles from dust mites)
pollen avoidance
- keep windows/doors closed during pollen season
- avoid using fans to draw in outside air
- use air conditioning
- minimize outdoor activities during pollen season
- shower and change clothes after outdoor activity
- don’t use an outside clothesline to dry clothes
mold avoidance
- similar recommendations as general & pollen avoidance
- avoid working with compost, dry soil, and raking leaves
- remove moldy surfaces in the home
- reduce indoor humidity to <40%
intranasal corticosteroids (INCS) MOA
- reduce inflammation by suppressing mediator and cytokine release and recruitment of neutrophils, basophils, eosinophils, mononuclear cells
- reduce antigen-induced hyper-responsiveness of the nasal mucosa to subsequent challenge by antigen and histamine release
- intranasal steroids treat congestion, rhinorrhea, sneezing, nasal itching, ocular symptoms
INCS: Budesonide
- Rhinocort Allergy 32 mcg/act (ages 6+)
- Budesonide 32 mcg/act (ages 12+)
INCS: Fluticasone propionate
-Flonase allergy relief and various brand/generic 50 mcg/act (ages 4+)
INCS: Fluticasone furoate
-Flonase Sensimist 27.5 mcg/act (ages 2+)
INCS: Triamcinolone
- Nasacort Allergy 24HR Children and various brands/generics 55 mcg/act (ages 2+)
- Nasacort Allergy 24HR and various brands/generic 55 mcg/act (ages 2+)
INCS side effects
- headache, dryness, burning, stinging, blood-tinged secretions, epistaxis (nosebleed)
- minimize epistaxis via proper administration
- avoid use in those with nasal septum ulcers, recent nasal surgery, or trauma
- HPA suppression unlikely
- patients with HIV may have more systemic absorption
- growth suppression in children (mixed results in studies but fluticasone, mometasone, triamcinolone appear to have no effect)
- local candida albicans infection
INCS clinical pearls
- general dosing: 1-2 sprays in each nostril QD (step up or step down based on symptoms)
- onset: 3-5 hours; maximal benefit may take several days
- continuous is better than intermittent dosing
- PRN intranasal fluticasone > placebo
- start several days before the start of known seasonal AR
- assume efficacy should be reached after 1 week of continuous used
- all preparations comparable in efficacy
antihistamines MOA
- competitively antagonizes histamine-1 (H1) receptors to prevent receptor activation
- first generation (nonselective)
- second generation (selective)
- oral antihistamines: not going to treat congestion. WILL treat rhinorrhea, sneezing, nasal itching, ocular symptoms
1st generation oral antihistamines (OAH): side effects
- sedation
- anticholinergic side effects
- changes in appetite and GI discomfort
1st generation oral antihistamines (OAH): caution use in?
- elderly patients
- use of other CNS depressants or anticholinergic agents
- urinary retention issues/BPH
- slowed GI motility
- narrow-angle glaucoma
- combination products
2nd generation OAH: side effects
- much more favorable SE profile
- headache
- sedation: less common than 1st gen
- dry mouth: less common than 1st gen
- cetirizine and levocetirizine: most sedating
Zyretc
most sedating of the non-sedating antihistamines
oral antihistamines (OAH)
- rapid onset of action than INCS
- most effective when administered prior to allergen exposure
- one fails? try another
- maximal benefit with continuous use
- PRN use can provide significant symptoms relief & may be appropriate for some (i.e. intermittent symptoms)
OAH time to onset
- <2 hours
- rapid onset of action compared to intranasal corticosteroids
intranasal antihistamines (INAH)
- advantage of more targeted delivery vs OAH
- increased dosage to nasal tissue while limiting systemic effects
can you take an OAH with INCS?
-no evidence to show that combining them does better than one alone
INAH side effects
- local: bitter taste, runny nose, headache
- systemic: less due to nasal route of administration, but sedation may still occur
what does intranasal antihistamines (INAH) treat?
- congestion, rhinorrhea, sneezing, nasal itching
- NOT ocular symptoms
INAH onset of action
- 15-30 minutes
- relief may be seen within 3 hours of the first dose
INAH equal or superior to OAH?
- can be effective in patients who fails OAH
- INAH > OAH for nasal congestion
what is the only INAH OTC?
- Azelastine (Astepro Allergy, Children’s Astepro Allergy) 0.15%
- dosing: 1-2 sprays in each nostril 2x/day OR 2 sprays in each nostril 1x/day (12+)
- OTC (1st Q 2022)
ophthalmic antihistamines
- relieves allergic conjunctivitis
- appropriate as mono therapy or in combination with oral agents
ophthalmic antihistamines side effects
- headache
- blurred vision
- burning/stinging of the eyes
- discomfort
- bitter taste
- pharyngitis
what do ophthalmic antihistamines treat?
- ocular symptoms
- NOT congestion, rhinorrhea, sneezing, nasal itching
ophthalmic antihistamines OTC
Ketotifen (Alaway, Zaditor, others)
- 0.025% Solution: Instill 1 drop into the affected eye(s)
- BID can be administered 8-12 hours apart
decongestants MOA
- produce vasoconstriction to widen nasal passages
- sympathomimetic agents that target adrenergic receptors in the nasal mucosa to produce vasoconstriction
- reduce swollen nasal mucosa and improve ventilation; systemic & topical
topical decongestants
-can only be used for a few days
oral decongestants
-pseudoephedrine & phenylephrine
pseudoephedrine
IR: 60 mg q4-6 hours
SR: 120 mg q12 hours
MDD: 240 mg
oral decongestants: combination products
cetirizine/pseudoephedrine
loratidine/pseudoephedrine
fexofenadine/pseudoephedrine
other intranasal medications: Cromolyn OTC
- useful for treating and preventing sinus symptoms (runny nose, stuffy nose, sneezing, itching)
- MOA: mast cell stabilizer
- treats: congestion, rhinorrhea, sneezing, nasal itching
- NOT ocular symptoms
Cromolyn downsides
- dosing: 1 spray in each nostril 3-6 times daily (that’s a lot)
- slow onset of action: 3-7 days for initial improvement
- 2-4 weeks for maximal benefit
general care measures
- allergen avoidance
- saline nasal spray/neti pot
- relieves nasal mucosa irritation/dryness
- removes dried, encrusted mucus
- cool-mist humidifier
- NOTE: for neti pot, use distilled/sterile/boiled (and cooled) water only to prevent infection
special populations
pregnant and breastfeeding
elderly and children
pregnant 1st line
intranasal cromolyn
pregnant 2nd line
chlorpheniramine
pregnant: alternative products if others are not tolerated
-loratadine, cetirizine, levocetirizine, diphenhydramine
breastfeeding 1st line
intranasal cromolyn
limited systemic absorption
breastfeeding: alternative products
intranasal corticosteroids (INCS) antihistamines can pass into breast milk (avoid)* 1st gen antihistamines can adversely effect maternal milk supply*
elderly 1st line
-loratadine and intranasal cromolyn
elderly: AVOID 1st gen AH due to risk of?
- sedation, confusion, hypotension = risk of falls
- paradoxical excitation
children 1st line
loratadine
-alternatives: cetirizine, fexofenadine, intranasal cromolyn in children >5 years old
what to avoid in children?
-AVOID 1st gen AH due to risk of paradoxical excitation and potential serious adverse effects with misuse
exclusions for self-treatment
- children <12 years
- pregnant or lactating women
- symptoms of non-AR
- symptoms of otitis media, sinusitis, bronchitis, or other infection
- symptoms of undiagnosed or uncontrolled asthma (wheezing, SOB)
- COPD or other lower respiratory disorder
- severe or unacceptable side effects of treatment
treatment for: episodic AR or mild IAR symptoms
-oral anti-histamines
treatment for: moderate-severe IAR
- INCS (preferred)
- or oral AH (that depends if there’s congestion
moderate to severe
-losing sleep (reduction in QOL)
would an OAH have a faster onset of action vs INCS?
-yes
can you be given too much fluticasone?
- no if both are locally administered
- there is still not a lot of systemic side effects, even when you combine them
- INCS onset: 3-5 hours for initial benefit, but up to 1 week for maximal benefit
- ClaritinD/Zyrtec D might be better/quicker
- INAH onset of action is quicker than steroids
