Allergic Rhinitis

Question 1

Why do we have allergies?

Answer 1

Humanity developed a robust immune system against real invaders, but now we are reacting to benign substances

Question 2

What causes allergic responses?

Answer 2

Mast cells release histamines once a specific allergen has been identified. Histamines mediate some inflammatory activities

Question 3

What is sensitization?

Answer 3

Sensitization is the first exposure to a potential allergen and it becomes ready for subsequent exposure. Mast cells have developed immunoglobulins against a particular protein

Question 4

What happens in early phase reaction in allergies?

Answer 4

Lots of rhinorrhea and itching

Question 5

What happens in the late phase reaction in allergies?

Answer 5

asthma
reccurent ear infections
sinusitis
nasal polyps
sleep apnea

Question 6

What are some common allergens? seasonal or perrenial

Answer 6

Seasonal allergens:
trees
grasses
outdoor moulds

Perrenial allergens:
house dust mite
animal danders
indoor moulds

Question 7

How do allergy tests work?

Answer 7

Allergens are exposed to small sections of skin and compared against positive and negative controls

Question 8

What are some non-allergy causes for rhinorrhea?

Answer 8

Vasomotor rhinitis (temp. changes cause runny nose)

Rhinitis medicamentosa (decongestant-induced and rebound decongestant)

Hormonal (getting on birth control can cause runny nose)

Geriatric rhinitis (very common and idiopathic and usually not alergies because people don’t develop them in old age)

Question 9

What are some symptoms of allergic rhinitis?

Answer 9

Rhinnorhea
itchy eyes
headaches
sore throat
ear pain

Question 10

How to differentiate between seasonal and perrenial allergies?

Answer 10

Nasal congestion is usually seen in perrenial allergies and not so much in seasonal allergies

Question 11

How to differentiate between colds and allergies?

Answer 11

Allergies occur at the same time(especially if seasonal)
more sneezing and itching
Runny nose and congestion are back and forth
Allergies last longer than colds
PND
and more effects on the eyes

Question 12

How can allergies be misdiagnosed for ADHD?

Answer 12

The symptoms of allergies can cause children to be uneasy. This can result in misdiagnosis of ADHD

Question 13

How to control allergies?

Answer 13

Avoid allergens/triggers (hard to do if allergens are everywhere)

Nasal irrigation helps flush out pollens and other allergens (pouring water into nostril sucks for kids and adults)

Lubricants help provide relief if nose is raw on the inside

Question 14

What are antihistamines?

Answer 14

These drugs target histamine receptors and they have best effectivity if taken before allergen exposure.

take it everyday if you need it, don’t take it once in a while. Antihistamines do not develop tolerance

This is the best agent for seasonal allergies, topical steroids are meant for perrenial allergies.

Question 15

What are some first generation antihistamines?

Answer 15

Promethazine (in a category of its own)

Ethanolamines:
diphenhydramine
doxylamine
clemastine

Alkylamines:
chlorpheniramine
brompheniramine
dexbrompheniramine
triprolidine

Question 16

How do antihistamines cause drowsiness?

Answer 16

First generation histamines cross the blood brain barrier and induce drowsiness

Ranking of drowsy effects
alkylamine (least drowsy)<ethanolamine<promrthazine (most drowsy)

Question 17

What are the anticholinergic effects of antihistamines?

Answer 17

Drying effect on mucous membrances like mouth and lungs.

Question 18

What is a paradoxical reaction from antihistamines?

Answer 18

Makes kids hyper rather than tired (usual effect)

Question 19

Why do we have to be cautious with asthma patients who take antihistamines?

Answer 19

1st gen antihistamines have anticholinergic effects (drying out of tissues)

Question 20

What generation of antihistamines is used to help with allergic rhinitis?

Answer 20

2nd gen antihistamines are used more often today because they have fewer adverse effects.

Question 21

Should seniors avoid first generation antihistamines?

Answer 21

There is increased concern for the anticholinergic effects(drying) in seniors. They respond to these drugs more severely than younger adults

Question 22

What are some interesting qualities of second generation antihistamines?

Answer 22

Second gen antihistamines are less sedating, don’t cross blood brain barrier, and it has greater affinity for histamine receptors

the dosing is also more convienient (once daily vs. BID)

They take slightly more time to show full effects vs, 1st gen antihistamines

Question 23

Is there a difference between Reactine 5mg and 10mg?

Answer 23

There is no clinical difference between the two doses

Question 24

Can kids under 6 take second generation antihistamines?

Answer 24

Yes, all second generation antihistamines can be given to kids older than 2 except fexofenadine(legal history, it is safe though)

Question 25

What is an advantage of diphendhyramine in pediatrics?

Answer 25

Diphendyramine can be given to kids under 2.

Question 26

Why does grapefruit an other citrus fruit juices affect some drugs?

Answer 26

Grapefruit juice inhibits absorption in the gut, which limits the amount of drug that enters circulation

Question 27

Issues with antihistamines?

Answer 27

Might have to try different antihistamines to find one that works If condition is perrenial and long-term, might have to go with topical steroids Plan drug holidays to se how effective the drug is on symptoms When should I start? (start before allergies become common)

Question 28

Is patient adherance important for ensuring antihistamines work?

Answer 28

Yes, patients must take antihistamines as directed for the entire period that they have allergies

Question 29

Can you develop a tolerance for antihistamines?

Answer 29

No, it works the 600th time just as good as the first time. It can be used for years

Question 30

What are intranasal antihistamines?

Answer 30

They were not the best products because they were usually made with 1st gen antihistamine + decongestant(concern for rebound congestion) Dymista is a new product that doesn't have decongestant. It contains a steroid+antihistamine

Question 31

What are ocular antihistamines?

Answer 31

Like old school intranasal antihistamine products, they also contained decongestants (concern with rebound congestion) Emedastine and ketotifen are better as they are antihistamines alone

Question 32

What are intranasal steroids?

Answer 32

Once steroids go in the nose, there are almost no classic steroid oveuse effects. Try 2nd gen antihistamine first, but go to steroids if congestion is particularly bad ex. Nasacort, budesonide

Question 33

Do oral decongestants cause rebound congestion?

Answer 33

No, only long-term use of topical decongestants causes rbound congestion

Question 34

How effective are intrasnasal steroids?

Answer 34

These allow even more relief than second generation antihistamines. They cover almost all symptoms (runny nose, decongestion) The only downside is that these drugs take longer to acheive max effect vs antihistamines

Question 35

How to use intranasal steroids?

Answer 35

Can be taken once daily or twice a day. Regular dosing(once a day, once a week, etc) is the best for symptom management. Side effects: local irritation PND-esque throat irritation caused by spray running down back of throat These drugs can be used long-term, take drug holidays to check your symptoms

Question 36

Can intranasal steroids cause stunted growth?

Answer 36

Theoretically yes, but this is largely a legal liability Bioavailability(absorption=potential growth stunting) is very small for an agent like nasonex. avoid budesonide for kids, fine for adults bc they are done growing

Question 37

Can kids under 6 use intranasal steroids?

Answer 37

Yes Avamys can be used in 2 year olds and up Flonase can be used in 4 year olds and up

Question 38

How to spray intranasal steroids?

Answer 38

Spray inside the nose away from the nasal septum and don't need to breath in

Question 39

What is Cromolyn?

Answer 39

It is a mast cell stabilizer and it prevents the release of histamines. This product is still developing and must be used multiple times a day(6x per day)

Question 40

What is something we can use for eye-related symptoms of allergic rhinitis?

Answer 40

Patanol: mast cell stabilizer and antihistamines. This should be prescibed all the time for eye symptoms Cromolyn works great and there are no side effects

Question 41

What are allergy shots?

Answer 41

Exposes body to allergens and allows immune response to develop in preparation for the real deal sublingual options are also available

Question 42

How do leukotriene antagonists work?

Answer 42

Leukotrienes are relased by mast cells and it is like histamine as it helps promote inflammation This product didn't live up to hopes

Question 43

Why is ipratropium used?

Answer 43

This drug has anticholinergic effects and it is used for vasomotor rhinitis therapy

Question 44

How does pregnancy effect allergic rhinitis?

Answer 44

It is a wild card, allergies may get worse or get better We try not to use agents in pregancy, but first-generation histamines are safe(long history) but their efficacy is unknown

Question 45

How should asthmatics approach allergic rhinitis therapies?

Answer 45

Most asthmatics are on interlung inhaled steroids. We can easily use intranasal steroids for congestion, no concern about overdose. This is in the realm of physicians

Question 46

How should kids use allergic rhinitis therapies?

Answer 46

Antihistamines are very safe newer topical steroids are also safe (growth stunting is an overstated side effect)

Question 47

Should a topical steroid be using in conjuction with an antihistamine?

Answer 47

There is no real value in doing both because the topical steroid is already doing all of the heavy lifting. The antihistamine does not improve the situation significantly