Allergic Rhinitis Flashcards
1
Q
What is allergic rhinitis
A
IgE-mediated hypersensitivity reaction triggered by allergens
2
Q
Allergic rhinitis has the same pathophysiology as more severe hypersensitivity reactions, but
A
symptoms are localized to the nose
3
Q
Common outdoor allergens
A
Pollen
Mold spores
Cigarette smoke
Air pollutants
4
Q
Common indoor allergens
A
Dust mites
Cockroaches
Pet dander
Mold spores
5
Q
Common occupational allergens
A
Dust
Latex
Chemicals
Wool
6
Q
Common food allergens
A
Peanuts/tree nuts Eggs Wheat/gluten Soy Milk
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
8
Q
Hygiene Hypothesis
A
childhood exposure to germs and certain infections helps the immune system develop.
9
Q
Pathophysiology: Sensitization
A
Initial allergen exposure
IgE production
10
Q
Pathophysiology: Early Phase
A
Occurs minutes after exposure
Release of histamine from mast cells, production of inflammatory mediators including leukotrienes & prostaglandins
11
Q
Pathophysiology: Cellular Environment
A
Leukocytes are recruited to nasal mucosa
More inflammatory mediators are released
12
Q
Pathophysiology: Late Phase
A
Occurs 2-4 hours after exposure
Nasal congestion and hypersecretion of mucus
13
Q
Classifying AR
A
Duration/Severity
14
Q
Episodic AR
A
Symptoms occur when exposed to allergen outside of normal routine
15
Q
Intermitten AR
A
Symptoms occur ≤4 days/week OR ≤4 weeks
16
Q
Persistent AR
A
Symptoms occur >4 days/week AND >4 weeks
17
Q
Mild-Moderate Severity AR
A
Symptoms are not bothersome, do not interfere with daily activities or sleep
18
Q
Moderate-Severe AR
A
Symptoms are bothersome, interfere with daily activities or sleep
19
Q
Signs/Symptoms
A
Itchy eyes, nose, palate
Watery rhinorrhea
Repetitive sneezing
Nasal congestion
20
Q
Conjunctival injection
A
red eye as eye is inflamed
21
Q
Allergic shiners
A
dark circle under eye as a result of change in blood flow
22
Q
Allergic salute and crease
A
get a crease above bridge of nose from constantly itching
23
Q
Diagnosis AR
A
Primarily based on medical history
Skin prick allergy sensitivity testing
Radioallergosorbent testing (RAST)
24
Q
Complications of untreated AR
A
Sinusitis
Otitis Media
Asthma linked to allergies
Speech or dental abnormalities possible
25
Goal of treatment for AR
Relieve or prevent symptoms and improve functionality
26
Self-Treatment exclusions AR
Child < 12 years
Pregnant / lactating
History of non-allergic rhinitis
Symptoms of 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
27
Allergen Avoidance
Household dust mites
Pet allergens
Cockroaches
Pollen
Vacuum, Dust, HEPA filters, wash sheets
28
Non-pharm therapy
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
29
Drug treatment is
symptom specific
30
Recommend taking medications
1 week prior to anticipated allergen exposure to prevent / reduce reaction
31
Intranasal Corticosteroids (INCS) MOA
Broad anti-inflammatory properties that reduce inflammation by
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Reducing mediator release
Suppressing neutrophil chemotaxis
Reducing intracellular edema
Mildly vasoconstricting
Inhibiting mast cell–mediated late phase reaction
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32
INCS ADRs
epistaxis, stinging, itching, headache
33
INCS oral therapy
in severe cases, short courses of oral corticosteroids may be used to alleviate symptoms
34
Corticosteroids
Nasal corticosteroids considered 1st line treatment for perennial rhinitis
Benefits are not immediate
35
peak response to corticosteroids
few days to 2 weeks
36
Corticosteroid counseling
Shake before use, prime before first use, and if not used for > 1 week
37
Fluticasone propionate
Flonase
RX and OTC
38
Triamcinolone
Nasacort
RX and OTC
39
Budesonide
Rhinocort
RX and OTC
40
Beclomethasone
QNASL, Beconase AQ
RX
41
Mometasone furoate
Nasonex
RX (soon to be OTC)
42
Counseling points for intranasal meds
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
Antihistamines
Alternative treatment for mild to moderate symptoms, add-on treatment with intranasal steroids for moderate to severe symptoms, or treatment of episodic AR
44
Antihistamine available forms
Oral
Ophthalmic
Intranasal
45
___ generation antihistamine preferred in AR
2nd
46
Cetirizine
Zyrtec (OTC)
47
Fexofenadine
Allegra (OTC)
48
Loratadine
Claritin (OTC)
49
2nd gen antihistamines MOA
Antagonist at peripheral H1 receptors, some central activity but less CNS penetration compared to 1st generation antihistamines
50
2nd gen antihistamines ADEs
Headache, dry mouth, drowsiness
51
2nd gen antihistamines DDIs
Additive CNS depression possible with sedative agents and cetirizine, antacids interfere with fexofenadine absorption – separate doses by as much time as possible
52
Cetirizine clinical pearls
Considered “most sedating” of 2nd gen
53
Fexofenadine clinical pearls
Grapefruit/orange/ apple juice can inhibit absorption of fexofenadine, separate by >4 hours
54
Loratadine clinical pearls
Preferred in pregnancy & pediatrics
55
Less potent and less sedating
loratadine and fexofenadine
56
more potent and more sedating
Cetirizine
57
1st gen antihistamines
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
2nd gen antihistamines
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
Local intranasal antihistamines
azelastine (Rx), olopatadine (Rx)
60
local ophthalmic antihistamines
ketotifen (Zatidor, OTC), olopatadine (Pataday, OTC) or azelastine (Optivar, RX)
61
Antihistamine precautions
For 1st generation and cetirizine - use caution in patients with conditions aggravated by anticholinergic ADRs, especially:
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Infants/ breast feeding mothers
Narrow-angle glaucoma
Symptomatic BPH
GI/GU obstruction
Use caution in elderly patients (especially sedating agents)
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62
Antihistamine clinical pearls
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
Mast Cell Stabilizer: Cromolyn Sodium
NasalCrom (OTC)
64
Cromolyn Sodium MOA
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
Cromolyn Sodium ADEs
Well tolerated, may cause sneezing, nasal stinging/burning, unpleasant taste in mouth
66
Pseudoephedrine (sudafed)
| Phenylephrine (Sudafed PE) MOA
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
Pseudoephedrine (sudafed)
| Phenylephrine (Sudafed PE) Clinical Pearls
eudoephedrine is more effective than phenylephrine
| Decongestants are most effective for AR when combined with an antihistamine
68
Pseudoephedrine (sudafed)
| Phenylephrine (Sudafed PE) DDIs
MAOIs and TCAS: dangerous increase in BP, concurrent use contraindicated
69
Oral Decongestant ADEs
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
Intranasal Decongestants: Oxymetazoline 0.05%
Afrin (OTC)
71
Phenylephrine 0.25% or 0.5%
Neo-Synephrine (OTC)
72
Intranasal Decongestants MOA
Agonist at local alpha adrenergic receptors in nasal mucosa
73
Intranasal Decongestants ADEs
Local irritation, burning, stinging
| Mild systemic effects if any
74
Intranasal Decongestants Clinical Pearls
Use for >3-5 days may cause Rhinitis Medicamentosa (rebound congestion)
75
Intranasal Decongestants DDIs
MAOIs and TCAS: dangerous increase in BP, concurrent use contraindicated
76
Decongestant Warnings
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
Combo Antihistamine + Decongestant OTC products
Zyrtec-D (cetirizine-pseudoephedrine)
Allegra-D (fexofenadine-pseudoephedrine)
Claritin-D (loratadine-pseudoephedrine)
78
Intranasal Anticholinergic Spray
Ipratropium 0.03% or 0.06% Spray (Rx)
79
Ipratropium 0.03% or 0.06% Spray brand
Atrovent
80
Ipratropium 0.03% or 0.06% Spray MOA
Anticholinergic=antisecretory, drys up nasal secretions. Relieves rhinorrhea from any cause, allergic or non-allergic.
81
Ipratropium 0.03% or 0.06% Spray ADEs
Bitter taste in mouth, dry nasal mucosa, dry mouth
82
Leukotriene Receptor Antagonist
Montelukast (rx)
83
Montelukast (Rx) brand
Singulair
84
Montelukast MOA
Blocks action of leukotrienes at their receptors, ultimately preventing inflammation, edema, and smooth muscle contraction
85
Montelukast ADEs
Headache
Black box warning: concerns for psychiatric ADRs, including: anxiety, depression, agitation, aggressive behavior, hallucinations, nightmares, suicidality
86
Immunotherapy
Typically reserved for those symptoms not relieved by medication or if patient has an allergy-complicated illness (e.g., asthma or sinusitis)
87
Treatment of AR: Pregnancy
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
Treatment of AR: Breastfeeding
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
Treatment of AR: pediatrics
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
Treatment of AR: Geriatrics
Avoid first generation antihistamines in fail older adults due to sedation/falls risk (Beers criteria)
Drugs of choice: intranasal cromolyn & loratadine/ fexofenadine
