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Clinical Pharmacy > Allergic Rhinitis > Flashcards

Allergic Rhinitis Flashcards

1
Q

People that have allergic rhinitis will often likely have what?

A

asthma

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2
Q

What is allergic rhinitis?

A
  • IgE airway condition that occurs due to inhaled allergens and results in mucosal inflammation and airway obstruction
  • characterized by nasal symptoms of sneezing, pruritus and discharge
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3
Q

What is the impact of AR?

A
  • fatigue, reduced concentration or loss of productivity

- can be quite significant for some

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4
Q

What are the key facts associated with AR?

A
  • Age (most prevalent in adolescents and young adults, some people grow out of it- onset approx 10 y/o)
  • Family history (30% chance for children with one atopic parent - 50% with 2 parents)
  • repeated exposure to multiple offending allergens
  • presence of other allergic conditions (asthma, atopic dermatitis)
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5
Q

What are the 3 stages of pathophys of allergic rhinitis?

A
  1. Sensitization
    - 1st contact with inhaled aeroallergen
    - IgE produced which binds to mast cells and basophils
  2. Immediate Reaction
    - recognition of allergen by IgE bound to mast cells and basophils
    - degranulation (release of preformed mediators, histamine, TNF, new formed mediators, leukotrienes, prostaglandins D2 and kinins)
    - result in symptoms of sneezing, rhinorrhea, congestion and pruritus
    - happens within minutes of re-exposure
    - lasts for 30-90 minutes
  3. Late Reaction
    - migration of inflammatory cells, eosinophils, monocytes, macrophages and basophils
    - symptoms similar to immediate action, but congestion predominates
    - occurs 4-8 hours after exposure
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6
Q

Over time, the persistent inflammation is thought to ____ the tissue, decreasing the threshold of allergen needed to produce an immediate response

A

prime

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7
Q

What are some common occupational allergies?

A
  • seed dust
  • woods
  • cockroaches
  • animal dander
  • moulds
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8
Q

What are the common nasal symptoms that are seen with allergic rhinitis?

A
  • frequent, paroxysmal sneezing
  • itching of the nose and palate
  • anterior watery rhinorrhea
  • nasal congestion
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9
Q

What are the common ocular symptoms associated with allergic rhinitis?

A
  • red, irritated eyes with prominent conjunctival blood vessels
  • itching or burning that may be intense
  • tearing
  • stringy or watery discharge
  • puffy eyelids- especially in the morning
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10
Q

What are the common facial features that are associated with allergic rhinitis?

A
  • allergic gape (open-mouthed breathing secondary to nasal obstruction)
  • allergic salute
  • allergic shiners (periorbital darkening secondary to venous congestion)
  • donnie’s lines (wrinkles beneath the lower eyelids)
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11
Q

What are some of the systemic symptoms of allergic rhinitis?

A
  • cognitive impairment
  • fatigue
  • irritability
  • malaise
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12
Q

What are some common perennial allergies?

A
  • dust, mould
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13
Q

What is classified as intermittent allergic rhinitis?

A

< 4 days/week

< 4 weeks/year

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14
Q

What is classified as persistent allergic rhinitis?

A

> 4 days/week

>4weeks/year

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15
Q

What constitutes vasomotor rhinitis?

A
  • a form of non-allergic rhinitis, which onset later on in life
  • presentation: nasal congestion, rhinorrhea and postnasal drip (dripping in back of throat)
  • patients usually 40-60 y/o
    triggers: temperature, exercise, environmental changes, cigarettes, perfume, paint, smoke and emotional stress
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16
Q

True or false: vasomotor rhinitis is immune mediated. Antihistamines would work for vasomotor rhinitis

A

False

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17
Q

What are some common medications that can cause non allergic rhinitis?

A
  • antihypertensive agents (prazosin, beta blockers, ACE inhibitors)
  • oral contraceptives
  • NSAIDS
  • topical decongestants
  • older antipsychotics agents
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18
Q

What are the red flags to be aware of with allergic rhinitis?

A
  • age < 2 y/o
  • wheezing and shortness of breath
  • tightness in the chest
  • painful ear or sinuses
  • fever
  • purulent nasal or ocular discharge
  • allergen not identifiable
  • failed medication - inadequate response to appropriate OTC rx after about 2 weeks
  • poor quality of life/missing school or work
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19
Q

What are the general treatments of allergic rhinitis?

A
  • non-pharmacological treatments (avoid the offending allergen- eliminate the allergen from the environment)
  • pharmacotherapy
  • immunotherapy
  • education
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20
Q

What is normal saline used for?

A
  • used to soothe irritated nasal tissues and moisturize the nasal mucosa
  • used on a prn basis
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21
Q

Controlled clinical studies suggest that nasal irrigation might do what?

A
  • reduce nasal concentration of inflammatory mediators, therefore possible helping to prevent or eliminate congestion
  • flush out mucus and allergens
  • improve nasal airflow
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22
Q

How do nasal breathing strips work?

A
  • drug free option
  • work by mechanical means to improve nasal airflow in patients suffering form congestion
  • symptomatic relief
  • considered a device
  • NO EVIDENCE THAT IT WORKS
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23
Q

What are the treatment goals for allergic rhinitis?

A
  • avoid or minimize the exposure to allergen
  • alleviate symptoms associated with allergic rhinitis
  • minimuse actual and potential adverse events associated with medication
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24
Q

What is the MOA for antihistamines?

A
  • competitive, reversible antagonist at H1 receptor
  • prevents histamine binding and action at the receptor site
  • does not affect histamine synthesis or chemically inactivate histamine
  • effective in reducing sneezing, rhinorrhea and itch (nasal, palatal and ocular) associated with AR
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25
Q

With the exception of desloratadine, these antihistamines are generally _________

A

not effective at relieving nasal congestion and stuffiness

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26
Q

Do antihistamines get rid of histamine that has already been released?

A

NO it does not - they just block histamine at the site of action - if the mast cells have already degranulated and have bound to their active site, they will have no further affect

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27
Q

Describe first generation antihistamines

A

non selective and sedating antihistamine

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28
Q

Describe second generation antihistamines

A

peripherally selective and non-sedating

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29
Q

____ generation antihistamines have a high amount of anticholinergic SE

A

First

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30
Q

What are the known first generation antihistamines?

A
  • chlorpheniramine
  • diphenhydramine
  • brompheniramine /doxyalamine/pyrilamine/triprolidine
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31
Q

What are the known second generation antihistamines?

A
  • loratadine
  • cetirizine
  • fexofenadine
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32
Q

What is the one known 3rd generation antihistamine?

A
  • desloratidine
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33
Q

With ____ it is important to avoid all juices

A

fenofexadine

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34
Q

10% of patients that have ____ will have sedating SE

A

cetirizine

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35
Q

What is the dosing of Diphenhydramine?

A

Onset: 15-30 mins
Dosing: every 6-8 hours
Adverse effects: anticholinergic (dry mouth and eyes, constipation, urinary retention)
and CNS effects (sedation, fatigue, disease, impairment of cognition and performance)
Drug Interactions: alcohol, hypnotics, sedatives, CNS depressants

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36
Q

What is the dosing of Chlorpheniramine?

A

Onset: 30 minutes
Dosing: every 4-6 hours
Adverse effects: anticholinergic effects as well as CNS effects (sedation, fatigue, dizziness, impaired cognition and performance)
Drug interactions: alcohol, hypnotics, sedatives, CNS depressants

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37
Q

What is the dosing of cetirizine?

A

Onset: 20-60 minutes
Dosing: once daily
Adverse effects: minimal to no anticholinergic or CNS effects - may cause drowsiness in some headache
** avoid if hypersensitivity to hydroxyzine

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38
Q

What is the dosing of fexofenadine?

A

Onset: 1 hour
Dosing: OD ( 120 mg) or BID (60 mg)
Adverse effects: minimal to no anticholinergic or CNS effects, headache
** take with water, do not take straight with antacids

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39
Q

What is the dosing for loratadine?

A

Onset: 1-3 hours
Dosing: OD
Adverse effects: minimal to no anticholinergic or CNS effects - headache

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40
Q

What is the dosing for desloratadine?

A

Onset: 1.25 hours
Dosing: OD
Adverse effects: minimal to no anticholinergic or CNS effects, headache

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41
Q

Central effects of antihistamines depends on the drug’s ability to cross the ____

A

BBB

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42
Q

Antihistamines should be taken _____ before pollen season or onset of symptoms (for seasonal/intermittent allergies)

A

10-14 days

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43
Q

Should continue antihistamines throughout the season and for ______ afterwards

A

2-3 weeks

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44
Q

For infrequent exposure to allergens, such as visiting a house with a cat, the AH should be taken _____ before exposure to the allergen

A

2-5 hours

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45
Q

What are some of the causes of ineffectiveness of antihistamines?

A
  • patient non-adherence
  • increased antigen exposure
  • worsening condition
  • limited effectiveness of AH in severe disease
  • develops similar symptoms due to unrelated disease
  • suggest switching to another class of AH
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46
Q

What are the most common side effects of AH?

A
  1. Sedation: mild drowsiness to deep sleep
  2. CNS depression: disturbed coordination, dizziness, drowsiness and inability to concentrate
    - may be increased with alcohol
    - mucus secretion thickened
  3. Anticholinergic effect: this is typically associated with the 1st generation AH
    - dry mouth/dry eyes/dry nose, constipation, tachycardia, urinary retention, increase intraocular pressure
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47
Q

What are the contraindications of using a 1st generation AH?

A
  • narrow angled glaucoma
  • severe bladder obstruction
  • stenosing peptic ulcer or pyloroduodenal obstruction
  • hyperthyroidism
  • cardiac disease
  • prostate disease
  • chronic lung disease
  • Caution: patients with MAOIs
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48
Q

Can you take a first generation antihistamine with hypertension?

A
  • YES

- it does not cause an increase in blood pressure, only HEART RATE

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49
Q

What is the action of decongestants?

A
  • they sole the symptoms of congestion only, they do not treat the inflammatory cause of the allergic rhinitis
  • cause vasoconstriction of the alpha receptors, inflammatory mediators do not flood the area as much so you do not get as much inflammation and congestion
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50
Q

What are the two used oral decongestants?

A
  • phenylephrine

- pseudophedrine

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51
Q

Of the oral decongestants, which is the only one that is effective?

A
  • pseudoephedrine
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52
Q

What are the most common intranasal decongestant?

A
  • oxymetazoline
  • xylometazoline
  • phenylephrine
  • naphazoline
53
Q

What symptoms do decongestants treat?

A
  • do not treat any of the other symptoms of allergic rhinitis - itchy watery eyes, watery nose, etc
54
Q

Antihistamines have their full effect in about _____ days

A

3

55
Q

Decongestants should be used for only about ___ days, and should only be used for short term symptom relief

A

3-7

56
Q

How do decongestants work?

A
  • decongestants cause vasoconstriction of the alpha receptors in the nasal mucosa and decreased inflammation
  • sympathomimetics
57
Q

Phenylephrine is a ___ adrenergic agonist

A

alpha 1

58
Q

Oxymetazoline and xylometazoline are ____ adrenergic agonists

A

alpha 2

59
Q

Pseudoephedrine is a ____ releaser

A

noradrenaline

60
Q

Onset of action of an oral decongestant is ______

A

15 to 30 minutes

61
Q

You can use oral decongestants in this over _____

A

6 years of age

62
Q

What are the adverse effects of using an oral decongestant?

A
  • irritability
  • dizziness
  • headaches
  • tremor
  • insomnia
  • peripheral vasoconstriction
    and tachycardiaor palpitation
  • may adversely affect blood sugar in diabetics
63
Q

It is best to avoid using oral decongestants in those with what?

A
  • patients with heart disease, angle-closure glaucoma, diabetes, hyperthyroidism. prostate enlargement are at risk of adverse effects with these agents
64
Q

What are the absolute contraindications to using oral decongestants?

A

-patients with severe hypertension and coronary artery disease

65
Q

What other drugs interact with oral decongestants?

A
  • MAOI
  • TCA
  • methyldopa
66
Q

What is the onset of action for all three intranasal decongestants?

A

5-10 minutes

67
Q

What are the dosing differences of all three intranasal decongestants?
(oxymetazoline, phenylephrine, xylometazoline)

A

Oxymetazoline: Q12H
Phenylephrine: Q4H
Xylometazoline: Q8-10H

68
Q

What are the side effects of intranasal decongestants?

A

nasal burning, stinging, dryness or mucosal ulceration

** can also cause rebound nasal congestion

69
Q

What is the benefit of using a intranasal decongestant over a systemic one?

A
  • topical products have fewer side effects
70
Q

Explain rhinitis medicamentosa (RM)- rebound congestion form using intranasal decongestants

A
  • prolonged use (>3-5 days)
  • caused by the down regulation of alpha adrenergic receptors
  • rebound swelling of nasal mucosa and drug induced rhinitis
  • thought to be less risk with oxymetazoline and xylometazoline due to longer acting formulations
  • use in adults and children over 12 years old
71
Q

Intranasal decongestants treat nasal obstruction in _______

A

both allergic rhinitis and non-allergic rhinitis

72
Q

Intranasal decongestants are used as prophylaxis in ____

A

air travel (15-30 minutes)

73
Q

Local vasoconstriction occurs within ____ of administration

A

10 minutes

74
Q

An ophalmic decongestant can be used for short term use in combination with an AH to relieve ____

A

conjunctivitis

75
Q

What is the mechanism of action of ophthalmic decongestants?

A

vasoconstriction results in a decrease in eye redness

** does NOT actually treat the congestion - ONLY treats the red eye

76
Q

Ophthalmic decongestants are contraindicated in what disease state?

A
  • in patients with angle closure glaucoma
77
Q

What are the side effects associated with ophthalmic decongestants?

A
  • burning

- stinging

78
Q

What is the rebound effect associated with ophthalmic decongestants?

A
  • increased redness and swelling is used more than 10 days
79
Q

What are the 4 medications that are typically in ophthalmic decongestants?

A
  • naphazoline
  • phenylephrine
  • tetrahydrazoline
  • oxymetazoline
80
Q

What is the mechanism of action of mast cell stabilizers?

A
  • inhibits degranulation of mast cells or intracellular events that follow the binding of the IgE to the mast cell
  • does not have antihistamine, anticholinergic or antiinflmmatory effects
  • alleviates runny nose, nasal itching and sneezing, but are NOT antihistamines
81
Q

What are the disadvantages of using a mast cell stabilizer?

A
  • delayed onset of action, may take 4-7 days for any improvement and full benefit will take 304 weeks if used after exposure to an allergen
82
Q

What is the dosing of a mast cell stabilizer?

A
  • 2-4 sprays TID-QID dosing
83
Q

It is important to use mast cell stabilizers ____, 2-3 weeks before the start of allergy season

A

prophylactically

84
Q

Mast cell stabilizers are considered to be ___ effective than antihistamines and intranasal corticosteroids

A

less

85
Q

What is considered to be the most effective agent for AR?

A
  • intranasal corticosteroids
86
Q

What is the mechanism of action of intranasal corticosteroids?

A
  • decreased influx of inflammatory cells and inhibiting release of cytokines which leads to a reduction of inflammation
87
Q

Intranasal corticosteroids are more effective if used _____

A

continuously

88
Q

Onset of action of intranasal corticosteroids is ________, but maximal effect takes place in ______ days

A

30 minutes

7-14 days

89
Q

What are the side effects of using intranasal corticosteroids?

A
  • burning, stinging, nosebleeds, headache, throat irritation and nasal dryness
90
Q

Do intranasal corticosteroids have a negative effect on growth in children?

A
  • no, they do not
91
Q

Triamcinolone nasal spray is schedule ___, for over ___ years of age in packaging that contains no more than 120 sprays

A

3

12 y/o

92
Q

Fluticasone propionate is schedule ____, for over ___ years of age in packaging containing no more than 120 sprays

A

3

18 y/o

93
Q

Intranasal antihistamines have a similar efficacy to what?

A

oral antihistamines

94
Q

What are the common side effects associated with intranasal antihistmines?

A
  • bitter taste, headache, fatigue, irritation and epistaxis
95
Q

A combination product that is both intranasal corticosteroid and antihistamine is known to resolve symptoms in those with what?

A
  • moderate to sever AR
96
Q

What is the mechanism of action of an intranasal anticholinergic?

A
  • prevents secretions of the nasal mucosa

- dosing is bid to tid

97
Q

What are the side effects of intranasal anticholinergics?

A
  • dryness of nasal mucosa
  • nosebleeds (episaxis)
  • dry mouth and throat
  • headache
98
Q

What is the only benefit of using intranasal anticholinergics?

A
  • excessive rhinorrhea. therefore use only when rhinorrhea symptom or refractory rhinorrhea
  • helpful in vasomotor rhinitis
  • ipratropium does not cross the BBB and is not systemically absorbed
99
Q

Oral steroids should be used in combination with what?

A
  • intranasal steroids
100
Q

For persistent symptoms that affect quality of life, _____ are preferred

A

intranasal corticosteroids

101
Q

For mild intermittent symptoms, oral _________ are preferred

A

second generation antihistamines

102
Q

What is the process of immunotherapy?

A
  • is the process of giving the patient some of the allergen, so that when the patients is exposure to the allergen in the environment, the immune system would not respond
  • indicated for moderate or severe persistent allergic rhinitis when:
    1. usual treatments have failed
    2. patient does not want to use medications long term
    3. patients with allergic rhinitis
103
Q

What are the 2 types of immunotherapy?

A
  1. subcutaneous injection - given at regular intervals at the doctors office
  2. Sublingual - first dose must be taken at the doctor’s office, then patient can take medication at home daily (to make sure they do not have an anaphylactic reaction)
104
Q

Subcutaneous may be more ____, but sublingual is _____

A
  • effective

- safer

105
Q

Generally immunotherapy is taken for _____ years and results may last _____ years

A

3-5 years

7-12 years

106
Q

Do not use OTC products in patients under _____

A

2 y/o

107
Q

What is the one exception of an antihistamine that cannot be used in children >2 and has to be used in those over 12?

A
  • fenofexadine
108
Q

What is the age limit for using an intranasal glucocorticosteroid?

A
  • can be prescribed in children over 4 y/o
109
Q

___ generation antihistamines are generally recommended for children with allergic rhinitis?

A

Second

110
Q

Second generation agents are preferred fir children unless treating what?

A
  • allergic skin reactions

- anaphylactic reaction

111
Q

Disodium cromoglycate can also be used in children - true or false?

A

True

112
Q

Why is rhinitis so common in pregnancy?

A
  • increased estrogen and progesterone that causes vasomotor rhinitis - nasal congestion is non-allergic
  • should try non-pharm methods (saline)
113
Q

___ of women with AR will experience increased in symptoms during pregnancy (may worsen, stay the same or even improve)

A

33%

114
Q

What is the recommended medications to use to treat allergic rhinitis in pregnancy?

A
  • loratadine
  • cetirizine
    (do NOT give desloratidine- do not have enough studies)
  • sodium cromylglycate (was not absorbed systemically)
115
Q

Actual allergic rhinitis is NOT common in elderly but non-allergic rhinitis is very common due to changes in the vasculature of the nose. What symptoms may it cause?

A
  • congestion

- rhinitis

116
Q

What medications can cause non-allergic rhinitis in the elderly?

A
  • antihypertensives

- ASA/NSAIDS

117
Q

_____ can be recommended to treat non-allergic rhinitis in the elderly

A

Intranasal ipratropium

118
Q

The effectiveness of fexofenadine may be reduced by ____, ____, and _____ juice

A
  • grapefruit
  • orange
  • apple
119
Q

_____ may cause drowsiness in some patients. Alcohol may increase the sedative effect

A

Cetirizine

120
Q

A slight increase in _____ may be noticed with systemic decongestants

A

heart rate

121
Q

If congestion does not improve after ____ days after taking a decongestant, it is recommended to see the doctor

A

5-7

122
Q

Decongestants should be taken in the ____ to avoid insomnia

A

morning

if needed to be taken, should take the evening dose 3-5 hours before bedtime to avoid insomnia

123
Q

Mast cell stabilizers should be frequently administered on a ____ basis

A

TID

124
Q

How many weeks will it take for mast cell stabilizers to reach its full effectiveness?

A
  • 2-4 weeks
125
Q

What are some side effects that can be experienced by a person taking mast cell stabilizers?

A

nasal dryness, nosebleeds and a sore throat

126
Q

Symptomatic relief with initial nonprescription drug therapy is how long?

A

3 to 4 days

127
Q

Complete relief of symptoms may take _____

A

2-4 weeks

128
Q

The use of ophthalmic antihistamines should result in symptom resolution within ______

A

72 hours

Clinical Pharmacy (24 decks)

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