Allergic Rhinitis Flashcards by Rachel Illias

Define rhinitis

inflammation of the nasal mucous membrane with one or more of the following:
nasal congestion
rhinorrhea
sneezing
itching

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Define allergic rhinitis

rhinitis caused by a mucous membrane exposure to inhaled allergenic materials that elicit a specific response mediated by IgE

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Define allergic conjunctivitis

inflammation of the conjunctiva that is mediated by IgE and is associated with itching, erythema, tearing

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seasonal allergic rhinitis

occurs in response to specific allergens present at predictable times of the year

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perrennial allergic rhinitis

allergic rhinitis that occurs year round

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episodic allergic rhinitis

allergic rhinitis that occurs by sporadic exposures to allergens that are not usually encountered in the patient’s indoor/outdoor environment

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Seasonal Allergic Rhinitis allergens

Tree pollen - spring
Grass pollens - late spring to early summer
Weed pollens - late summer to early fall

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Perrennial Allergic Rhinitis allergens

Mold spores
House dust mite fecal proteins
Animal dander
Cockroaches

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Risk factors for allergic rhinitis

Family history of atopy
Higher socioeconomic class
Higher serum IgE levels (>100 IU/mL) before age 6
Positive allergy skin prick test

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Most common causes of drug induced rhinitis

ACE inhibitors
a-receptor antagonists
Phosphodiesterase-5 selective inhibitors

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Structure of nasal cavity

Posterior to external nose
Surface area lined by mucous membrane
Serous glands - lysozyme chemical destroys bacteria
Epithelial cells - natural anitbiotics
Cilia - moves toward throat
Nasal mucousa - warms air
Nasal conchae - mucous covered projections

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Functions of nasal cavity

Airway for respiration
Moistens and warms entering air
Filters and cleans inspired air
Resonating chamber for speech
Houses olfactory receptors

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Structure and function of the mucous membrane

Epithelium supported by underlying layer of connective tissue, coated with viscous fluid (mucus) secreted by goblet cells and/or mucus glands

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What is the function of nasal turbinates and what is the impact on airflow through the nasal cavity?

Mucus covered projections

Can increase mucosal surface area when engorged with blood; swelling can reduce airflow and cause nasal congestion

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Structure and function of conjunctiva

Thin, transparent mucous membrane that lines the eyelids and covers the visible part of the eye. It functions to lubricate the eye by secreting oils and mucus.

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Hypersensitivity reactions

immune responses that are excessive, injurious, or pathologic

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Four types of hypersensitivity reactions

Immediate Hypersensitivity (Type 1; allergies)
Antibody-Mediated Diseases (Type II)
Immune complex-mediated diseases (Type III)
T cell mediated diseases (Type IV)

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Type I Hypersensitivity

Rapid IgE anitbody and mast cell-mediated vascular and smooth muscle reaction, often followed by inflammation

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Type II Hypersensitivity

Antibodies other than IgE against cells/extracellular components may react with any tissue that expresses specific antigen
Antibodies self-reactive - injury by local inflammation

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Type III Hypersensitivity

Immune complexes of circulating/soluble antigens and antibodies can deposit in blood vessels in tissues - inflammation and injury

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Type IV Hypersensitivity

T cell-mediated autoimmune reactions against cell antigens with restricted tissue distribution

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Allergens

foreign molecules, antigens?, that aren’t harmful normally but can cause an immune response

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Sensitization

occurs when IgE antibodies bind to receptors in the plasma membrane of mast cells and basophils and become sensitive to subsequent encounters to the same allergen

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Process of sensitization

APCs digest and process allegen - display class II MHC
Activation of CD4 Helper Cells
Secretion of cytokines IL-4 and IL-13
Stimulate B cells specific for same allergen to switch to IgE producing plasma cells
Sensitization

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Role of mast cells, eosinophils, and basophils in allergic rhinitis

Degranulation - mast cells and basophils rapidly release contents of secretory vesicles after exposure to allergen cross links IgE. Molecules cause immune reaction. Eosinophils release chemical mediators that promot the migration of additional immune cells to site and chemicals destructive to epithelia

Most important products of mast cell activation

Histamine - vasodilation, increased vascular permeability, contraction smooth muscle Proteases - damage to local tissues Prostaglandins - vacular dilation Leukotrienes - prolonged smooth muscle contraction Cytokines- local inflammation and recruitment

Role of TH2 cells

Stimulate mast cell and eosinophil mediated immunity | Secretion of mucus

Histamine role and effects

Binds to and activates Histamine -1 (H1) receptos - Rhinorrhea - from reflexive stimulation of PNs - Itching/Sneezing - stimulation of H1 receptors on nerve endings - Nasal congestion, redness, heat - vasodilation, increased vascular permeability

symptoms of allergic rhinitis

- Rhinorrhea - Sneezing - Nasal congestion - Pruritic ears, nose, or palate - Allergic conjunctivitis (itchy eyes and tearing)

Complications of allergic rhinitis

-Inability to sleep -Fatigue -Poor work/school efficiency -Post nasal drip with cough -Loss of smell or taste -High arched, V shaped palate -Permanent transverse crease -Dark circles around eyes Asthma -Recurrent and chronic sinusitis -Epistaxis (nosebleed) -Nasal polyps -Sleep apnea

Epicutaneous skin test

Superficial wound with drop on antigen on it Fastest and least expensive Positive test - flare within 15-30 min

Intradermal skin test

Inject diluted allergen between layers Negative prick test, but still suspect 15-30 min

Radioallergosorbent test (RAST)

In vitro assay More expensive and less sensitive Helpful when antihistamine therapy can't be discontinued

Non pharmacotherapy

``` Identify triggers and avoid Maintain household humidity <50% Clean house - mold, carpet, bedding Seasonal - close windows, use mask Cold compress, saline, artificial tears Nasal irrigation ```

Advantages of intranasal drug delivery

Directly to the site of problem | Minimizes systemic drug exposure

Counseling points for intranasal

Clear nose before admin Don't blow nose ~10 min after Direct spray away from nasal septum (don't use in patients with nasal septum ulcers, recent nasal surgery/trauma) Local irritation may occur

Immunotherapy

The gradual process of injecting increasing doses of antigens responsible for eliciting allergic symptoms with hope of increasing tolerance

Adverse effects of immunotherapy

``` Mild local reactions Generalized urticaria (hives) Bronchospasms Laryngospasm Vascular collapse Anaphylactic reactions ```

Good candidates for immunotherapy

Strong history of severe symptoms unsuccessfully controlled Unable to tolerate adverse effects of properly managed drug therapy Committed to necessary regular office visits Evidence of specific IgE antibodies to clinically relevant allergens

Poor candidates for immunotherapy

With any medical condition that would compromise the ability to tolerate an anaphylactic reaction Impaired immune systems History of nonadherance

Acrivastine/Pseudophedrine

Second Gen. Antihistamine

Azelastine

Intranasal Antihistamine

Azelastine/Fluticasone

Intranasal Antihistamine

Olopatidine

Intranasal antihistamine

brompeniramine

first gen antihistamine

cetirizine

second gen antihistamine

levocetirizine

second gen antihistamine

fexofenadine

second gen antihistamine

loratadine

second gen antihistamine

chlorpheniramine

first gen antihistamine

desloratadine

second gen oral antihistamine

carbinoxamine

first gen

clemastine

first gen

cyproheptadine

first gen

diphenhydramine

first gen

promethazine

first gen

pyrilamine

first gen

alcaftadine

ophthalmic antihistamine

antazolineine

ophthalmic antihistamine

azelastine

ophthalmic antihistamine

bepotastine

ophthalmic anti

emedastine

ophthalmic anti

epinastine

ophthalmic anti

ketotifen

ophthalmic

levocabastine

ophthalmic

olopatidine

ophthalmic

Systemic Decongestants

Phenylephrine | Pseudoephedrine

Intranasal decongestants

``` Naphazoline Phenylephrine Oxymetazoline Tetrahydrozoline Xylometazoline ```

Ophthalmic Decongestants

Naphazoline | Tetrahydrozoline