Allergic Rhinitis

Question 1

Allergic Rhinitis

Answer 1

IgE mediated inflammatory response of nasal mucous membrane secondary to inhaled allergenic particles

Question 2

Presentation

Answer 2

-clear rhinorrhea
-sneezing
-nasal congestion
-postnasal drip
-itchy eyes, ears nose, or palate
-malaise/fatigue
-pale or bluish discoloration and swelling of nasal mucosa
-conjunctivitis

Question 3

< 4 days per week or < 4 weeks per year & no interference with quality of life

Answer 3

Intermittent/mild

Question 4

< 4 days per week or < 4 weeks per year & interference with QOL

Answer 4

intermittent/moderate to severe

Question 5

> 4 days per week or > 4 weeks per year & no interference with QOL

Answer 5

Persistent/mild

Question 6

> 4 days per week or > 4 weeks per year & interference with QOL

Answer 6

persistent/moderate to severe

Question 7

no pharm options

Answer 7

-nasal saline irrigations
-adhesive nasal stips

Question 8

Pharmacotherapy

Answer 8

-intranasal steroids
-antihistamines
-decongestants
-LTRA

Question 9

Intranasal steroids

Answer 9

-help with congestion, rhinorrhea, sneezing, nasal itching, ocular sx
-Fluticasone, mometasone, triamcinolone, ciclesonide, budesonide, beclomethasone

Question 10

Intranasal steroids

Answer 10

-help with congestion, rhinorrhea, sneezing, nasal itching, ocular sx
-Fluticasone, mometasone, triamcinolone, ciclesonide, budesonide, beclomethasone

Question 11

Oral Antihistamines

Answer 11

-most effective when given prior to allergen exposure
-first generation (diphenhydramine) - lipophilic, crosses BBB, anticholinergic, sedative
-second generation (loratadine, cetirizine) - limited CNS penetration
-SX: minimal effects on congestion, help with rhinorrhea, sneezing, nasal itching, ocular symptoms

Question 12

Intranasal antihistamines

Answer 12

-rapid onset
-limits systemic effects
-Helps with congestion, rhinorrhea, sneezing, nasal itching, not ocular symptoms
-Azelastine, Olopatadine, Azelastine/Fluticasone

Question 13

Ophthalmic antihistamines

Answer 13

-can be used as mono therapy or in combo with oral agents
Helps with ocular symptoms only
-Ketotifen, Azelastine, Olopatadine, Alcaftdadine, Emedastine, Epinastine

Question 14

topical decongestants

Answer 14

-reduce swollen nasal mucosa and improve ventilation
-applied to nasal mucosa, rapid onset, prolonged use (more than 3-5 days) can lead to rhinitis medicamentosa (rebound congestion) - therapy should be 3 days or less
-Phenylephrine, tetrahydrozoline, naphazoline, oxymetazoline

Question 15

oral decongestants

Answer 15

-slower onset
-available as combo products with antihistamines
-SE: inc BP (avoid in combo w/ MAOIs), CNS stimulation, urinary retention
-pseudoephedrine, phenylephrine, cetirizine/pseudoephedrine, loratadine, pseudoephedrine, fexofenadine/pseudoephedrine

Question 16

Other intranasal therapies

Answer 16

-cromolyn: treat/prevent sinus sx, mast cell stabilizer (helps with everything besides ocular symptoms)
-ipratropium: treats runny nose, anticholinergic (helps with runny nose and minimal help with sneezing and nasal itching)
-montelukast: not primary therapy (minimal symptom relief)

Question 17

Nasal congestion is dominant complaint

Answer 17

INS or oral decongestant

Question 18

Intermittent sneezing, nasal itching and rhinorrhea

Answer 18

Oral antihistamine or intranasal antihistamine

Question 19

Mild sx

Answer 19

oral antihistamine

Question 20

Moderate/severe sx

Answer 20

INS, intranasal antihistamine, combination therapy

Question 21

Combo therapy

Answer 21

-INS (add intranasal antihistamine or oxymetazoline)
-oral antihistamine (add oral decongestant or next would be LTRA)
-intranasal antihistamine (add intranasal steroid)