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phm 516: self-care > allergic rhinitis > Flashcards

allergic rhinitis Flashcards

1
Q

presenting symptoms

A
  • sneezing
  • clear rhinorrhea
  • itchy noses, eyes, palate
  • nasal congestion
  • malaise/fatigue (especially in children)
  • post nasal drip (frequent throat clearing, cough)
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2
Q

SCHOLAR-MAC considerations

A
  • 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?
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3
Q

physical findings

A
  • 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”
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4
Q

classification of AR

A
  • by temporal pattern
  • by frequency of symptoms
  • by severity of symptoms
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5
Q

temporal pattern

A
  • seasonal, perennial (continually recurring), episodic

- may be difficult to determine

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6
Q

frequency of symptoms*

A
  • intermittent (IAR): <4 days per week OR <4 weeks per year

- persistent (PER): >4 days per week AND >4 weeks per year

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7
Q

severity of symptoms*

A
  • 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
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8
Q

exclusions for self-care

A
  • 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
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9
Q

general avoidance

A
  • 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)
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10
Q

pollen avoidance

A
  • 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
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11
Q

mold avoidance

A
  • 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%
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12
Q

intranasal corticosteroids (INCS) MOA

A
  • 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
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13
Q

INCS: Budesonide

A
  • Rhinocort Allergy 32 mcg/act (ages 6+)

- Budesonide 32 mcg/act (ages 12+)

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14
Q

INCS: Fluticasone propionate

A

-Flonase allergy relief and various brand/generic 50 mcg/act (ages 4+)

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15
Q

INCS: Fluticasone furoate

A

-Flonase Sensimist 27.5 mcg/act (ages 2+)

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16
Q

INCS: Triamcinolone

A
  • 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+)
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17
Q

INCS side effects

A
  • 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
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18
Q

INCS clinical pearls

A
  • 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
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19
Q

antihistamines MOA

A
  • 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
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20
Q

1st generation oral antihistamines (OAH): side effects

A
  • sedation
  • anticholinergic side effects
  • changes in appetite and GI discomfort
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21
Q

1st generation oral antihistamines (OAH): caution use in?

A
  • elderly patients
  • use of other CNS depressants or anticholinergic agents
  • urinary retention issues/BPH
  • slowed GI motility
  • narrow-angle glaucoma
  • combination products
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22
Q

2nd generation OAH: side effects

A
  • much more favorable SE profile
  • headache
  • sedation: less common than 1st gen
  • dry mouth: less common than 1st gen
  • cetirizine and levocetirizine: most sedating
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23
Q

Zyretc

A

most sedating of the non-sedating antihistamines

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24
Q

oral antihistamines (OAH)

A
  • 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)
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25
Q

OAH time to onset

A
  • <2 hours

- rapid onset of action compared to intranasal corticosteroids

26
Q

intranasal antihistamines (INAH)

A
  • advantage of more targeted delivery vs OAH

- increased dosage to nasal tissue while limiting systemic effects

27
Q

can you take an OAH with INCS?

A

-no evidence to show that combining them does better than one alone

28
Q

INAH side effects

A
  • local: bitter taste, runny nose, headache

- systemic: less due to nasal route of administration, but sedation may still occur

29
Q

what does intranasal antihistamines (INAH) treat?

A
  • congestion, rhinorrhea, sneezing, nasal itching

- NOT ocular symptoms

30
Q

INAH onset of action

A
  • 15-30 minutes

- relief may be seen within 3 hours of the first dose

31
Q

INAH equal or superior to OAH?

A
  • can be effective in patients who fails OAH

- INAH > OAH for nasal congestion

32
Q

what is the only INAH OTC?

A
  • 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)
33
Q

ophthalmic antihistamines

A
  • relieves allergic conjunctivitis

- appropriate as mono therapy or in combination with oral agents

34
Q

ophthalmic antihistamines side effects

A
  • headache
  • blurred vision
  • burning/stinging of the eyes
  • discomfort
  • bitter taste
  • pharyngitis
35
Q

what do ophthalmic antihistamines treat?

A
  • ocular symptoms

- NOT congestion, rhinorrhea, sneezing, nasal itching

36
Q

ophthalmic antihistamines OTC

A

Ketotifen (Alaway, Zaditor, others)

  • 0.025% Solution: Instill 1 drop into the affected eye(s)
  • BID can be administered 8-12 hours apart
37
Q

decongestants MOA

A
  • 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
38
Q

topical decongestants

A

-can only be used for a few days

39
Q

oral decongestants

A

-pseudoephedrine & phenylephrine

40
Q

pseudoephedrine

A

IR: 60 mg q4-6 hours
SR: 120 mg q12 hours
MDD: 240 mg

41
Q

oral decongestants: combination products

A

cetirizine/pseudoephedrine
loratidine/pseudoephedrine
fexofenadine/pseudoephedrine

42
Q

other intranasal medications: Cromolyn OTC

A
  • 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
43
Q

Cromolyn downsides

A
  • 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
44
Q

general care measures

A
  • 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
45
Q

special populations

A

pregnant and breastfeeding

elderly and children

46
Q

pregnant 1st line

A

intranasal cromolyn

47
Q

pregnant 2nd line

A

chlorpheniramine

48
Q

pregnant: alternative products if others are not tolerated

A

-loratadine, cetirizine, levocetirizine, diphenhydramine

49
Q

breastfeeding 1st line

A

intranasal cromolyn

limited systemic absorption

50
Q

breastfeeding: alternative products

A 
intranasal corticosteroids (INCS) 
antihistamines can pass into breast milk (avoid)* 
1st gen antihistamines can adversely effect maternal milk supply*
51
Q

elderly 1st line

A

-loratadine and intranasal cromolyn

52
Q

elderly: AVOID 1st gen AH due to risk of?

A
  • sedation, confusion, hypotension = risk of falls

- paradoxical excitation

53
Q

children 1st line

A

loratadine

-alternatives: cetirizine, fexofenadine, intranasal cromolyn in children >5 years old

54
Q

what to avoid in children?

A

-AVOID 1st gen AH due to risk of paradoxical excitation and potential serious adverse effects with misuse

55
Q

exclusions for self-treatment

A
  • 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
56
Q

treatment for: episodic AR or mild IAR symptoms

A

-oral anti-histamines

57
Q

treatment for: moderate-severe IAR

A
  • INCS (preferred)

- or oral AH (that depends if there’s congestion

58
Q

moderate to severe

A

-losing sleep (reduction in QOL)

59
Q

would an OAH have a faster onset of action vs INCS?

A

-yes

60
Q

can you be given too much fluticasone?

A
  • no if both are locally administered

- there is still not a lot of systemic side effects, even when you combine them

61
Q
A
  • 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

phm 516: self-care (5 decks)

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