Allergic Rhinitis Flashcards
1
Q
Allergic Rhinitis leads to increased risk of (9)
A
Asthma
Chronic rhinosinusitis
Otitis media
Nasal polyposis
Atopic dermatitis
Sleep disordered breathing
Conjunctivitis
Resp Infections
Orthodontic malocclusions
2
Q
4 defining sx of allergic rhinitis
A
Sneezing
Runny nose
Nasal congestion
Nasal itching
3
Q
Patients with seasonal allergic conjunctivitis appear with
A
Red, itchy watery eyes
4
Q
Allergic salute
A
Rubbing hand up against nose to quell itching
5
Q
Patients may also have a bruised appearance under eyes known as
A
Allergic shiner
6
Q
Non-Pharm treatment of allergic rhinitis
A
AVOIDANCE of known allergens
DECREASING BODY RESPONSE
NASAL RINSES AND STRIPS
7
Q
How do we decrease the body response to allergens?
A
Hyposensitization via subcutaneous immunotherapy
Exposing a patient to increasing amounts of the causative allergen to build an immune tolerance
8
Q
Irrigation of the nasal passages with __________ is useful for what?
A
Saline;
Useful for removing allergens and preparing the membranes for admin of intranasal meds
9
Q
Pharmacotherapy options for allergic rhinitis (8)
A
Intranasal corticosteroids
Oral antihistamines
Intranasal antihistamines
Oral decongestants
Intranasal decongestants
Intranasal anticholinergics
Intranasal cromolyn
Oral antileukotrienes
10
Q
Therapeutic effects of intranasal corticosteroids are due to the ________________
A
Topical effects
11
Q
Intranasal corticosteroids MOA
A
Potent ANTI-INFLAMMATORY effects mast cells, eosinophils, and lymphocytes
AFFECT MEDIATORS of these cells that are involved in inflammation (histamine, leukotrienes, cytokines)
12
Q
1st line treatment of allergic antihistamines
A
Intranasal corticosteroids
13
Q
Onset of action for intranasal corticoids
A
7 hours after first dose
14
Q
When should a patient expect to start feeling better after taking an intranasal corticosteroid?
A
Sx reduce in sever days
Max improvement in 2 weeks
15
Q
All intranasal corticosteroids seem to work equally in reducing _________, __________, and ___________
A
Sneezing, itching, or rhinorrhea
16
Q
What is the MOST effective treatment for nasal sx of seasonal and perennial allergic rhinitis?
A
Intranasal corticosteroids
17
Q
Side effects of nasal corticosteroids
A
Epistaxis
Dry nose
Bad taste
Headache
18
Q
Contraindications/precautions of intranasal corticosteroids
A
Avoid use with nasal trauma/recent nasal injury
Do periodic nasal checks for nasal perforations and ulcerations every few months
19
Q
Names of the 1st gen Intranasal corticosteroids
A
Budesinide
Flunisolide
Beclomethasone
Triamcinolone
20
Q
2nd gen intranasal corticosteroids
A
Fluticasone
Mometasone
21
Q
Intranasal Decongestant MOA
A
Stimulates 𝛼 adrenergic receptors in arterioles—> vasoconstriction—> decrease sinus vessel engorgement and mucosa edema
22
Q
Dosing of intranasal decongestants
A
2-3 days
23
Q
Prolonged used of intranasal decongestants can cause what?
A
Rebound congestion—> RHINITIS MEDICAMENTOSA
24
Q
Intranasal decongestants provide effective, short term __________
A
Relief of nasal congestion
25
What sx do intranasal decongestants NOT COVER?
Itching
Sneezing
Nasal secretion
26
Indication of use for Intranasal decongestants
Provide prompt relief of nasal congestion
Short term relief
27
Onset of action of intranasal decongestants
5-10min
28
Rhinitis medicamentosa
Caused by many days of regular use of OTC nasal decongestant sprays
Physical exam= SWOLLEN, RED NASAL MUCOSA
29
Decreasing risk of rhinitis medicamentosa
Limited use of otc nasal sprays to max of 5 days with as few doses as possible during those days
30
Tx of Rhinitis medicamentosa
Withdrawal of causative medication
Use of intranasal corticosteroids to help with sx
Counsel patients that rhinitis will get worse temporarily
31
SE of intranasal decongestants
Rhinitis medicamentosa
Nasal stinging/burning
32
Precautions in intranasal decongestant use
CV disease
Uncontrolled HTN
Thyroid disease
Diabetes
BPH
33
What medication is contraindicated for concurrent use with intranasal decongestants
MAOIs
34
What are the 2 commonly used intranasal decongestants
Phenylephrine
Oxymetazoline
35
MOA of intranasal antihistamines
Competes with histamine for H1 receptor sites—> inhibition of release of histamine—> decrease of allergic response
36
Indication of use for Intranasal Antihistamines
Seasonal and persistent allergic rhinitis
Situations where known exposure to allergens can be predicted
37
What do the guidelines suggest use of intranasal antihistamines? Or intranasal glucocorticoids?
Intranasal glucocorticoids
38
Onset of action of Intranasal glucocorticoids
<15 min
39
Dosing of Intranasal antihistamines
Can be administered ON DEMAND
40
Side effects of intranasal antihistamines
Bitter taste
Epistaxis
Drowsiness
Headache
41
What are the 2 intranasal antihistamines?
Olopatadine
Azelastine
42
What 2 agents may be helpful in concurrent use of patients that dont find relief with one agent?
Topical antihistamine + topical corticosteroid
43
MOA Of intranasal anticholinergics
Inhibits serous and sernomucous gland secretions—> decreases Rhinorrhea via nasal dryness
44
What sx do intranasal anticholinergics treat?
RHINORRHEA ONLY
(No antihistamine or antiinflammatory effect_
45
What is the available Intranasal anticholinergic?
Ipratropium Bromide
46
Indications for use of Intranasal anticholinergics
Useful for sx relief only
Used in patients with Rhinorrhea that is in sufficiently managed with other agents
47
Side effects of intranasal anticholinergics
Headache
Epistaxis
PHARYNGITIS
Dry nose
Nasal mucosa irritation
48
Intranasal Cromolyn MOA
Mast cell stabilizer
Inhibits the degranulation of sensitized mast cells—> prevention of release of mediators of allergic response and inflammation
49
Intranasal cromolyn works by…..
PREVENTING THE ALLERGIC RXN rather than alleviating sx
50
Cromolyn is useful for what population
Individuals who experience episodic sx to allergens
51
When can Cromolyn be taken for EPISODIC allergens?
30 min prior to exposure
52
When should cromolyn be started for seasonal allergy relief?
Most effective when initiated PRIOR TO POLLEN SEASON
53
When do we prescribe these?
Episodic relief
Patients whose response to inhaled corticosteroids and antihistamines are INSUFFICIENT
54
What line agent is cromolyn?
3rd line
( frequent dosing with lower efficacy)
55
Antileukotriene MOA
Montelukast= leukotriene receptor antagonist—> inhibition of action of leukotrienes—>decrease sx associated with allergic rhinitis
56
What is the ONLY antileukotriene that is approved for the treatment of allergic rhinitis?
Montelukast
57
What USED TO BE the indication for use of montelukast? s
Patients who couldn’t tolerate or refused nasal sprays
Patients with concomitant asthma and allergic rhinitis
58
Why did the FDA put a BBW on montelukast
Due to its neuropsychiatriac changes, fda recommended avoidance of montelukast in favor of other treatments
59
Examples of the Neuropsychiatric changes associated with use of Motelukast?
Dream abnormalities
Insomnia
Anxiety
Depression
Suicidal thinking (and possibly suicide)
60
Oral decongestant MOA
Directly stimulate 𝛼-adrenergic receptors in respiratory mucosa—> vasoconstriction—> decrease of venous engorgement and mucosal edema—> REDUCE SWELLING AND NASAL CONGESTION
Directly stimulate β-adrenergic receptors—> bronchial relaxation, increased HR and contractility
61
Who are oral decongestants most effective in?
Those with nasal congestion as primary sx
Those with congestion unbelievable by ICS or antihistamine products
62
Pseudoephedrine
OTC oral decongestant
Placed BEHING THE COUNTER due to the Combat Methamphetamine Epidemic act (CMEA)
63
What is a requirement of the CMEA act?
Customer identify must be verified
Fed law limited the quantities of pseudoephedrine that patient can buy at once and within a specific time period
64
CMEA led to the introduction of the less-effective agent known as
Phenylephrine
65
Issues with Phenylephrine
Effectiveness=questionable
When taken orally, it is not likely to be significantly effective due to extensive gut metabolization
4x FDA approved dose still would not cause significant effects on congestion
Poor oral absorption
66
SE of Oral decongestants
Insomnia
Loss of appetitie
Elevated BP
Palpitations
Restlessness
67
Precautions of pseudoephedrine
Use cautiously
- controlled HTN
- arrythmias
- CHD
- uncontrolled hyperthyroid
- narrow angle glaucoma
- BPH
68
What population is pseudoephedrine NOT RECOMMENDED IN?
Patients taking stimulants for ADHD (together can increase BP and HR—> increase CV risk)
Patients on MAOIs
69
2 oral decongestants available
Pseudoephedrine
Phenylephrine
70
1st gen oral antihistamines
Target central and peripheral H1 receptors
Lipophilic—> cross BBB—> SEDATING
Bind to cholingergic, 𝛼-adrenergic, and sertonergic receptors—> anticholinergic effects
71
What are the anticholinergic SE that 1st gen antihistamines can cause?
Dry mouth
Dry eyes
Difficulty urinating
Constipation
Increased HR
72
2nd gen antihistamines
Lipophilic—> do not cross BBB
More specific to peripheral H1 receptors
Minimally sedating and less cognitive effects
73
What sx do oral antihistamines combat?
Itching
Sneezing
Runny nose
Itchy, red eyes—> allergic conjunctivits
74
What sx is not covered by oral antihistamines
Nasal congestion
75
______________________ provide greater relief for allergic rhinitis sx than oral antihistamines, without sedation and other anticholinergic effects
Intranasal glucocorticoids
76
1st gen SE
Sedation
Decreased cognitive and motor skills
ANTICHOLINERGIC SX
Some patients (esp. children may notice stimulating effects
Insomnia
Anxiety
Hallucinations
77
2nd gen antihistamine SE
Sedation (less so than 1st gen)
78
Precautions of 1st gen oral antihistamines
No use in patients with NARROW ANGLE GLAUCOMA—> pupillary dilation—> worsen narrow angle
ELDERLY- increased risk of falls and dry mouth—> avoid
79
For best sx relief, antihistamines should be taken when?
Prophylactically (2-5 hours prior to exposure)
OR
Regular basis if needed chronically
80
What are the 1st gen antihistamines?
Chlorpheniramine
Diphenhydramine
Clemastine
Hydroxyzine
81
What are the 2nd gen antihistamines?
Cetirizine
Levocetirizine
Fexofenadine
Loratadine
Desloratadine
82
Diphenhydramine roles
Treatment of acute allergic reactions
Prevention of allergic reaction as premedications
Allergic rhinitis
Cough (antitussive properties)
Insomnia
Dystonias
Motion sickness
83
Mechanism of saline on sx reduction of allergic rhinitis
Depends on washing away allergens and inflammatory mediators induced by allergic reactions
84
What type of saline seems to decrease edema of the nasal mucosa?
Hypertonic solutions
85
What type of saline doesn’t seem to have an anti-allergy affect?
NaCl
86
SE of saline
Minor burning or stinging in the nose
87
Use of hypertonic saline irrigation TID reduces what after 3–6 weeks of tx
Reduces allergy sx and use of oral antihistamines
88
What is the MOST EFFECTIVE single-agent maintenance therapy that has few side effects?
Glucocorticoids
89
What is the preferred antihistamines if antihistamine therapy is desired?
2nd gen antihistamines
90
For patients with mild or intermittent sx, what is the suggested treatment?
Glucocorticoids
91
For a patients with persistent/ moderate-severe sx, what is the suggested treatment?
Glucocorticoid nasal spray
92
If glucocorticoid monotherapy is not adequately relieving sx, what is the recommendation
Add antihistamine nasal spray
OR
Start oral antihistamine/decongestant combo
93
For patients with mild sx who prefer other agents bc oral admin or desire to avoid ICS, what are some options they can use?
Antihistamine nasal spray
2nd gen antihistamines
Cromolyn Nasal Spray
94
What is the main complaint of patients with allergic conjunctivitis?
Itchy red watery eyes
95
What type of reaction is allergic conjunctivits?
IgE mediated type I hypersensitivity reaction
96
MOA of Ophthalmic Anthistamines/ Vasoconstrictors
Antihistamine component—> works by competitively and reversibly blocking histamine receptors to prevent the actions of histamine
Vasoconstrictor component—> activates 𝛼-adrenergic receptors of the blood vessels to vasoconstriction and decrease edema
97
Dosage information for opthalmic antihistamines/vasoconstrictors
Can be used 4x/day for up to 1-2 weeks during acute reactions
98
Why is suggested to only use Ophthalmic antihistamines and vasoconstrictors for up to 2 weeks?
Risk of rebound reactions from the vasoconstrictor
99
What is the name of the ophthalmic antihistamine/vasoconstrictor?
Pheniramine
100
MOA of Ophthalmic antihistamine w/o vasoconstrictor
Same as above
Works by competitively and reversibly blocking histamine receptors to prevent actions of histamine
101
Names of the Ophthalamic antihistamines
Olopatadine
Azelastine
Epinastine
Cetitizine
102
MOA of antihistamine/mast stabilizer ophthalmic solutions
ANTIHISTAMINE PROPERTIES: decrease late phase allergic response by decreasing inflam cells from being released
MAST CELL PROPERTIES: stabilize mast cells—> release fewer inital proinflammatory mast cell mediators
REDUCE inflammation by inhibiting leukocytes and decreases the release of other inflammatory mediators (i.e basophils)
103
Which are more effective:
Antihistamine/Mast Cell stabilizers
Antihistamine/ Vasoconstrictors
Antihistamine/ Mast Cell Stabalizers
104
Side effects of Ophthalmic antihistamines/mast cell stabalizers
Burning
Stinging
Headaches
Dry eyes
105
What are the 2 antihistamine/mast cell stabilizer ophthalmic solutions?
Ketoifen
Alcaftadine
106
Indications of use for Ophthalmic mast cell stabalizers
For seasonal allergic conjunctivits IF:
- pt can predict onset of sx
- pt cant tolerate other drops
- frequent recurrent or persistent sx
107
When should ophthalmic mast cell stabilizers be started?
2-4 weeks before exposure to allergens
108
How long does it take for Ophthalmic mast cell stabilizers to take effect?
5–14 days
109
T/F: Mast cell stabalizers are effective for ACUTE relief of sx
False
110
T/F: antihistamines with mast cell stabilizing properties are usually more effective and preferred over mast cell stabilizers alone
True
111
What are the 3 Ophthalmic mast cell stabalizers?
CLN
Cromolyn sodium
Lodoxamide
Nedocromil
112
__________ ophthalmic drops have more efficacy compared to placebo but are far less effective than an antihistamine with mast cell stabilizing effects
Ophthalmic NSAIDs
113
What is the Ophthalmic NSAID approved for treatment of allergic conjunctivits?
Keterolac Ophthalmic
114
What drops are prescribed for refractory cases of allergic conjunctivitis?
Ophtahalmic corticosteroids
115
MOA OF Ophthalmic Glucocorticoids
Glucocorticoids suppress the late phase reaction of allergic inflammation
116
How are Ophthamic corticosteroids dosed?
Pulse therapy with max of 2 weeks duration for those who antihistamine/mast cell stabilizing drops dont work
117
SE of ophthalmic glucocorticoids
Cataract formation
Elevated IOP
Glaucoma
2ndary infection
118
What do ophthalmic corticosteroids do so that mast cell stabilizers and antihistamines have a greater chance to work?
They help to SLOW THE IMMUNE RESPONSE
119
What are SOFT STEROIDS?
Group of topical glucocorticoids that have reduced risk of increasing IOP bc formulated to undergo RAPID INACTIVATION upon corneal penetration
120
What are the Opthalmic glucocorticoids that are considered “SOFT”?
Loteprednol .2% solution
Prednisolone .12% suspension
Fluorometholone .1% solution
121
What are the 2 ophthalmic corticosteroids that can increase IOP?
Prednisolone 1% suspension
Dexamethasone .1% solution
