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Pharmacology > Allergic Rhinitis > Flashcards

Allergic Rhinitis Flashcards

1
Q

Rhinitis

A

Inflammation of the lining of the nose and other parts of the upper respiratory tract.

Most common is allergic rhinitis: allergen induced and IgE mediated, releases inflammatory markers.

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2
Q

Allergic rhinitis

A

Seasonal (hay fever) versus Persistent (perennial rhinitis)

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3
Q

Seasonal allergic rhinitis

A

Specific, seasonal allergies. Predictable times of the year. Pollen from trees, grasses and weeds.

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4
Q

Perennial rhinitis

A

Non-seasonal allergens. Year round, or specific months throughout the year. Dust mites, animal dander, molds. Less variable, chronic symptoms.

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5
Q

AR risk factors

A

Genetics, family history, exposure to allergens, IgE >100 before age 6, eczema, heavy secondhand smoke exposure, higher socioeconomic status.

Protective: exposure to harmless microbes in first year of life.

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6
Q

Pathophysiology of the nose

A

Heating, humidification, filtration.
Air moves through the nose, particulate matter sticks to the mucous membrane, cilia moves mucous towards throat, trapped particles are swallowed and excreted by GI tract.

Concentrates foreign proteins in the nasopharynx, identification by lymph system, produces allergic antibodies, allergic rhinitis occurs.

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7
Q

Immediate phase of AR

A

Within minutes, mast cell degranulation. Release of pro-inflammatory mediators (histamine, cytokines), release of inflammatory mediators (leukotrienes, prostaglandins, bradykinin).

Nerve stimulation: nasal itching, sneezing
Histamine: nasal drainage and obstruction

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8
Q

Late phase of AR

A

4-8 hours after allergen exposure in 50% of patients.
Cytokines released by mast cells and T lymphocytes migrate to site of allergen exposure.
Nasal congestion: primary characteristic of the late phase and can be persistent and chronic.

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9
Q

AR signs

A

Allergic salute: crease on nose
Allergic shiners: bags under eyes
Mouth breathing

Symptoms: rhinorrhea, post-nasal drip, sneezing, itchy eyes, ears, nose, red, watery eyes.

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10
Q

Complications of AR

A

Poor performance, malaise, asthma, acute otitis media, chronic middle ear infections, lack of sleep, sinusitis, vocal polyps and hearing problems.

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11
Q

AAAA/ACAAI classifcation

A

Seasonal: symptoms present during specific portion of the year
Perennial: symptoms present throughout the year
Episodic: symptoms present only during intermittent exposure to allergen trigger

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12
Q

Classification on intermittent/persistent

A

Intermittent: <4 days a week or <4 consecutive weeks.
Mild: symptoms do not interfere with sleep, school, or daily activities.
Moderate/severe: impairment of sleep, impairment of daily activities or school/work, troublesome symptoms.

Persistent: >4 days a week or >4 consecutive weeks.
Mild: same as above
Moderate/severe: same as above

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13
Q

Treatment goals

A

Minimize frequency and severity of symptoms, improve QOL, prevent complications, improve attendance/performance, minimize adverse effects of therapy.

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14
Q

Approaches to treatment

A

Allergen avoidance, pharmacotherapy, immunotherapy

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15
Q

Non-pharmacologic therapies

A

Breastfeed infants exclusively for 3 months, avoid environmental secondhand smoke, attempt environmental control by avoiding allergens, consider the use of nasal saline.

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16
Q

Nasal saline

A 
Moisten nasal cavity and promote mucocilliary clearance. Alternative or adjunct to treatment. 
Irrigation, spray, drops or neb.
Relief of sneezing, nasal congestion.
Can cause nasal irritation, infection.
Use purified water.
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17
Q

Antihistamines

A

H1 receptor antagonist: competitive antagonist to histamine. Binds to H1 receptor without activating them, prevents histamine from binding and causing effects.

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18
Q

First generation antihistamines

A

Non-selective, sedating.

OTC: Chlorpheniramine, Clemastine, Diphenhydramine

SE: sedation, dry mouth, dry eyes, urinary retention

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19
Q

Second generation antihistamines

A

Peripherally selective, non-sedating.

OTC: Zyrtec, Allegra, Claritin.

SE: Less likelihood of sedation

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20
Q

Ophthalmic antihistamines

A

Can be used with or without nasal steroids for ocular symptoms.

Bepotastine (Bepreve)
Azelastine (Optivar)
Ketotifen (Alaway/Zatidor)
Olopatadine (Pataday/Patanol)

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21
Q

Intranasal antihistamines

A

Consider for seasonal allergic rhinitis. Rapid symptom relief.
SE: drowsiness, drying effects, headache, tolerance.

Azelastine
Olopatadine (selective H1, less drowsy)
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22
Q

Decongestants

A

Topical, systemic. For nasal congestion.

Alpha adrenergic receptor agonist on nasal mucosa, cause vasoconstriction.
Shrinks swollen mucosa, improves ventilation.

Phenylephrine (alpha 1)
Oxymetazoline and naphazoline (alpha 2)
Pseudophedrine (a and norepi)

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23
Q

Topical decongestants

A

Max 3-5 days, rebound congestion.
Use smallest dose, use infrequently, use only when necessary.
Adverse effects: burning, stinging, dryness, sneezing.
Minimal systemic effects, decreased blood pressure effects (compared to systemic ones)

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24
Q

Phenylephrine (Neo-Synephrine)

A

Nasal decongestant. Short acting, up to 4 hours. Alpha 1.

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25
Q

Naphazoline

A

Nasal decongestant. Intermediate acting, 4-6 hours. Alpha 2.

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26
Q

Tetrahydrozoline

A

Nasal decongestant. Intermediate acting, 4-6 hours.

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27
Q

Oxymetazoline (Afrin)

A

Nasal decongestant. Long acting, up to 12 hours. Alpha 2.

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28
Q

Systemic decongestants

A

Onset of action slower than topical, onset of action longer. No risk of rebound congestion.

CI: MAOIs, uncontrolled HTN, severe CAD, BPH

SE: increased BP, tachy, decreased appetite, CNS stimulation, tremor, difficulty sleeping.

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29
Q

Pseduoephedrine (Sudafed)

A

Regulated. Available in combo products: Claritin-D, Allegra-D.

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30
Q

Phenylephrine (Sudafed PE)

A

Not regulated. Available in combo products, several OTC cough and cold products!

31
Q

Intranasal steroids

A

Seasonal: important to start before allergen exposure!
Perennial: useful with year round therapy.

MOA: reduce inflammatory mediator release, decrease inflammation. Inhibit mast cell late phase reactions.

SE: headache, stinging, sneezing, epistaxis.

Onset: improvement may be seen within days, peak 2-3 weaks.

32
Q

Beclomethasone

A

Intranasal steroid

33
Q

Triamcinolone (Nasacort)

A

OTC, no alcohol in formulation. Intranasal steroid.

34
Q

Flunisolide

A

Intranasal steroid

35
Q

Fluticasone (Flonase)

A

Intranasal steroid. OTC, CONTAINS ALCOHOL.

36
Q

Mometasone (Nasonex)

A

Intranasal steroid

37
Q

Budesonide

A

Intranasal steroid, OTC, no alcohol.

38
Q

Mast cell stabilizers

A

MOA: stabalize mast cells and interfere with chloride channel function, weak anti-inflammatory effects.
Used for seasonal allergic rhinitis, prior to allergy season. Perennial AR.

SE: sneezing, nasal stinging.

39
Q

Cromolyn

A

OTC, mast cell stabilizer. Prevents and treats symptoms. Requires 2-4 weeks to notice effect. Dosed every 6 hours!

40
Q

Intranasal anticholinergic

A

MOA: inhibits nasal mucosa serous and seromucous gland secretions. Used for anti-secretory effects when applied locally (rhinorrhea). Use ONLY if cannot tolerate other therapies.

SE: epistaxis, nasal dryness, headache.

41
Q

Ipratropium bromide (Atrovent)

A

Intranasal anticholinergic.

42
Q

Leukotriene receptor antagonists

A

MOA: inhibit leukotriene receptor, block leukotriene release, interfere with pathway of inflammatory mediators from mast cells.
Relief of sneezing, rhinorrhea, congestion, itching. Used for monotherapy in patients with asthma and coexisting allergic rhinitis. 3rd line agent.
SE: headache, GI upset, hepatotoxicity (rare)
When used with antihistamines, more effective than antihistamines alone.

43
Q

Montelukast (Singulair)

A

AR, leukotriene receptor antagonist

44
Q

Zafirlukast (Accolate)

A

Not for AR, only asthma. Leukotriene receptor antagonist.

45
Q

Immunotherapy

A

Gradual process of injecting doses of antigens to develop tolerance.
Induction of IgG blocking antibodies, reduced IgE. More beneficial with seasonal.

46
Q

Immunothearpy

A

Oralair: grass allergies (first one in US)
Grastek: grass allergies
Ragwitek: ragweed allergies

47
Q

Pregnancy

A

Nasal saline is 1st line for mild-moderate nasal symptoms.
Budesonide recommended for severe or persistent (b).
Intranasal cromolyn (c) not as effective as budesonide
Oral antihistamines: 1st generation, chlorphenieramine (b). 2nd generation, loratadine or cetirizine (b)

48
Q

Chlorpheniramine

A

First generation antihistamine

49
Q

Clemastine

A

First generation antihistamine

50
Q

Diphenhydramine

A

First generation antihistamine

51
Q

Cetirizine (Zyrtec)

A

Second generation antihistamine

52
Q

Fexofenadine (Allegra)

A

Second generation antihistamine

53
Q

Loratadine (Claritin)

A

Second generation antihistamine

54
Q

Levocetirizine

A

Second generation antihistamine, Rx

55
Q

Desloratadine

A

Second generation antihistamine, Rx

56
Q

Bepotastine

A

Ophthalmic antihistamine

57
Q

Azelastine

A

Ophthalmic antihistamine, also intranasal

58
Q

Ketotifen

A

Ophthalmic antihistamine

59
Q

Olopatadine

A

Ophthalmic antihistamine, also intranasal

60
Q

Phenylephrine

A

Short acting topical decongestant

61
Q

Naphoazoline

A

Intermediate topical decongestant

62
Q

Tetrahydrozoline

A

Intermediate topical decongestant

63
Q

Oxymetazoline (Afrin)

A

Long acting topical decongestant

64
Q

Beclomethasone

A

Intranasal steroid

65
Q

Triamcinolone

A

Intranasal steroid, otc, no alcohol

66
Q

Flunisolide

A

Intranasal steroid

67
Q

Fluticasone (Flonase)

A

Intranasal steroid, otc, alcohol

68
Q

Budesonide

A

Intranasal steroid, otc, no alcohol

69
Q

Mometasone (Nasonex)

A

Intranasal steroid

70
Q

Cromolyn

A

Mast cell stabilizer, dosed frequently

71
Q

Ipratropium bromide (Atrovent)

A

Intranasal anticholinergic

72
Q

Singulair

A

Leukotriene receptor antagonist

73
Q

Zafirlukast

A

Leukotriene receptor antagonist, not for AR, only asthma

Pharmacology (11 decks)

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