Allergic Rhinitis

Question 1

Describe the allergic process

Answer 1

• Allergic response to allergens (proteins)
• Mast cells exist at body interface (stomach, eyes, skin)
• Initial exposure –> No rxn however leads to sensitization
• Subsequent exposure enacts symptoms via mast cells release of mediators 9e.g. histamine)

Question 2

What is sensitization?

Answer 2

Sensitization = your body has seen this before and now stands ready. The mast cell now has receptors ready to pick up the allergen when it next appears (allergy season)

Question 3

Early Phase vs. Late Phase RXN

Answer 3

Early –> Rhinorrhea, itchiness, maybe some sneezing

late –> oedema and congestion

Question 4

What is the link between asthma and allergies?

Answer 4

Some component of allergic rhinitis . If can’t control one, other gets worse. Need to have control of both.

Question 5

Is anti-histamine effective for all mediators?

Answer 5

No
can control histamine; however, other receptors activated and mediators released

Question 6

Perennial Allergies

Answer 6

• Year round; all the time

Question 7

Acute Allergies

Answer 7

• Can be long; but after 2 months stops –> Seasonal

Question 8

What are some differentials?

Answer 8

Vasomotor rhinitis (temp)
Rhinitis Medicamentosa (decongestants-rebound)
Hormonal (birth control)
geriatric Rhinitis

Question 9

How is allergic rhinitis classified (new)?

Answer 9

Intermittment - Less than 4 days per week, or less than 4 weeks at a time

Persistent - Greater than 4 days per week and greater than 4 weeks at a time

Mild –. Normal sleep, normal activities

Moderate-severe –> Abnormal sleep, impairement of daily activities

Question 10

Common symptoms of allergies

Answer 10

Sneezing, rhinorrhea, congestion, itchy eyes, nasal drip

Question 11

Facial cues of allergic rhinitis

Answer 11

• Puffy eyes, mouth breathing

Question 12

Allergies vs a cold

Answer 12

• same time every summer
  Increase sneezing and itchiness
  Runny nose and congestion
  Last longer
  PND
  More ocular

Question 13

Avoidance of Alergens

Answer 13

• Very hard to do

Question 14

Nasal irrigation

Answer 14

Well tolerated
Small benefit
- helps flush out allergens

Question 15

Nasal Sprays

Answer 15

• not the same as irrigation
• tortured by irritation; lubrication can provide relief
• can use long term

Question 16

Anti-histamines MOA

Answer 16

H1 –> Mast Cells –> prevent histamine release

H2 –. Stomach

Question 17

How should anti-histamines be used for optimal effectiveness?

Answer 17

• Best used prior to allergen exposure
  Regular dosing is bttter than prn use

Question 18

When would a topical steroid be more useful?

Answer 18

• Topical steroid better for congestion phase than antihistamine

Question 19

First genration ANti-histamines

Answer 19

Promethazine

ETHANOLAMINES:
diphenyhydramine
doxylamine
clemastine

ALKYLAMINES
chlorpheniramine
brompheniramine
debroxmpheniramine
tripolidine

Question 20

1st gen sedation

Answer 20

promethazine > ethanoamines > alkylamines

Question 21

What are some symptoms of anti-histamines?

Answer 21

• Block H1 receptors alows blockage of cholinergic receptors
• Anticholinergic symptoms –> dry mouth, drowsiness, constipation

Question 22

1st Gen in Kids and Older People

Answer 22

Kids –> Avoid –> use 2nd gen –> Does not cause paradoxical excitation

Avoid in elederly

Question 23

Second Genration ANti-histamines and age of use

Answer 23

Loratidine - 2
Desloratidine - 2
cetrizine - 2
Fexofenadine - 12

Question 24

Interactions 2nd gen

Answer 24

• Fexofenadine + grapefruit/orang/apple juice and when taken with food

Question 25

Why are 2nd gen better than first gen?

Answer 25

- Higher affinity for receptor - Less s/e - Not sedating

Question 26

Patient Dynamics

Answer 26

- Little chance for complete relief - Expect trial and error

Question 27

Intranasal Antihistamines

Answer 27

- Dristan - phenylephrine and pheniramine Dymista - flucatisone (topical steroid) and azelastine

Question 28

Ocular Anti-histamines

Answer 28

OTC pyrillamine, antazoline, pheniramine RX Emedastine, ketotifen

Question 29

Decongestant and Anti-histamine

Answer 29

- Want them seperate

Question 30

Intransal Steroid Examples, safety and Use

Answer 30

Mometasone Flucatisone Ciclesonide - Safe --> Will not get rebopund congestion When we put the in the nose, do not see common steroidal effects as on the skin --> unheard of --> no mucosal thinning - Useful for congestion - Budesonide -Beclomethasone - Flunisolide

Question 31

Efficacy and Onset of ACtion of Intransal Steroid

Answer 31

- More effective than 2nd gens - Gonna need 2 weeks to get onset of action (will get some relief in first few days)

Question 32

Intransal Steroids Dosing, S/e and duration of therapy

Answer 32

- OD or BID - regular use is better - S/e --> Local irritation, nose bleeds (epitaxis), spray runs down back of throat - Can use for 2 years; take drug holidays

Question 33

Ages for Intransal Steroids

Answer 33

- Go with what label says

Question 34

Directions for Intransal Steroid Use

Answer 34

- Shake and Prime (makes sure you get ful dose) - Blow nose - Look down - Use right hand for left nostril and vice versa - Spray to outside of nose wall - Do not sniff hard

Question 35

Cromolyn

Answer 35

- Mast cell stabilizer --> prevents mediator reease - Cromolyn, Nalcrom, Opticrom Dose frequently

Question 36

Opthalmic Allergies

Answer 36

- Therapeutics for eye often underdosed - Mast cell stabilizers: Cromolyn Alocri Patanol Alomide

Question 37

Immunotherapy

Answer 37

- Allergy shots - Really bad allergies

Question 38

Montelukast

Answer 38

Lukotriene antagonist - Asthma, allergic rhinitits - Add on therapy

Question 39

Ipratropium

Answer 39

- anti-cholinergic mechanims Used in vasmotor rhinitis therapy

Question 40

Allergies Pregnancy

Answer 40

Nasal Congestion Common - MD realm 1st gen and 2nd gen appear to be safe

Question 41

Anti-histamines and Intranasal steroids in Asthma

Answer 41

Avoid 1st gen, 2nd gen of choice Patient is on inhaled steroid, adding an intranasal steroid is reasonable

Question 42

Children ANti-histamines

Answer 42

- 1st gen safe; however use second gens - newer topical steroids are safe --> no negative growth effects