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CDM Exam 3 > Allergic Rhinitis > Flashcards

Allergic Rhinitis Flashcards

1
Q

What is allergic rhinitis

A

IgE-mediated hypersensitivity reaction triggered by allergens

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2
Q

Allergic rhinitis has the same pathophysiology as more severe hypersensitivity reactions, but

A

symptoms are localized to the nose

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3
Q

Common outdoor allergens

A

Pollen
Mold spores
Cigarette smoke
Air pollutants

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4
Q

Common indoor allergens

A

Dust mites
Cockroaches
Pet dander
Mold spores

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5
Q

Common occupational allergens

A

Dust
Latex
Chemicals
Wool

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6
Q

Common food allergens

A 
Peanuts/tree nuts
Eggs
Wheat/gluten
Soy
Milk
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7
Q

Common risk factors for AR

A

Personal or family history of asthma/eczema
High socioeconomic status
Non-white ethnicity
Exposure to pollution or indoor allergens
Firstborn/ few siblings
No daycare
Exposure to heavy cigarette smoke in 1st year of life
Heavy alcohol consumption
High IgE concentrations (>100 IU/mL before age 6)
(+) allergen skin prick tests
Early introduction of food or formula
No regular contact with farm animals before age 7

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8
Q

Hygiene Hypothesis

A

childhood exposure to germs and certain infections helps the immune system develop.

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9
Q

Pathophysiology: Sensitization

A

Initial allergen exposure

IgE production

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10
Q

Pathophysiology: Early Phase

A

Occurs minutes after exposure

Release of histamine from mast cells, production of inflammatory mediators including leukotrienes & prostaglandins

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11
Q

Pathophysiology: Cellular Environment

A

Leukocytes are recruited to nasal mucosa

More inflammatory mediators are released

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12
Q

Pathophysiology: Late Phase

A

Occurs 2-4 hours after exposure

Nasal congestion and hypersecretion of mucus

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13
Q

Classifying AR

A

Duration/Severity

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14
Q

Episodic AR

A

Symptoms occur when exposed to allergen outside of normal routine

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15
Q

Intermitten AR

A

Symptoms occur ≤4 days/week OR ≤4 weeks

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16
Q

Persistent AR

A

Symptoms occur >4 days/week AND >4 weeks

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17
Q

Mild-Moderate Severity AR

A

Symptoms are not bothersome, do not interfere with daily activities or sleep

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18
Q

Moderate-Severe AR

A

Symptoms are bothersome, interfere with daily activities or sleep

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19
Q

Signs/Symptoms

A

Itchy eyes, nose, palate
Watery rhinorrhea
Repetitive sneezing
Nasal congestion

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20
Q

Conjunctival injection

A

red eye as eye is inflamed

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21
Q

Allergic shiners

A

dark circle under eye as a result of change in blood flow

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22
Q

Allergic salute and crease

A

get a crease above bridge of nose from constantly itching

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23
Q

Diagnosis AR

A

Primarily based on medical history
Skin prick allergy sensitivity testing
Radioallergosorbent testing (RAST)

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24
Q

Complications of untreated AR

A

Sinusitis
Otitis Media
Asthma linked to allergies
Speech or dental abnormalities possible

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25
Q

Goal of treatment for AR

A

Relieve or prevent symptoms and improve functionality

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26
Q

Self-Treatment exclusions AR

A

Child < 12 years
Pregnant / lactating
History of non-allergic rhinitis
Symptomsof an upper respiratory tract infection (such as sinusitis, otitis media) or lower respiratory pathology (such as asthma, pneumonia, bronchitis)
History of symptoms unresponsive to OTC treatment
Unacceptable adverse effects

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27
Q

Allergen Avoidance

A

Household dust mites
Pet allergens
Cockroaches
Pollen

Vacuum, Dust, HEPA filters, wash sheets

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28
Q

Non-pharm therapy

A

Sodium Chloride nasal spray, irrigation (e.g., with neti pots) or drops (e.g., Ocean Spray, generic)

Do not share nasal saline bottles
Use sterile water with neti pot
Emphasize proper cleaning of saline irrigation devices

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29
Q

Drug treatment is

A

symptom specific

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30
Q

Recommend taking medications

A

1 week prior to anticipated allergen exposure to prevent / reduce reaction

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31
Q

Intranasal Corticosteroids (INCS) MOA

A

Broad anti-inflammatory properties that reduce inflammation by

Reducing mediator release
Suppressing neutrophil chemotaxis
Reducing intracellular edema
Mildly vasoconstricting
Inhibiting mast cell–mediated late phase reaction
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32
Q

INCS ADRs

A

epistaxis, stinging, itching, headache

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33
Q

INCS oral therapy

A

in severe cases, short courses of oral corticosteroids may be used to alleviate symptoms

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34
Q

Corticosteroids

A

Nasal corticosteroids considered 1st line treatment for perennial rhinitis

Benefits are not immediate

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35
Q

peak response to corticosteroids

A

few days to 2 weeks

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36
Q

Corticosteroid counseling

A

Shake before use, prime before first use, and if not used for > 1 week

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37
Q

Fluticasone propionate

A

Flonase

RX and OTC

38
Q

Triamcinolone

A

Nasacort

RX and OTC

39
Q

Budesonide

A

Rhinocort

RX and OTC

40
Q

Beclomethasone

A

QNASL, Beconase AQ

RX

41
Q

Mometasone furoate

A

Nasonex

RX (soon to be OTC)

42
Q

Counseling points for intranasal meds

A

Wash hands
Blow nose to clear nasal passages
Shake container to evenly distribute suspension
Tilt head forward
Breathe out
Block one nostril with your finger
Insert nasal applicator into other nostril, aiming the spray toward the top of the ear on the same side of the head
Inhale slowly through the nose as you quickly press the spray applicator
Breathe out and repeat for the recommended number of sprays
Repeat on the other nostril

43
Q

Antihistamines

A

Alternative treatment for mild to moderate symptoms, add-on treatment with intranasal steroids for moderate to severe symptoms, or treatment of episodic AR

44
Q

Antihistamine available forms

A

Oral
Ophthalmic
Intranasal

45
Q

___ generation antihistamine preferred in AR

A

2nd

46
Q

Cetirizine

A

Zyrtec (OTC)

47
Q

Fexofenadine

A

Allegra (OTC)

48
Q

Loratadine

A

Claritin (OTC)

49
Q

2nd gen antihistamines MOA

A

Antagonist at peripheral H1 receptors, some central activity but less CNS penetration compared to 1st generation antihistamines

50
Q

2nd gen antihistamines ADEs

A

Headache, dry mouth, drowsiness

51
Q

2nd gen antihistamines DDIs

A

Additive CNS depression possible with sedative agents and cetirizine, antacids interfere with fexofenadine absorption – separate doses by as much time as possible

52
Q

Cetirizine clinical pearls

A

Considered “most sedating” of 2nd gen

53
Q

Fexofenadine clinical pearls

A

Grapefruit/orange/ apple juice can inhibit absorption of fexofenadine, separate by >4 hours

54
Q

Loratadine clinical pearls

A

Preferred in pregnancy & pediatrics

55
Q

Less potent and less sedating

A

loratadine and fexofenadine

56
Q

more potent and more sedating

A

Cetirizine

57
Q

1st gen antihistamines

A

Antagonist at central and peripheral H1 receptors
Readily cross BBB
Also antagonist at cholinergic receptors  anticholinergic ADRs
Tolerance can develop to sedative effect, but concerns that CNS impairment may persist even w/o sedation

58
Q

2nd gen antihistamines

A

Antagonist at peripheral and some central H1 receptors
Less CNS penetration
Typically less anticholinergic and sedative effects at recommended doses, but still some particularly with cetirizine

59
Q

Local intranasal antihistamines

A

azelastine (Rx), olopatadine (Rx)

60
Q

local ophthalmic antihistamines

A

ketotifen (Zatidor, OTC), olopatadine (Pataday, OTC) or azelastine (Optivar, RX)

61
Q

Antihistamine precautions

A

For 1st generation and cetirizine - use caution in patients with conditions aggravated by anticholinergic ADRs, especially:

Infants/ breast feeding mothers
Narrow-angle glaucoma
Symptomatic BPH 
GI/GU obstruction
Use caution in elderly patients (especially sedating agents)
62
Q

Antihistamine clinical pearls

A

Patients may react differently to various agents
If one is not effective, reasonable to try another one
Emphasize potential ADRs in counseling, especially potential for sedation and/or cognitive changes in elderly patients

63
Q

Mast Cell Stabilizer: Cromolyn Sodium

A

NasalCrom (OTC)

64
Q

Cromolyn Sodium MOA

A

Stabilizes mast cells by Interfering with chloride channel function thereby inhibiting mast cell activation and subsequent release of mediators from eosinophils and epithelial cells

Inhibits acute response to exercise & cold air

65
Q

Cromolyn Sodium ADEs

A

Well tolerated, may cause sneezing, nasal stinging/burning, unpleasant taste in mouth

66
Q

Pseudoephedrine (sudafed)

Phenylephrine (Sudafed PE) MOA

A

Sympathomimetic; agonists at adrenergic receptors in nasal mucosa, causing vasoconstriction.
Phenylephrine acts directly on sympathetic receptors while pseudoephedrine has a mixed effect with some direct action and some displacement of neurotransmitters from storage vesicles

67
Q

Pseudoephedrine (sudafed)

Phenylephrine (Sudafed PE) Clinical Pearls

A

eudoephedrine is more effective than phenylephrine

Decongestants are most effective for AR when combined with an antihistamine

68
Q

Pseudoephedrine (sudafed)

Phenylephrine (Sudafed PE) DDIs

A

MAOIs and TCAS: dangerous increase in BP, concurrent use contraindicated

69
Q

Oral Decongestant ADEs

A

Cardiovascular stimulation and increase in CV event risk (increased BP, tachycardia, palpitations, arrhythmia)
CNS stimulation (insomnia, restlessness, anxiety)
Other effects urinary retention, worsen narrow angle glaucoma

70
Q

Intranasal Decongestants: Oxymetazoline 0.05%

A

Afrin (OTC)

71
Q

Phenylephrine 0.25% or 0.5%

A

Neo-Synephrine (OTC)

72
Q

Intranasal Decongestants MOA

A

Agonist at local alpha adrenergic receptors in nasal mucosa

73
Q

Intranasal Decongestants ADEs

A

Local irritation, burning, stinging

Mild systemic effects if any

74
Q

Intranasal Decongestants Clinical Pearls

A

Use for >3-5 days may cause Rhinitis Medicamentosa (rebound congestion)

75
Q

Intranasal Decongestants DDIs

A

MAOIs and TCAS: dangerous increase in BP, concurrent use contraindicated

76
Q

Decongestant Warnings

A

Avoid in patients taking MAOIs or TCAs
May exacerbate diabetes or worsen glucose control, use caution
May worsen hyperthyroidism, coronary heart disease, ischemic heart disease, glaucoma, and benign prostatic hypertrophy
Avoid in uncontrolled hypertension, for patients with controlled hypertension consider local therapy or low doses
Decongestants are considered illegal or ‘doping’ agents in organized sports
Large quantities of pseudoephedrine are used in manufacture of methamphetamine

77
Q

Combo Antihistamine + Decongestant OTC products

A

Zyrtec-D (cetirizine-pseudoephedrine)
Allegra-D (fexofenadine-pseudoephedrine)
Claritin-D (loratadine-pseudoephedrine)

78
Q

Intranasal Anticholinergic Spray

A

Ipratropium 0.03% or 0.06% Spray (Rx)

79
Q

Ipratropium 0.03% or 0.06% Spray brand

A

Atrovent

80
Q

Ipratropium 0.03% or 0.06% Spray MOA

A

Anticholinergic=antisecretory, drys up nasal secretions. Relieves rhinorrhea from any cause, allergic or non-allergic.

81
Q

Ipratropium 0.03% or 0.06% Spray ADEs

A

Bitter taste in mouth, dry nasal mucosa, dry mouth

82
Q

Leukotriene Receptor Antagonist

A

Montelukast (rx)

83
Q

Montelukast (Rx) brand

A

Singulair

84
Q

Montelukast MOA

A

Blocks action of leukotrienes at their receptors, ultimately preventing inflammation, edema, and smooth muscle contraction

85
Q

Montelukast ADEs

A

Headache

Black box warning: concerns for psychiatric ADRs, including: anxiety, depression, agitation, aggressive behavior, hallucinations, nightmares, suicidality

86
Q

Immunotherapy

A

Typically reserved for those symptoms not relieved by medication or if patient has an allergy-complicated illness (e.g., asthma or sinusitis)

87
Q

Treatment of AR: Pregnancy

A

Refer to OB to diagnose allergic vs. non-allergic rhinitis
If AR diagnosis is confirmed, intranasal cromolyn is 1st line
1st generation antihistamines are considered safe
2nd generation antihistamines – loratadine is preferred
INCS considered safe however systemic corticosteroids have caused birth defects
Intranasal oxymetazoline is preferred decongestant during pregnancy

88
Q

Treatment of AR: Breastfeeding

A

Refer to OB/GYN to evaluate if self-care is appropriate
If OK by OB/GYN, intranasal cromolyn is considered safe
Avoid first generation antihistamines, may reduce milk supply and cause sedation in infant
If using 2nd generation antihistamines, recommend short-acting formulation and counsel to take at bedtime after last feeding of the day

89
Q

Treatment of AR: pediatrics

A

Children < 12: refer to pediatrician to assess for asthma
If approved for self-care, loratadine is antihistamine of choice
Children my experience paradoxical excitation from antihistamines
Use of INCS >2 months linked to growth inhibition

90
Q

Treatment of AR: Geriatrics

A

Avoid first generation antihistamines in fail older adults due to sedation/falls risk (Beers criteria)
Drugs of choice: intranasal cromolyn & loratadine/ fexofenadine

CDM Exam 3 (8 decks)

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